May 30, 2008 - Snapshots in the Funeral Home

Today I stop by one of our local funeral homes, to attend visiting hours for Diane, a member of the Cancer Concern Center support group I used to attend. Diane was a multi-year survivor of breast cancer, but it caught up with her in the end.

I remember her as one of the most welcoming, affirming members of the group – even though she was one of the ones who found it hardest to stop calling me “Reverend,” and simply call me by my name. Some habits are hard to unlearn – especially for someone who grew up attending Catholic school, as she did. As a kid, she’d never have dreamed of calling a priest anything other than “Father,” and that formality carried over to a Protestant pastor like me.

I find I know only a few other people in the room – one other member of the support group, and a couple I know from some other contexts. I explain to Diane’s daughter how I knew her mother from the Cancer Concern Center, and always found her to be a positive, affirming presence. I don’t identify myself as a pastor, just as a member of the support group.

There’s no casket present – must have been a cremation. I walk over and take a gander at the photo collages. There are several of these, jam-packed with snapshots of a smiling Diane with family and friends I’ve never met.

I feel a little out of place. I knew Diane from such a narrow segment of her life – the support group – and from a time when she wasn’t feeling her best. These are images of a life that was rich and full, until cancer burst in and overturned the game board, scattering the playing-pieces.

Still, I felt I ought to come. Diane was a fellow member of the cancer underground. I want to honor her memory.

As I lean close to the displays of photos, I feel a twinge of survivor’s guilt. Why her and not me? There’s no answer to that question. Why ask why?

May 29, 2008 - No Concierge Medicine for Me

This evening I pick up the phone to listen to our voice mail. Waiting for me is a message from Dr. Cheli. He’s calling to tell us he’s decided not to move forward with the new affiliation with MD-VIP, because he’s been hearing that it would create “too much of a hardship” for his patients. So, he tells us, it will be “business as usual” in his office. He assures us he’ll continue to practice medicine with an emphasis on prevention. (Scroll down to the May 15th entry, for more on this story.)

Reading between the lines, it seems likely that he and the MD-VIP marketing people failed to convince 600 of his 2,700 patients to make the switch (and to pay $1,500 per year for the MD-VIP physical and other services).

That’s not surprising, given the sluggish state of the economy. With gas prices rising faster than anyone can remember, folks are being extra cautious about all their expenditures.

While I feel sorry for what must surely be a huge disappointment for Dr. Cheli, I’m glad for our sake. Claire and I hadn’t told him yet, but we’d pretty much decided to go ahead and take a risk on MD-VIP (despite the severe strain it would have put on our budget). We made that decision reluctantly – not because we were overflowing with enthusiasm about MD-VIP’s services, but because we didn’t want to leave Dr. Cheli.

This means we can continue to see him, without the worry of coming up with that huge fee every year.

I don’t fault Dr. Cheli for trying. The health-care funding situation in this country is an abominable mess. I can fully understand why he’d want to carve out a little island of calm amidst the chaos, where he could practice the sort of medicine he trained for, and make a good living doing so.

It’s going to be stormy sailing for him and everyone else connected with health care – until our political leaders come up with the will to stand up to big insurance and big pharma, and develop a national health-insurance program, like most every other industrialized nation already has.

May 28, 2008 - Slo-Mo Gets Even Slower

Today I see Dr. Lerner for my 3-month appointment. It’s the usual routine: CBC blood test (with instant results, thanks to his spiffy machine), and a physical exam (stethoscope, feeling my neck, armpits and groin for enlarged lymph nodes, then thumping on my abdomen).

The doctor asks me how I’ve been feeling. I tell him I continue to have no symptoms and am feeling fine. Everything looks good, he tells me, so he’s going to recommend I wait a little longer for my next CT scan. I won’t go in for that until the first week of July – just shy of 5 months since my last one.

Previously, my scan interval has been every 3 months – but, the last 2 scans have indicated no change in the size of my enlarged lymph nodes. This lymphoma has been out of remission for more than a year, but the biopsy has shown it to be of the indolent, couch-potato variety – so, Dr. Lerner doesn’t seem overly concerned.

Sometimes, in action movies, the director slows the film down, so a character facing some extreme, physical challenge moves in slow motion. I’ve been describing my current situation as a slow-motion crisis: and, it looks like it just slowed down a little more. It’s odd to think of relaxing our vigilance with respect to an out-of-remission cancer, but that’s the nature of the beast, I suppose.

May 26, 2008 - Random?

Another thoughtful response from Christine, over in the comments section. She writes:

“Following from your proposition, by allowing ‘creation’s freedom,’ God has inadvertently (or not) introduced randomness of events/tragedies into the human realm. If this is so, then where I am today (with cancer) might possibly be the result of a random event. So essentially it boils down to the luck of the draw. And as such, there can be no purpose to life or life's struggles.”

I wonder if “random” was the best word to use, in my last post. In suggesting that God the creator allows certain things to happen randomly – like the genetic mutations that lead to the evolution of animal species – I didn’t mean to suggest creation is purposeless. Quite the contrary: God has imbued the world with such a powerful purpose – evolution – that a great many things we see around us are in service to that higher goal.

Take the human tailbone, for instance. Most anatomists agree it’s the useless, vestigial remnant of something that was far more useful to our distant ancestors. Lots of people’s tailbones give them trouble, causing back pain. Perhaps it’s a small comfort to some of those people (or at least, to those who contemplate such weighty philosophical matters) that the bone that causes them such pain at one time had a purpose – a purpose that was one of many factors leading to the appearance of the human race on earth. Because God’s temporal frame of reference spans eons rather than human lifetimes, this means generations of human beings will have to suffer with vestigial tailbones, until – through the slow work of genetic mutations that fuel natural selection – this annoying anatomical feature finally disappears completely.

It’s possible (although probably not terribly comforting) to say to a back-pain sufferer, “God is doing something about that pesky tailbone, but it’s going to take a few hundred thousand years before the job is done.”

Maybe the cell mutations that lead to cancer have a similar purpose. Maybe, without those millions upon millions of mutations – a very few of which are incidentally responsible for cancer – other, more positive mutations could never occur. Such mutations appear, from our perspective, to be random. But, from God’s perspective?

How can we possibly say? We don’t have the God’s-eye view. All we can do is trust, in faith, that God is working the divine purpose out.

The prophet Isaiah seems to think the God’s eye view is worth thinking about:

“It is he who sits above the circle of the earth, and its inhabitants are like grasshoppers; who stretches out the heavens like a curtain, and spreads them like a tent to live in; who brings princes to naught, and makes the rulers of the earth as nothing. Scarcely are they planted, scarcely sown, scarcely has their stem taken root in the earth, when he blows upon them, and they wither, and the tempest carries them off like stubble. To whom then will you compare me, or who is my equal? says the Holy One. Lift up your eyes on high and see: Who created these? He who brings out their host and numbers them, calling them all by name; because he is great in strength, mighty in power, not one is missing.” (Isaiah 40:22-26)

The classic Western image of the creator God is that of a divine watchmaker, creating an intricate machine by fussing over every flywheel and gear. It’s the sort of metaphor that worked well in Enlightenment times, but in this present era it’s more than a little dated. With what we know about the unimaginable complexity of evolution, it seems to make more sense to view God as the creator who cooks up the primordial soup out of which life springs, then steps back to watch it all unfold.

I don't see this as a Deist understanding of God (the cosmic watchmaker who winds the blame thing up, then slinks off, letting it tick away). Rather, the God of evolution is still involved with the created order, although without manipulating it like a puppetmaster. That’s because freedom itself is too important a principle to compromise. It’s the very fuel on which the universe runs.

I prefer to speak of freedom, rather than randomness, with respect to God’s creation. I believe there is a purpose to it all – although it’s a purpose we can understand only in the most fragmentary of ways.

We await the full revealing. In the meantime, we live by faith.

May 21, 2008 - And It Was... Good?

Last Sunday, I had occasion to read Genesis 1:1-2:4a in our worship service. Joanne, our seminary assistant, was preaching, and had chosen that passage from out of the Revised Common Lectionary selections for the day.

Not often do I have the opportunity to read that famous passage – the first of Genesis’ two creation stories – aloud, in its entirety. “God saw everything that he had made, and indeed, it was very good.” (Genesis 1:31) I was struck by the sheer majesty of those ancient words.

Funny that today I should see those very same words pop up in a comment posted on my blog. A reader named Christine referred to Genesis as she commented on the May 18th entry, “The Imperfect Is Our Paradise.” Here’s what she has to say:

“Dear Carl, can you really see God in the immense suffering as a result of the China earthquake or the Myanmar cyclone or in any other tragedies? I truly would like to but how does one begin? Does the answer lie in finding a purpose in the imperfection? I thought the Bible says that when God created the world, he saw that all was good. Perhaps I am missing the point.”

Ordinarily, I respond to comments in the Comments section, but Christine’s remarks set me to thinking. The more I think about it, the more I realize that her objection, and my response, belong not just among the comments, but here in prime time.

The theological issue Christine raises is a big one – perhaps the biggest. I’m speaking, of course, about the question theologians call theodicy: the problem of evil.

Christine puts it bluntly: “Can YOU really see God in the immense suffering as a result of the China earthquake or the Myanmar cyclone...?” It’s kind of like Jesus’ question to Peter at Caesarea Philippi: “But who do YOU say that I am?” (Christine has a way of putting a preacher on the spot. Which is OK with me. It goes with the territory.)

Well, Christine, let me attempt an answer. Please understand, before I begin, that any answer I attempt can hardly break new ground. This question has both preoccupied and baffled the sharpest theological minds down through the centuries.

Archibald MacLeish put it colorfully, in J.B., his play in verse based on the book of Job. There, the poet has the devil taunt the long-suffering Job, saying,

“If God is God, he is not good,
if God is good, he is not God,
take the even, take the odd.”

The writer of Genesis punctuates his narrrative of creation with the repeated mantra, “And it was good.” But was it? That’s really what Christine is asking. She wants to know if it was good through and through, if there were any seeds of evil in that idealized, primordial realm. In other words, was creation perfect? And, if so, what happened to it? How could the loving, omnipotent, “and it was good” God tolerate a world with earthquakes and cyclones in it, let alone Non-Hodgkin Lymphoma?

I’ve spent a fair amount of time wondering about that question myself, over the last several years. As I’ve pondered it, I’ve come to the conviction that creation need not be perfect to be good – at least, not as we commonly understand the word, “perfect.”

Anyone who takes a hard, unblinking look at creation quickly realizes it’s far from perfect. I’m no creationist; I firmly believe God used – and still uses – random processes like Darwin’s natural selection to fashion the universe. Think of the wild profusion of seeds that never make it to fertile soil. Think of the billions of animals gobbled up by larger, fiercer beasts. Think of humans who are blessed with free will, but who turn around and misuse that gift to create everything from Mein Kampf to child pornography to “Swift Boat Veterans for Truth.” Yes, indeed, creation is a messy business. Sometimes it seems the creator God operates more like Jackson Pollock than Andrew Wyeth: sending shiny strings of paint swirling through the air, spattering as much color upon the floor and walls as ends up on the canvas. Yet, somehow God loves the wild imperfection of it all. And it was good.

It’s an imperfect world, no doubt about it. One strain of thinking within Christianity posits that creation began with perfection, but then something called the Fall intervened, as a saltshaker lid comes unscrewed over a bowl of soup. It blames human sin for the mess. I don’t buy that. There in the Garden, Adam and Eve have free will. The serpent may croon to them seductively, but at the end of the day they choose the forbidden fruit on their own. Adam and Eve have that capacity for choosing wrongly within them, all along – and isn’t it true that God created them, including their capacity to choose evil?

There’s another meaning to the word “perfect,” and this one I can affirm with respect to the creation story. “Perfect” doesn’t only mean “without flaw.” It can also mean “finished.” Like the grammarians’ “perfect tense,” this sort of perfection means just what Genesis 1 asserts: that God created, then God rested. When God rested n the seventh day, the work of creation was finished: flaws and all. And it was good.

When the author of Genesis says it was good, I think he’s using that word the way parents use it of their children: “He’s a good boy, she’s a good girl.” In saying such a thing, parents never mean their offspring are free from errors or flaws. They mean, “They are who they are. What they are is mine, and I love them.”

Yet, this world God created – good as it was, and still is – is far from static. It’s a living, growing thing. God may have perfected it eons ago, speaking a word of love into chaos, but the divine work of creation continues to unfold, through spouting volcanoes, shuddering earthquakes and swirling cyclones. Evolution continues, in its glorious profusion of species – some destined to become ancestors of species yet unborn, others bound only for the scrap heap of extinction. It’s all God’s, and it’s all good.

Could God intervene to prevent a shoddily-constructed Chinese school building from collapsing on the unsuspecting heads of its students? Could God send a cyclone spinning out into the open ocean, rather than letting it careen into a heavily-populated river delta, dotted with fragile bamboo huts?

In theory, God could. But, in practice, God typically won’t. That’s because God values one aspect of creation as especially good, so good it needs to be left alone: creation’s freedom. Were God to begin censoring creation’s every impulse to randomness, then it would cease to be the starkly beautiful place it is. It would become, instead, a wasteland of dreary predictability. The Pollock canvas would be transformed into a Stalinist propaganda poster. The lumpy, fresh-off-the vine tomato would become the perfectly-spherical but tasteless hothouse variety.

Did God create cancer? Maybe not directly, but God did bestow upon creation the gift of freedom. God stepped back and said, “I’m finished. Let it be.” Then there began a wild profusion of changes and mutations, continuing through the eons, even unto our own day. As in all living cells, the DNA in certain cells of the human body eventually mutates, changing the intricate pattern of chemical switches. One of these chemical switches controls the cells’ programmed instructions to die on schedule, making room for new cells. In their wild freedom, the newly-immortal cancer cells grow in size and number, squeezing out their healthier neighbors. Repeat this process millions of times, and the complex creature of which those cells are an essential part falls ill, even dies prematurely. Such a turn of events causes God to weep. Yet, through the tears, God keeps loving creation – enough to refrain from laying hands on it, robbing it of its precious freedom. God continues to call it good.

Ultimately, it’s love that’s at the center of creation. Out of love God fashioned the whole thing in the first place. Out of love God said, “Let us make humankind in our image, according to our likeness.” Out of love, God allows the human prodigal to run free, even if that one is squandering the family fortune. The child’s got to fall before it can walk.

“Love never ends. But as for prophecies, they will come to an end; as for tongues, they will cease; as for knowledge, it will come to an end. For we know only in part, and we prophesy only in part; but when the complete comes, the partial will come to an end.” (1 Corinthians 13:8-10)

The poet Isaiah promises that, one day, God will roll up the whole cosmic burrito, leveling earth’s mountains and raising up the valleys to make a grand processional highway of celebration. Then, there shall be no more weeping, nor crying, nor pain. They shall not hurt or destroy on all God’s holy mountain.

I’m coming to believe Philip Simmons – the ALS survivor whom I quoted, in the blog entry to which Christine took exception – is right. Because of his experience of suffering, he of all people is worthy to be our guide in such matters. The world is imperfect, as we normally define the term. Yet, the world is good, all the same. That good, but imperfect, world can even be our paradise.

It’s the only world we’ve got. Until the day. Until the day...

May 18, 2008 - The Imperfect Is Our Paradise

Some time ago, I saved this quotation from Philip Simmons’ book, Learning to Fall: The Blessings of an Imperfect Life. Simmons suffers from ALS (Lou Gehrig's disease):

“We have all heard poems, songs, and prayers that exhort us to see God in a blade of grass, a drop of dew, a child’s eyes, or the petals of a flower. Now when I hear such things I say that’s too easy. Our greater challenge is to see God not only in the eyes of the suffering child but in the suffering itself. To thank God for the sunset pink clouds over Red Hill – but also for the mosquitoes I must fan from my face while watching the clouds. To thank God for broken bones and broken hearts, for everything that opens us to the mystery of our humanness. The challenge is to stand at the sink with your hands in the dishwater, fuming over a quarrel with your spouse, children at your back clamoring for attention, the radio blaring the bad news from Bosnia, and to say ‘God is here, now, in this room, here in this dishwater, in this dirty spoon.’ Don’t talk to me about flowers and sunshine and waterfalls: this is the ground, here, now, in all that is ordinary and imperfect, this is the ground in which life sows the seeds of our fulfillment.

The imperfect is our paradise.”

I can’t say my suffering begins to approach that of an ALS patient like Philip Simmons. In fact, whatever suffering I experienced during my chemotherapy is becoming more and more of a distant memory. I’m still troubled by the thought of the recurrent cancer inside me, of course, but I’m trying to be thankful for days that approach normalcy, for the absence of symptoms and for the absence of the need to pursue further treatment at this time.

Sure, life’s imperfect. I’d prefer to still be in remission, or to be pronounced cured. But this life is the only life I've got.

Tomorrow morning, Claire and I pick up Ania at the airport, as she returns home from her freshman year of college. We’re looking forward to seeing her.

Life – even an imperfect life – is good.

May 15, 2008 - Concierge Medicine?

A couple of nights ago, Claire and I attended an informational meeting put on by our family-practice physician, Dr. David Cheli. Starting this July, he’s associating himself with a nationwide group called MD-VIP. This decision will bring big changes for his patients.

For us patients, there’s some good news and some bad news.

The good news is, Dr. Cheli’s going to be focusing very intentionally on preventive medicine. Each patient will receive an elaborate annual physical, including a host of diagnostic tests. That physical exam takes about one and a half hours, and is – the company claims – comparable to the “executive physicals” long offered by world-class medical facilities like the Mayo Clinic. Each patient gets a personalized website with health-related resources, and a mini-CD-ROM containing personal medical history to carry around and present to emergency-room doctors, if necessary. Dr. Cheli also promises to be available 24/7 by cell phone, and further promises that no patient will ever have to wait longer than one day for an appointment. He’ll continue to take all medical-insurance plans for routine office visits – no change there, he assures us.

Dr. Cheli will continue to have a solo practice, but he’s cutting his roll of patients from 2,700 to 600. That’s what makes the more personal attention possible.

OK, that’s the good news. Now for the bad news. Each patient must pay an up-front fee of $1,500 a year – which (except for, perhaps, a small portion) is not covered by insurance.

Do the math. 600 patients times $1,500. That’s 900 grand. Dr. Cheli doesn’t get all of it, of course. MD-VIP gets their cut, and those elaborate tests associated with the annual physical do cost something. Yet, what he does receive from these annual fees is evidently enough to cut his patient roll by more than three-quarters.

I can understand what’s in it for him. As he explained the other night at the public meeting, he’s been practicing medicine for 31 years. Along with many of his colleagues, he’s feeling increasingly frustrated with a health-care system that forces him to rush through patient appointments so he can spend hours on the phone arguing with insurance adjusters. He knows the type of medicine the system forces him to practice isn’t as good for his patients as the type of medical care he was trained to deliver.

MD-VIP claims their patients’ hospitalization rates are just 65% of the general population. They attribute this to two causes: better prevention, and same-day or next-day appointments (which allow MD-VIP doctors to identify and treat serious conditions in the office, keeping their patients out of the emergency room).

That may be part of it, but I’d be willing to bet that a significant portion of this favorable statistic can be explained by the fact that patients willing to pony up the $1,500 fee are younger and healthier to begin with.

Why do I say that? Several reasons. First of all, MD-VIP relies heavily on the internet. Patients have to be familiar enough with computers to derive the full advantage from this service. While some senior citizens have taken to the internet with a vengeance, a great many still don’t know the difference between hypertext and hyperactive. Second, chronically sick people are more likely to have burned through their financial resources and would have a harder time coming up with the $1,500 annual fee. Third, patients who see the value of preventive medicine, and are willing to pay for it, are more likely to have already adopted positive lifestyle habits. (How many chain smokers or alcoholics are willing to go for this?) Fourth, those who simply have an aversion to going to the doctor are not likely to pay top dollar for the privilege of spending more time doing the thing they hate.

So, Claire and I have a tough decision to make. We both really like Dr. Cheli. He’s been our family doctor for 17 years. He diagnosed my cancer before I was displaying any obvious symptoms. He’s a got a caring bedside manner, and he’s always been responsive to our needs. But, can we find the $3,000 a year to keep going to him?

My medical insurance, provided by the Presbyterian Church (U.S.A.), has a preventive health benefit that reimburses 100% of the cost of an annual physical, independent of deductibles and co-payments. That benefit’s got a cap on it, though, that falls way short of $1,500 for each of us. Most of the MD-VIP fee we’d have to pay out of pocket.

If Dr. Cheli will be able to work with me to overcome my #1 preventive-medicine challenge – losing weight – it will be money well spent. But, will the MD-VIP philosophy really give him the time and resources to do that? Is it really as good as the rosy description on the website claims?

They call this “concierge medicine” (although MD-VIP's website disavows this label, saying they’re “beyond concierge healthcare”). As with any pricey “concierge floor” in a hotel, the question is, “will we get our money’s worth out of the enhanced service?”

Or, is this one of those situations where, as they say, “if you have to ask the price, you can’t afford it”?

May 12, 2008 - Unbroken

At the age of 20, Jerry White lost his leg – and nearly his life – as he stepped on a landmine while on a camping trip in Israel. Later, he went on to work as a leader of the International Campaign to Ban Landmines and become co-founder of Survivor Corps. White has just published a book about how to survive a catastrophic life event. Here’s a selection:

“They say what doesn’t kill you makes you stronger. It’s not quite that simple. I believe you have to decide it will make you stronger. Experience has taught me that happy endings can never be taken for granted. They must be chosen. When I was in the hospital for six months in Israel, no one did my physical therapy for me. No one underwent the pain or the fear of six operations for me. I would have liked for someone to, maybe. I confess, the first time I was put in a wheelchair, I sat there and waited for someone to push it for me. I had just had another surgery, I was weak, in pain, exhausted. And when I looked up at my nurse, she looked down at me and laughed. “If you want to move, push.” And so, I did. And I continue to do.

Whether we like it or not, personal determination is required to build resilience – to become fit for whatever the future may hold. We have to tap inner resources and develop some emotional muscle. It’s both a discipline and our responsibility. No one can do it for us.

The good news is we are not alone. We are surrounded by survivors who have gone before us, and their examples will help mark the way forward.”(I Will Not Be Broken: 5 Steps to Overcoming a Life Crisis, from the Introduction.)

White’s experience was of a sudden, traumatic injury. One moment, he was hiking with two friends through the Israeli countryside. The next moment, the earth exploded around him, and his right foot disappeared. The next day, he lost more of his right leg to the surgeon’s knife.

Even so, I think White’s conclusions can be generalized to include the experience of being diagnosed with a slowly-progressing disease like cancer. In the book, he recalls a conversation he had with Princess Diana, with whom he worked as an anti-landmine activist. Touring Bosnia and speaking with survivors, they observed that everyone seemed to have “their date.” They could all state precisely on which date they had been injured or bereaved.

Many of us cancer survivors can do the same with our dates of diagnosis (mine was December 2, 2005). Before that date, we may have a suspicion something is wrong, but we still have the luxury of hoping it’s nothing serious. After that date, we can never return to such naiveté. We will, forever after, be cancer survivors.

White identifies five essential steps in coming to terms with a life crisis. I think they can be generalized to include the experience of receiving a cancer diagnosis:

1. FACE FACTS. One must first accept the harsh reality about suffering and loss, however brutal. “This terrible thing has happened. It can’t be changed. I can’t rewind the clock. My family still needs me. So now what?”

2. CHOOSE LIFE. That is, “I want to say yes to the future. I want my life to go on in a positive way.” Seizing life, not surrendering to death or stagnation, requires letting go of resentments and looking forward, not back. It can be a daily decision.

3. REACH OUT. One must find peers, friends, and family to break the isolation and loneliness that come in the aftermath of crisis. Seek empathy, not pity, from people who have been through something similar. Let the people in your life into your life. “It’s up to me to reach for someone’s hand.”

4. GET MOVING. Sitting back gets you nowhere. One must get out of bed and out of the house to generate momentum. We have to take responsibility for our actions. “How do I want to live the rest of my life? What steps can I take today?”

5. GIVE BACK. Thriving, not just surviving, requires the capacity to give again, through service and acts of kindness. “How can I be an asset to those around me, and not a drain? Will I ever feel grateful again?” Yes, and by sharing your experience and talents, you will inspire others to do the same.(I Will Not Be Broken: 5 Steps to Overcoming a Life Crisis, from Chapter 1.)

There’s something of an up-by-the-bootstraps character to this way of thinking, but I think it makes good sense. We all depend on our medical professionals, family and friends to do things for us, but ultimately we’ve got to claim responsibility for our own healing.

May 11, 2008 - Outsourcing Health Care

I ran across a factoid not long ago that’s set me to thinking. In a Newsweek article by Fareed Zakaria, I came across this statistic: “U.S. carmakers now employ more people in Ontario, Canada, than Michigan because in Canada their health care costs are lower.”

Wow. That’s a telling snippet of information. The economy of the Detroit metro area – long the traditional heartland of the American automobile industry – has in recent years been devastated by layoffs and plant closings. I’ve heard that part of the reason for this – besides competition from Japan, Korea and other countries – is the heavy pension-and-benefits packages the big U.S. automakers have to bear, particularly for their retirees.

I never imagined, though, that these companies would find a way to outsource their medical benefits: by packing up their manufacturing plants and moving them lock, stock and barrel across the river to Canada.

Canada, of course, has a national health plan. Their workers’ health benefits are paid for by the government. The American auto executives, while urging “Buy American!” out of one side of their mouths, are whispering “Buy Canadian!” out of the other, with respect to health care.

It’s hard to imagine a more telling indictment of our health-care funding system than this. Our broken system has become a problem that’s bigger than the privations of individuals and families. It’s affecting the economic health of our entire nation.

May 5, 2008 - How Doctors Think

This morning, I finish reading How Doctors Think, by Jerome Groopman, M.D. I’d give this book an unequivocally positive recommen- dation. It’s one every patient should read.

That’s no exaggeration. I really mean it.

The book’s important because of the light it sheds on a mysterious chemistry: that of the doctor-patient relationship, particularly when it comes to diagnosis. As we patients lay down our magazines and make our way from the waiting-room into that medical holy of holies, the examining-room, many of us look for something magical to happen there. Doctors, clad in their priestly, lab-coat vestments, shuttle from room to room. We’re a little in awe of our doctors. They have the gift. The whole medical system is designed to maximize their precious time, so more patients can have their few brief moments in the presence of the gift of diagnosis.

The higher you climb up the ladder of medical specialists, it becomes less likely your doctors will occupy themselves with routine matters like asking medical-history questions or taking vital signs. Nurses and aides – and, in teaching hospitals, doctors-in-training – typically perform such tasks. If the system is working as it should, their careful observations will be laid out before the doctor as he or she performs the cognitive process leading to diagnosis and treatment. If the system’s not working well, the doctor’s understanding of the patient will be superficial, and mistakes become more likely. Decisions may be made in a two-dimensional way: mechanically matching up symptoms with slots on a treatment-protocol flow chart, ignoring the living, breathing, thinking complexity of the human being who’s sitting on the edge of the examining-table.

Groopman unpacks the mysterious, priestly work of diagnosis and treatment for us laypeople to understand. He probes the meaning of the diagnostic gift, and asks how it can best be utilized. He reminds us of a very old-fashioned idea: that medicine is an art as well as a science.

Groopman’s point is that a clinical consultation in a doctor’s office is an act not only of number-crunching scientific analysis, but also of communication. In the examining-room, two people come together and talk. What they say – and, often, what they don’t say – can mightily determine the outcome.

I come away from this book with a renewed appreciation for two types of physicians: the unsung, relatively underpaid family-practice doctors whose intuitive diagnostic skills are honed to a fine edge, and those specialists who possess the strength of character to buck the system’s pressures to think only in terms of numbers, not the person. It’s no wonder Groopman’s final chapter is entitled, “In Service of the Soul.”

I think back to my own experience of diagnosis. Groopman could have used it as an example in his book. I go into David Cheli’s office for an annual physical. Aware that I’m nearing 50, I mention the fact that my father nearly died of a dissecting aortic aneurysm. I know these can be hereditary, I tell the doctor. Is this something I should be checked for?

“That’s unlikely,” says Dr. Cheli. “You don’t smoke, and your blood pressure is fine.” He sends me on my way, with the usual encouragement to lose weight and exercise more.

At the next year’s annual physical, I mention an aneurysm again. I’m not reporting any symptoms relevant to such a diagnosis, but it’s been on my mind, for some reason. Thinking back to that time, I now realize that maybe, on some subconscious level, I was aware that the mid-section of my body felt somehow different. If you’d asked me directly about it, though, I would have scoffed at the suggestion. (In retrospect, I realize I was experiencing one symptom relevant to lymphoma, night sweats – but I wasn’t attuned enough to mention it to the doctor.)

What I could articulate, on a conscious level, was a vague anxiety that I could end up like my father someday – being airlifted to a major medical center for a herculean operation to replace a split-open section of my aorta with a nylon substitute. It wasn’t a rational thought – but, as it turned out, it did have a kind of truth behind it.

Who knows what went through Dr. Cheli’s mind, at that point? Here’s a patient – overweight and a bit stressed-out, but otherwise healthy – worrying for the second year in a row about a medical condition for which he doesn’t fit the profile and doesn’t have the usual symptoms.

What Dr. Cheli did was send me for an ultrasound scan of the abdomen. Did he have a reason for doing so, other than my repeated question about an aneurysm? Was he ordering that relatively inexpensive test simply to give me peace of mind, or did he intuitively suspect something else was up? I don’t know. But, I’m awfully glad he did order the ultrasound. It was in the grainy images on that screen that the bulky tumor in my abdomen was first revealed.

The light bulb goes on for me, this morning, as I read these words from the Epilogue to Groopman’s book, about the thoughts that may go through our minds, as patients, as we talk to the doctor: “Our notions sometimes come from knowing a friend or relative with a similar symptom, or ideas may have been sparked by looking on the Internet. Our thoughts about our unrelieved symptoms often focus on the worst-case scenario. Such self-diagnosis is a reality that neither patient nor physician should ignore. Since the doctor may not address it, you should. ‘I’m most worried that what seemed like acid reflux could be the first sign of cancer,’ one patient might say. Or another might recount to the doctor how her friend was told she had indigestion but it was actually a brewing heart attack.... A thoughtful doctor listens closely to these worries.” [Jerome Groopman, How Doctors Think (Houghton Mifflin, 2007), p. 261.]

Thanks, Dr. Cheli. Thanks for listening.

May 1, 2008 - Fill in the Blank: My Cancer...

On April 29, Leroy Sievers posted a request on his My Cancer blog on the National Public Radio website. It attracted hundreds of replies from readers. Leroy simply asked his readers to complete a sentence: “My cancer....”

The replies he got were many and varied. I’m copying a selection of them below. I’ve included only those that come from cancer survivors themselves – there were many other noteworthy responses that begin, “My husband’s cancer...” or “My wife’s cancer...”, but those are a subject for another day.

I’ve only included responses that are positive, that speak of learning or growth or gratitude. There were some negative responses, of the "cancer sucks" variety – expressions of anger, pain, sadness, loss – but not nearly so many as you may think.

I’d guess there were 3 or 4 positive responses for every negative one. I’ve omitted the negative ones not because they don’t have validity (indeed, I think ANY honest response to cancer is valid), but simply because I’m more interested in the ways cancer has changed its survivors for the better.

If you want to read some more of the responses, I’d suggest you visit Leroy’s blog.

My cancer reminds me that no one is permanent and I will not be the exception to this. Also, my cancer has taught me that life and health is process not a final destination.

My cancer has made me more compassionate and more appreciative of the time I have left....

My cancer made me stop taking myself so seriously....

My cancer has taught me who my true friends really are...

My cancer has taught me valuable lessons about living, loving, and dealing with things, all of which I would have been happy to have learned from a book instead.

My cancer was a great teacher. It taught me gratitude, hope and that not everything is within my control....

My cancer grounded me in reality; made me more empathetic and compassionate for the suffering of others...

My cancer taught me I was stronger than I ever knew....

My cancer reinforced for me what is truly important in life – God, family, friends – pretty much in that order. And conversely, that I could safely put aside, career, status, things....

My cancer has given me FREEDOM I never had. I don't worry. I don't fret. I am free. I faced the beast. Lived and live with it. My shoulders are broader than I ever thought, and I can handle anything. The Beast may be lurking, but he is wasting his time....

My cancer finally made me give up, at 58, the illusion that I was still just a kid in a grown-up body. But I've worked hard to regain the feeling and find myself looking at children with more joy.

My cancer helped change the direction of my life. Time became precious and relationships even more important....

My cancer made me so aware.

My cancer has taught me that every day on this side of the grass is a Good Day!

My cancer taught me the power of others’ prayers for me. It also taught me humility.

My cancer sucked me up in a slashing, burning, poisoning tornado, then set me down in a new place, headed in different direction. I'm a better person since cancer, and in whatever time I have left, I'll add more to the world.

My cancer... has shown me what the real difference is between "wheat" & "chaff" in my life. It's a lot easier to deal with life's little irritations now....

My cancer has been a “life sentence.” A poster I found not long after my diagnosis and treatment says it all: “Everything changed the day she figured out there was exactly enough time for the important things in her life.”

My cancer showed me how much my husband really loves me and that his love truly is unconditional.

My cancer has enabled me to know both the fragility and the hopes of life, and with this knowledge to live most fully.

My cancer has brought out the talents, skills, devotion and strong faith for those that care for me. That is my reward, watching from my “cancer” vantage point as others improve their life’s journey.

My cancer will not define me or become the be and end all of my life. What it has done is make me stop and be aware that I am not the center of the Universe, and that I must be attuned to others, their ideas and needs.

My cancer has made me face up to the many things that were wrong with my life, and fix them.

My cancer brought me face to face with death. And that made me realize how important the gift of eternal life really is, and how glad I am I have it through my relationship with Jesus Christ. No outcome is bad now – if I live, that’s great, and I’m embracing life.
If I die, I go to heaven, a place of eternal rest and peace. And that’s a rather wonderful “backup.”

My cancer... saved my life.

My cancer taught me to pare down to the essentials in all things – to live large and travel light – trusting in the power of kindness and love to lead me where I need to go.

My cancer was the best worst thing that ever happened to me.

My cancer has made me worry less about what I can't control.

My cancer has... stretched my gratitude muscles but I have learned to be very, very grateful for the smallest of things.

My cancer taught me that I am living and dying at the same time. The living feels so full and so intense, filled with exquisite beauty and wonder. The dying feels like I am tearing away all the layers, seeing parts of me I didn't know were there, and it hurts, but just a little. And I am also learning forgiveness and gentleness and a lightness of being that will hopefully let me die with peace and grace.

My cancer has humbled me.

Cancer stripped me of my hair, breasts, uterus, ovaries, eyebrows, eyelashes, 60 pounds of excess weight, career, and marriage. But I looked in the mirror one morning and saw big green eyes, a beautiful smile and a spirit that filled the entire room and said “There you are. I wondered where you were all these years. Welcome home.”

My cancer has taught me patience....

My cancer is the thief of all the opportunities life has to offer, yet also the perspective by which I appreciate everything more.

My cancer taught me to “let it go”....

My cancer has taught me to treasure, not mourn, transience. Because the beauty of this spring will fade, or because it might be my last, does not make it less glorious.

My cancer is not me. My cancer has tried to change me. My cancer has tried to take me. But it only made me more and more what I am before my cancer. It made me discover parts of me that cancer cannot touch. Indestructible hope. An ability to laugh. A mind of my own.

As for me, I posted a response as well:

My cancer has made me a better pastor, husband and father.

If you're a cancer survivor (or someone who loves someone who's had cancer), why not try filling in the blank? Click on "Comments" and post your response here. Pass it on!