By Richard P. Holm MD
I think it is pertinent to this week’s topic of “ask anything” to pose the question: “What does it mean to be a doctor”? This is especially apropos as a new crop of doctors will be graduating from medical school this spring.
Did you know that in order to enter into the profession of medicine, each new doctor must make a serious promise? It is to profess or to give one’s solemn word to do the right thing in the name of all that is sacred, and this pledge is given in public for all to see and hear. By the way, it is this professing or promising that is the basis for the word “profession”.
In an issue of the medical journal Pharos, editor Edward Harris writes about the three parts to the promise. First it has to do with valuing service to others over personal reward. That means medicine is a profession that should not be undertaken with profit in mind. I would state here that clearly most premed students do not go into medicine for profit, although there may be a few that do, and I see them as the least blessed of the profession.
Next, Harris points out that as a medical profession, we should be responsible for monitoring who are ethical and competent enough to graduate from medical school, to be licensed to practice, and to continue to practice. It is important to protect the public from unethical or incompetent physicians, and that is why we have a State Board of Medical Examiners. Finally, we profess to keep the sacred trust of a valuable body of knowledge, to continuously critique, question, and challenge that knowledge, and to pass it on in order to benefit every individual patient.
Passing on knowledge is what we are trying to do with our television show On Call with the Prairie Doc®. That’s a promise.
Watch On Call with the Prairie Doc® most Thursdays at 7 p.m. central on SDPTV and follow the Prairie Doc® on Facebook and YouTube for free and easy access to the entire Prairie Doc® library.
Have you heard the myth of Prometheus, the Greek Titan who challenged Zeus? Prometheus stole fire from Olympus and brought it down to humankind, making Zeus furious with him for sharing with mere mortals the secret of such power. Zeus punished Prometheus by chaining him to a rock. Each day, birds with sharp beaks would open his abdomen and eat away his liver, and, each night, his liver would grow back. Each day Prometheus would suffer, repeatedly punished for his gift to humanity.
There are many interpretations of the myth, but probably the most famous comes with the Frankenstein story, written by 17-year-old Mary Shelly in 1816. In Shelly’s time, science was virtually exploding with new knowledge. Modern medicine was becoming effective, illustrated by how death rates were dropping; Galvani and Volt had just discovered how a dead frog leg would jerk when connected to a battery; chemists were showing how ether and nitrous gasses could make people stay asleep during surgery; and biologists were on the verge of realizing how microscopic bacteria cause contagion and fever, and how cleanliness could prevent such infection following surgery.
Thus, it is understandable why Shelly would create her famous story about scientist Victor Frankenstein. Like Prometheus who brought fire to mortals, her mad scientist brought life back to something once dead using newly discovered breakthroughs in electricity and chemistry. Shelly imagined how a mortal with scientific knowledge could create a superhuman being out of body parts stolen from a graveyard.
However, such a discovery should require responsibility and careful safeguards. Like fire that can jump its boundaries and spread destruction, creative scientific experimentation could quickly get out of control and cause monstrous harm and havoc to people and the environment. One cardinal rule of ethics we are taught in medical school demands: “first of all, do no harm.”
Most every significant advancement in science has a potential good and bad side. Consider how nuclear power can produce marketable energy and yet can cause explosions of mass destruction; how antibiotics can treat life-threatening infections and yet can cause life-threatening overgrowth diarrhea illnesses; how advancements in genetics can cure a chronic disease like hepatitis C yet can potentially cause harm to our society’s ability to afford health care. Indeed, great advancements in science can do tremendous good while still having the possibility to cause potential danger to public and environmental health.
Thus, the Greek myth of Prometheus and the monster story of Frankenstein both speak to us today. As we seek to advance science, we must understand the ethical responsibility of safety. First of all, do no harm.
This ancient wisdom often rings so very true: “You only teach by example.”
We all have mentors in our lives, people who serve as examples, whose patterns of living teach us how to face challenges. Of course, most of us start out with our parents as mentors, and then look to other relatives, teachers, partners, and heroes in stories worth emulating.
Even before my medical training, I watched and learned from our family physician, Dr. Bob Bell. I remember how his interests outside of medicine were very broad, including hunting and fishing, water skiing, sailing, playing cards, singing in the choir, enjoying art, etc. Dr. Bell and his wife Phyllis gave me a sense of how a superb physician family can enjoy and savor every moment of life.
I watched Dr. Karl Wegner, a Pathologist, lecturer, and the first dean of our South Dakota Medical School, as he taught through empathy. I remember how he made every one of his students feel like he was speaking directly to him or her. Dr. Wegner gave me a sense of how a superb physician values the other guy.
I watched Dr. Joe Hardison, an Internist at the VA hospital in Decatur, Georgia, whose diagnostic acumen and skills were famous among residents. I remember how he cleverly examined his patients, looking for subtle clues that would allow him to make a correct diagnosis. Dr. Hardison gave me a sense of how a superb physician uses her or his senses and brain to make a diagnosis.
I watched Dr. Keller, a cancer specialist at Emory Hospital in Atlanta, whose caring way remarkably helped cancer patients deal and cope with incredibly ominous conditions. I remember how he confidently listened and spoke with consoling words and eyes to those with widely spread cancer. Dr. Keller gave me a sense of how a superb, compassionate, physician gives relief and exemplifies medical ethics in action.
And I watched Dr. Bob Talley, a Cardiologist and former Dean of USD Sanford School of Medicine, whose concern for students and residents elevated our medical school to the some of the highest standards of training in the country. A specific example is how he helped mold a new method of integrated training in South Dakota, which Harvard has since copied, and which is also catching on throughout the country (our present Dean, Dr. Mary Nettleman is following through and expanding on this wonderful direction). Dr. Tally gave me a sense of how a superb physician, one who concentrates with all of his soul on helping young physicians learn, can result in an elevated quality of care by administered by his students to patients around the world.
We only learn from and teach by example.
The first day I met Amiel Redfish, Physician Assistant, in 1990. We discussed medical issues of our modern society and how stepwise improvements in longevity came with proper sanitation, clean water, and the discovery of antibiotics. I liked this man right away, this Amiel Redfish. Through the years, I’ve heard Amiel give wise council about many issues, recently about the value of eating a hunter-gatherer’s diet with more roots, vegetables, berries, fruit, eggs, and wild game meat. So impressive!
My colleague was taught traditional Indian medicine followed by formal medical physician assistant training. He’s a treasure, a true Sioux Indian Medicine-Man. However, despite the sagacity, insight, and traditional perspective he represents, I dare say there are those who, not knowing him, would look at his original American Indian features and prejudge him. Prejudice leads to prejudging—making an opinion about another individual using preconceived notions, coming to an opinion about someone before one has the facts. Typical prejudices are often parentally taught and are about perceived differences in race, gender, gender identity, nationality, social status, religious affiliation, age, disability, height, and weight.
Anthropologists speculate that, at one time, stereotyping or prejudice probably provided a survival advantage. In an unpoliced society, people were safer trusting only their family and their known community, while being careful with outsiders who looked different. 100,000 to 10,000 years ago, people not belonging to our tribe were more likely to cause us harm, and all this became hard wired into our middle brain. However, in this modern era, it is reversed; we are more likely to be murdered by family member than by outsiders.
Other research suggests that treating people with respect and not prejudging them by appearance allows an openness to operate and churns the wheels of commerce, community, and communication. Indeed, Martin Luther King Jr.’s communication rings true for all good people when he said “I have a dream that my four little children will one day live in a nation where they will not be judged by the color of their skin but by the content of their character.” That should go for all children of every color. Since our daughter is of Asian heritage, King’s statement has particular meaning for me and my family.
It is nice to find research which proves that those who break free of prejudicial stereotyping profit from it. It’s nice, too, to make friends . . . friends like Amiel Redfish.
Research tells us that regardless your age, exercising just 30 minutes daily of even mild to moderate walking increases energy levels, improves mood, and actually increases longevity. I submit that doing this outside is even better, weather permitting. Of course, on the northern high plains, sometimes the weather forces us to an indoor gym or to the personal exercise machine in the basement to get activity, but that’s OK too.
However, when we can, we should get out of the igloo and do our exercise outside. When the sun’s rays come pouring through our pupils, they not only give us vitamin D to strengthen our bones, but those rays tell our brains that we are alive. The views we see of the outside clue us into the changing cycle-rhythm of the day and season, prevent that seasonal affective disorder, and provide for a sense of a spiritual light of hope. Going outside, when possible, is very good for us.
Better yet, getting outside in South Dakota every season of the year makes the modern adventurer realize why they call this the “Land of Infinite Variety”. I especially relish my daily one-mile round trip walking trek to my morning café for breakfast and coffee (even in inclement weather when I have to put on boots and get all bundled up in my hooded 40 below winter coat). That said, there are many pleasant days in South Dakota throughout all four seasons.
I have wonderful memories of enjoying the outside in South Dakota. These include Black Hills riding snow-mobiles, down-hill skiing, and steep hill hiking to the summit of Black Elk’s Peak; spring and fall hiking through Oakwood Lakes and Lake Poinsett State Parks; sailing in the yearly Lake Poinsett Sailing Regatta; road biking through and around our community of Brookings; east and west river pheasant and deer hunting with friends; working in my vegetable and pepper garden; and walking or running some distance almost EVERY DAY for the last 40 years.
Take it from an experienced physician who has lived here for 57 out of his 69 years and who thinks he’s seen it all. Nothing comes close to improving one’s emotional and physical health than being an active interested person who gets outside and savors all four seasons on the northern high plains land of infinite variety.
Facing my own pancreatic cancer, I have read a few books recently recommended by friends who are lovingly trying to comfort me. A book written by neurosurgeon Eben Alexander, MD has been one of those stories that talks about a “near death experience” (NDE). Alexander developed bacterial meningitis and, during a seven-day coma experienced a NDE like others. He found himself drawn to a warm light while sensing tremendous reassuring comfort. A former skeptic of these stories, he has become a fervent advocate that these experiences (NDE) are evidence for God and Heaven. His final chapters discuss how inadequate science is in explaining consciousness and suggests that each of us is “more than our physical body.”
Throughout the ages, some of the greatest minds in the universe have addressed the question “what is consciousness?” From what source does our awareness come? Where does God fit into that question? Alexander states that “. . . the greatest clue to the reality of the spiritual realm is the profound mystery of our conscious existence.”
As a physician who has practiced for many years, I have tried my best to use evidence-based science to guide me in choosing the best diagnostic and therapeutic options for my patients. I define medical science as a search for truth using double-blinded studies that avoid the placebo effect and preconceived biases. As science advances, we are continuously improving what we can do for people. For example, we can now cure certain cancers that twenty years ago would have killed those affected. We can now relieve suffering from severe heartburn, from shortness of breath, from a heart that races, and from unrelenting depression. I am forever enthused and amazed by the continuous improvements in medicine that keep unrolling with proper use of the scientific method.
However, with all of our “method”, science has not been able to answer the consciousness question, the spiritual connectedness we can feel toward each other, the question about life after death, and the love and acceptance that many of us sense coming from God or another higher power. I agree with the neurosurgeon: answers to these questions must come, not from science, but from another place.
I love our home in Brookings, SD. When anyone asks me where I am from, instead of saying my home of 37 years, I almost always answer that I grew up in the sweet town of De Smet where I attended twelve years of school. Emotional and physical health starts in the community in which we were raised.
Many people take a lot of pride in being from that little town and much of that is from its history. Back then, within the library and the local Masonic Lodge, there were several original oil paintings by Harvey Dunn the famous painter and illustrator. It’s neat that De Smet has a connection to such a famous artist.
However, it’s most significant notoriety comes from the Laura Ingalls Wilder books because De Smet is the Little Town on the Prairie. Laura’s tales of growing up in the late 1800s in a pioneer town are famous throughout the world. Her clearly written words tell how those of European ancestry first moved and homesteaded onto American Indian land of the Minnesota and Dakota prairie. In particular, her book The Long Winter illustrates how challenging the conditions could be on the winter prairie, and how settlers (and Indians) had to be tough as nails to survive and thrive.
History is important, but the continued thriving character of present day De Smet is the result of the myriad of activities occurring in the community. For example, Old Settler’s Day is De Smet’s summer festival, usually taking place on June 10th, has parades, tractor pulling, (and a carnival that used to come to town). I remember, as an eight-year-old, thinking that June 10th was almost better than Christmas. It was a surprise and disappointment to my young self when I found out, one day, that June 10th wasn’t celebrated everywhere as it was in De Smet. I was not quite correct, however; South Dakota is abundant with similar community summer planting or harvest festivals.
Of course, most important are the lifetime friendships that develop in these communities. I remember joining with other families during holiday meals, celebrations and funerals, and even sitting around family campfires. There was sledding, camping, and canoeing with the Boy Scouts; hayrides, roller skating, dances, and rock and roll music; football, basketball games, track meets, talent contests, and many band and choir performances; and there was church.
Innumerable studies show how such social and community connections are related to enhancing the overall health of individuals. How lucky and healthy can a guy be, growing up in a little town on the prairie!
More than 3.5 million people in the U.S. are legally blind or visually impaired. Approximately 21 million Americans have some eye condition that compromises their vision, and many of these problems could have been prevented.
Mrs. E., who lived well into her 90s, would regularly come into my office years before her death, never complaining about her age-related macular degeneration (AMD). However, the diagnosis was obvious to me because, when she stared at my face, she would do so by looking a foot to the left of my nose. Since the AMD had destroyed her central vision, she used her peripheral vision to see. AMD is the most common cause of blindness in the elderly and we know it occurs in certain families, in races with lighter complexions, and in heavy smokers. Mrs. E. was a heavy smoker.
Glaucoma is another blinding eye condition, but unlike AMD, the peripheral vision is lost, and the central vision is spared. This gradual and painless loss of vision is due to injury of the optic nerve and is commonly the result of increased fluid pressure within the eye ball. However, glaucoma can occur in people with normal pressure, and it might not occur in people with increased pressure. About 2.5 million Americans have been diagnosed with glaucoma, and another 2 million don’t know they have it. If diagnosed, treatment helps.
Diabetic retinopathy is more common than AMD or glaucoma, with more than 5.5 million Americans affected. Diabetes causes new, tiny, and unfortunately very fragile, blood vessels to develop on the retina, and when these delicate blood vessels bleed, they cause swelling, scarring, and progressively spotty vision loss. If caught early, treatment helps.
Cataracts, which is the clouding of the lens of the eye, affects more than 22 million Americans and is the leading cause of blindness in the world. This condition is noted more commonly in obese or hypertensive people, in certain families, in diabetics, after excessive exposure to the sun and ultraviolet light, following eye surgery, in heavy smokers and drinkers, and following the use of steroids, estrogen therapy, or statin medications. Preventive methods and cataract surgery help.
For most of these eye conditions, there are methods to treat or prevent the blinding consequences, yet many people do not have regular eye exams. The message is staring you in your face, or perhaps a foot to the left of your nose. Get your eyes checked.
Thinking about bone fractures brings up an old English children’s rhyme. “Sticks and stones may break my bones, but words will never hurt me.” This ancient phrase has supplied many a verbally abused child with clever words in defense from a bully. I wondered if this old saying had an interesting history, but found nothing about its early beginning on the internet. The first written record of the phrase was in an English book authored in 1830 with the words “golden sticks and stones.” Later in 1862 the words, that are used now, popped up in a U.S. magazine printed by the African Methodist Episcopal Church.
Close to 15 million fractures occur yearly in the U.S. from various causes, mostly from falling and more rarely from sticks and stones. It’s intriguing to examine how a fractured bone heals. When a single bone breaks, there becomes two parts with the rough edges of the fracture held loosely together by muscle and soft tissue. Bleeding into the fracture site is a necessary step for healing since the blood clot that forms around the break initiates inflammation (redness, pain, swelling, and heat). Inflammation tells the body to avoid movement, stimulates new blood vessels to increase blood flow to the area, and calls in white blood cells to fight infection and clean up destroyed tissue and cells.
Over the first week or two after the fracture, stem cells are drawn in to help. They turn into cartilage-making cells and replace the blood clot with an early and soft cartilage. This material is sticky and if the bones are not yet reconnected, the gummy and adhesive cartilage helps them re-join and then binds the bones together. This soft callus hardens over the next couple of weeks, stem cells turn into bone making cells, and new bone tissue starts filling in.
Given proper nutrition, immobilization of the fracture, and enough time, bones will completely heal, even in very old persons. I believe it is a slow and constant miracle how our bodies are always and everywhere healing, repairing, and even replacing themselves from birth unto death.
Back to the children’s rhyme, “sticks and stones . . .” Isn’t it true that sometimes hurtful words cause broken hearts that never mend? Perhaps we should learn from the grace and speed of healing bones and let go of those hurtful words, forgive, reconcile, and heal.
Economists often explain high health care costs by comparing the selection of food at the grocery store when someone else is paying. The analogy still works but with a twist. Reported in a recent medical journal, Harvard researchers looked at health care spending here in the U.S. compared to the 10 next highest income countries of the world. They found that, in 2016, we spent almost 18% of our gross domestic product (GDP) on health care. Spending was much less for other countries, ranging from about 9.5% in Switzerland to 12.5% in Australia. That’s a significant difference!
Most surprising was that the problem in the U.S. did NOT appear to be from overutilization (getting too much care) as many have previously thought. Overall, people in the U.S. saw the doctor and were sent to the hospital about as frequently as people from other nations. The quality of the care received was also comparable. The study group also noted that our ratio of primary care doctors to specialists was similar, as were the number of specialist referral rates. The study found that, in the U.S., there was an overuse of expensive image testing and many more specific surgical procedures (60% more CT scans performed than the average of the other countries; 45% more MRIs; 38% more total knee replacements; and 32% more C-sections). Still, these accounted for only a small part of the large difference in spending. This was partly because, in the U.S., we sent people home from the hospital a little sooner than in other countries.
The rate of poverty was found to be higher in the U.S. than in other wealthy nations, and only 90% of our people were insured compared to 99-100% in all the other 10 countries. Those are big problems and could partially explain the high cost of health care here. However, the research suggested that higher U.S. health care spending stems mostly from the complexity of our payment system. This has resulted in high U.S. administrative costs (8% GDP vs. 3%), the higher price of hospitalizations, procedures, doctor visits, as well as the price of drugs. For every U.S. dollar equivalent Europeans spent on drugs, we spent $2.50 for the same drugs. For every dollar equivalent Europeans spent on angiograms, we spent $5.25 for the same procedure. Going after overutilization will likely not help much. It’s the price of things that matters the most.
It would be like going to your grocery store and finding the cost of milk is more than twice as high as the store on the other side of town, because payment for milk here comes NOT from you, the consumer, but rather after bargaining between your employer, their chosen insurance company, the government, the dairy, and the grocery store. It’s time to simplify!