wisdom

THE SMARTEST GUY “He’s so smart, I didn’t understand a word he said.”

Editor’s Note: Due to my ability to type really fast, one of my first jobs was to use the Dictaphone at my dad’s office to type information dictated by the psychiatrists. I would use my foot to press the peddle that played the tape and type along as they spoke. I typed letters to consulting physicians and articles they wrote for publications. I remember being surprised at my dad’s vast vocabulary. He certainly didn’t use those fancy words in the office or at home. When I discussed this perplexing issue with my dad, I learned two lessons that have stuck with me my entire life. 1) Don’t use a dollar word when a dime one will do. 2) Know your audience and communicate in the language they speak. One of our running family quotes is part of this blog post: “Doc, he was so smart I didn’t understand a word he said.”

THE SMARTEST GUY 
My Grandson gave me an interesting book for Christmas. This is not a book review so the title is not important. Suffice it to say, it has to do with some theological issues which he and I had discussed in the past, and in particular a “doubting Thomas” streak owned by me. There was much food for thought, some of which was not very digestible.
The author was obviously well read as there were 53 pages of references cited. It was well written; although I found some of the reasoning a bit convoluted. It was a tedious read for me, but I must confess that I also have trouble deciphering the Bible. All of the quotes the author offered throughout the book often added to my confusion. I am sure those guys are all very famous; however I had never heard of most of them. The author would make his point then throw in a “in the words of……….” which was not nearly as coherent as his original statement. Perhaps he was only paying homage to the experts in his field, but I was impressed that he must be a speed reader to have read all that stuff. I was also surprised to learn that Christianity could be so complicated. 
As I read the book, I was reminded of an experience from many years ago. I was seeing a patient for the first time. His was a chronic, although not disabling condition, which had been exacerbated by the unexpected death of his psychiatrist. He talked warmly of his feelings for the deceased, and shared that he missed his counsel. He also spoke of his respect for the man’s intelligence with: “Dr………. was the smartest man I ever knew. He was so smart that when he said something I couldn’t understand a word he said.”
Now all these years later, I can identify with this patient’s assessment of the good doctor’s intelligence for some of the guys quoted in the aforementioned book were much too smart for me to understand. You may be thinking that the alternate explanation might be that I am too stupid to understand, a conclusion that I am loath to accept. After all, I did manage to limp through 24 years of school even though my scholastic career was admittedly undistinguished. My mother proudly said that I knew my ABCs, and could count to 100 by the time I entered the first grade. I have a vivid memory of my father showing my third grade report card to everyone in Varner’s store who would look. Even though this was the first and last time he would be able to exhibit a report card with all A’s, I feel it should count for something. 
There is the possibility of another less flattering explanation, which could help explain the comprehension problem. I have a friend whom I have always admired for his scholarship. His writings demonstrate a vast knowledge of classical literature, history, philosophy and classical music. He is also a veritable expert in psychoanalytic theory. His writings make use of metaphor and relevant quotes. Imagine my surprise when in my confessions of envy for his use of all this knowledge in his writings, his wife responded, “I think it is just showing off.” Perhaps she was having a bad day or he had forgotten to take out the trash, for she has shown her love for him in many ways during the many years they have been together.
The comment by my friend’s spouse does raise the question as to whether our writings are often more about ourselves than the subject about which we are writing. Could it be that sometimes the message intended may be corrupted by our ego needs? How much of the motivation of this author’s writings were motivated by a need to “show off”? For that matter does that same dynamic have anything to do with my writing of this paper. I have often said in jest that I would like to be rich and famous. Since the former has escaped me, perhaps I am still holding out for the latter. But then I have also had fantasies of winning the $1.5 billion power ball thing; even though I have never bought a ticket. 

When I was a kid we sometimes perpetrated cruel party jokes designed to humiliate and embarrass. One such stunt involved telling a joke with a nonsense punch line. The group who was in on the joke would laugh loudly, and the butt of the joke would join in the laughter even though there was nothing remotely funny. We called such tactics “shaggy dog stories.” I must admit there are times when I feel I have nodded in agreement with someone when I had no idea what they were talking about, much as the patient who idolized his dead psychiatrist must have done. 
There are times when reading something that is clearly beyond my abilities to grasp, I wonder if I am the victim of a shaggy dog story, and that the author is having a good laugh at my expense. The most recent example is my attempt to wade through a book on quantum mechanics. I was humbled by my inability to make any sense of that stuff. Upon learning that the book was written for ordinary people like myself left my ego was left in shreds. This was not Greek to me. It was more like a mixture of Mandarin Chinese, Arabic and Apache indian. What I could decipher was so implausible that I found myself thinking “can this person be serious?” and again wondering if this was not a variation on the shaggy dog theme. 
It has been said the best defense against Alzheimer’s and similar dementias is to make liberal use one’s brain. All intellectual pursuits are encouraged, but I have noted that this can clearly be overdone. I submit that a brain can also become fatigued; consequently, I will now put down my book on particle physics, fire up my kindle, and escape to a mindless mystery novel. 

HEALTHCARE GOES DIGITAL

HEALTHCARE GOES DIGITAL
In my last blog, I promised to delight you with my observations about the Electronic Medical Record (EMR). In accordance with the current custom of using anachronisms rather than words in the medical literature, I will henceforth use the term EMR in my discussion of the topic. Since early on in its development the computer has contributed much to medicine. Without it the various scanners routinely used to make instant diagnoses could not have been developed. It has become an essential tool in medical research. Without computers what many believe was the most important medical discovery of the century, namely the unraveling of the complexities of the human genome could not have happened. One can hardly imagine any area of medicine that has not been influenced by the so called digital age.

Considering all this, it is little wonder that the computer would eventually be touted as the answer to all the problems said to exist in the delivery of healthcare in the United States. The promise was that it would: 1) save money, 2) reduce errors, and 3) improve outcomes. The stick that The Department of Health and Human Services used to encourage adoption of EMRs was to penalize those non-compliant by reducing their reimbursement rates.
1) SAVE MONEY (?)
It is a bit difficult to imagine there could be significant savings when one considers the cost of the initiation and ongoing support for these systems. One study estimates the initial cost of a five physician group to set up a system to be $233,000, not taking into account an average of 600 hours needed for training in its use. Following the initial investment it is estimated maintenance costs would average $17,000 per year. Since the costs for a solo practitioner would obviously be higher, it is not surprising that many such individualists are either retiring, joining a group, or taking a salaried position.

1) SAVE MONEY (continued) / Too many zeros…
But physicians’ costs are chickenfeed compared to the costs of hospital computer systems. Perhaps the most outlandish was the $4 billion spent by Kaiser Permanente. They report however that this will result in a cost of only $444.00 per each of their insured. This came after an admitted $300,000 dollars was spent on a previous plan which was abandoned. The interviewee, CIO Philip Fasano, insists that the $4 billion expended for the current plan is well spent as he believes it will save 15 to 17 percent of costs by eliminating duplicate testing. It will be interesting to see if such savings will result in a reduction of premiums. In addition to the price paid by hospitals and physicians to set up and maintain EMRs, there is the $30 billion spent by the feds on these projects. In my research on this subject I did come upon more numbers, but by then I was so busy counting zeros that I became too dizzy to record them.

2) REDUCE MEDICAL ERRORS ?
As for the reduction in medical errors, the most obvious benefit accrues from the virtual elimination of handwritten orders, reports, prescriptions etc. From personal experience I can attest these are often illegible, and consequently subject to interpretation. Some may insist that poor handwriting is a prerequisite for graduation from medical school. If that is true, then I have been imminently qualified as penmanship was not my strong suite in first grade and it has gone downhill from there. In spite of the problems associated with writing, verbal orders and reports carry an even greater risk of miscommunication. It has been demonstrated time and again that the more steps through which information passes, the greater the likelihood of error.

2) REDUCE MEDICAL ERRORS / The disconnect between theory and application
When information is communicated digitally, it follows there should be fewer errors. If such information can be delivered automatically the risk should be even less. For example, hospital laboratories are largely automated these days, and it follows that if a machine delivers its report seamlessly i.e. without touching human hands it should be less likely to be misread, misplaced, or ascribed to the wrong patient. Unfortunately, Erin McCann of Healthcare IT reports that in a nationwide study 74% of nurses reported feeling burdened by the need to do data entry, which took time away from patient care. The impression left is that much data must be entered manually; consequently most systems are anything but seamless, and therefore still subject to error.

It is easy to imagine the scenario in which a patient’s electronic medical record could be lifesaving. For example, when an unconscious patient is brought to an emergency room his medical record may be critical in making a diagnosis in situations where time may be literally a matter of life and death. As a matter of fact there are many situations when the instantaneous availability of a patient’s record may save time, unnecessary tests, and even lives. It should no longer be necessary to spend time in hospital record rooms or doctor’s offices copying records, x-rays, scans and such. Not only written reports, but actual copies of films, EKGs and such could be called up in order to see if changes have occurred. Come to think of it, there would be no need for record rooms or the floor to ceiling racks stuffed with file folders we see in our doctor’s offices. Yes, in a perfect digital world Joe Patient would carry his entire medical record with him wherever he went and it would be accessible whenever needed, but anyone who owns a computer knows that we are some distance from perfection when it comes to this computer stuff (more about that later).

3) BETTER OUTCOMES ?
The third premise that EMR would create “better outcomes” is still up for grabs. It is noteworthy that, according to a report in FiercehealthIT, 17% of physicians surveyed thought EMRs actually worsened patient care. One might be led to think this group would consist mostly of old digitally challenged physicians like myself, but the disturbing fact is that the number of negative comments has increased since 2012.

According to a Patrick Caldwell piece in Mother Jones5, 75.5% of hospitals were using EMR programs by 2014, but I am not aware of any indications that quality of medical care has improved. Indeed, I don’t know if it would be possible to do such an assessment of an issue that complex. He goes on to issue a scathing report on the business practices of competing providers of EMR software. He contends that the various programs do not share information with each other in order to protect company secrets. This would prevent the seamless passage of information unless all his healthcare providers subscribe to the same system thus defeating a major purpose of the program. Thus Joe’s record would only be available to a consulting doctor or hospital ER if they subscribed to the same version as did Joe’s regular physician. Peter Pronovost MD, director for patient safety and quality at Johns Hopkins, was likewise critical with his statement that: “Medicine invests heavily in medical technology, yet the promised improvement in patient safety and productivity has not been realized.”
EMRs and Me
My own brief experience with an EMR tends to validate the premise that interoperability is a problem. When a facility where I was working adopted a program, I was able to sufficiently overcome my age related aversiveness to change and make a half-hearted attempt at compliance. I tried to hone my deficient typing skills (we had no typing classes in medical school), and dutifully began typing check marks in the boxes provided, which often resulted in a great deal of useless information. There were some advantages, such as the ability to send prescriptions on line rather than writing them on paper or calling the pharmacy. In addition to the convenience for both myself and my patients, it solved my penmanship problem, reduced errors, and prevented forged or altered prescriptions.

Maybe this EMR thing will work after all
With that in mind, I was heartened by the news that our local hospital was going digital. We were dependent upon the hospital’s psychiatric department as a place to send our patients who needed intensive treatment, and for the psychiatric department’s extensive outpatient diagnostic capabilities. I had visions of entering my patients’ identifying numbers in the computer and instantly being privy to every bit of medical information about him. No longer would nurses spend time on the phone calling about lab work, or waiting for the record room to respond to requests for discharge summaries, or reports from consults. The fax machine would no longer go through a ream of paper every couple of days. I would no longer be accused of nurse abuse because of questions like: “Where in the hell did you put that lab work?” As some of my younger, more verbal patients would say: “Dream on baby!” For as computer geeks would say their system was incompatible with ours (in plain speak, their system would not talk to ours) and we were forced to continue to rely on that older, but more reliable invention called the telephone.

Is our healthcare system broken?
The statistics available seem to confirm the premise that the U.S. healthcare system is broken. In an interview by PBS, Mark Pearson the head of the health policy division of the Organization for Economic Co-operation and Development (OECD) provided some discouraging statistics. Politicians have long trumpeted the fact that we spend over 17% of the gross national product (GNP) on healthcare, which is second only to defense spending.
Healthcare by the numbers
Pearson reported that we spent $8,233 dollars per person in 2010, which was two and a half times more than the average per person cost in 33 other developed countries. The average cost for a hospital stay in the U.S. is $18,000 which is three times that of the other countries, in spite of the fact that hospital stays were shorter in the U.S. The Commonwealth fund  reports that 25% of that cost is for administration. Drug prices in other countries are sometimes less than half the price we pay, in spite of the fact that the majority of new medications are developed in the U.S., often with financial support from the National Institute of Health. Of course the drug companies also get some help from their friends in congress who have without apology passed a law forbidding Medicare from negotiating prices. Oh yes, just another example of the perverse golden rule of the corridors of power, namely: “those with the gold make the rules.”

What are we getting for all this money?
After digesting all this information, you may be asking, what am I getting for all this money? The answer: not much. There is no doubt that we lead the world in medical research, and people come from all over the world to study in our institutions. We have been the absolute leader in the development of medical technology.  Then, why is my life expectancy over one year less than it is in 33 other countries? We might blame it on lifestyle, obesity and such, or could it be that our shortened hospital stays could have a deleterious effect?

Words matter, but true listening requires vision
Patients have complained to me that they are often told their doctor cannot see them in between appointments and they are told to go to the emergency room sometimes with even minor complaints. But the most frequently heard grievance was “my doctor doesn’t listen to me.” Not surprisingly, this was more commonly heard as the digital age invaded the consultation room and some physicians pecked away at their computers while the patient talked. Of course, there is much more to effective communication than the use of words, and no matter how attentive the listener, without visual cues much of the message is lost.
In my humble opinion, it is incredibly naïve to think that computerization could have a major effect in closing the gap between us and the OECD nations. After all we are undoubtedly ahead of them in implementing EMRs and management systems; consequently, any advantage gained would be countered as they would inevitably follow suit with similar technology. You may be asking what is the answer, if EMRs are not. I have long held the position that there is a shortage of medical doctors in this country, and OECD study tends to bear this out. They report the U.S. has 2.4 physicians per 1,000 people while the average for the countries scrutinized was 3.1 per 1,000. Thus we have fewer physicians, fewer hospitals, and shorter hospital stays at 2 ½ times the cost.

What we do have are more CT and MRI scanners along with lots of other expensive gadgets, and they are utilized much more frequently than in other countries. One disturbing bit of research by the Dartmouth Institute for Health Policy concludes there are very large differences in the rates of utilization of such diagnostic machines in different areas of the country.
Even more upsetting is their conclusions that the number of elective surgeries, cardiac interventions, and even open heart surgeries are all performed at vastly different rates in different areas of the country. Should we conclude from this that some areas of the country are over treated or that others are undertreated? Information obtained from the OECD study would suggest the former is likely true. Hospitals are required to have a utilization committee composed of physicians who look for outliers among their peers; however, in my experience they are not very effective in rooting out excesses.  Indeed, if they were one would not expect to see such disparities in diagnostic procedures and treatments.

Enter Managed Care
In recent years insurance companies’ managed care programs have gotten into the act. They exercise control by simply not paying for services they feel are excessive. I believe it is safe to say that they are universally hated by physicians. I share that feeling with more intensity than most of my colleagues because I blame them for the too early discharge of one of my patients which led to his death. It is interesting that the courts have ruled in such cases that the managed care company suffers no liability with the rationale that they are not denying treatment, only refusing to pay for it.

No doubt, many of the problems I have enumerated with The EMRs will be fixed eventually, and the concept can be of marvelous benefit, but it is also clear to me that computers will not fix everything that is wrong with our medical system.

So, what is the answer?
At this point, if you are still awake, you may be thinking: “OK wise guy, if you are so smart, what would you do about it?” And I would reply, “Thanks for asking for of course I have all the answers.” After all, I have been a participant and observer as medicine evolved into the current mess, besides I now have learned how to use Google.

The Age of Assembly Line Medicine
It may seem counterintuitive, but I am convinced that a significant part of the problem is due to a shortage of physicians. No, it is not merely a matter of competition although that is not necessarily a bad thing, rather it has to do with the pressure to be productive. Dealing with lives merits deliberation, and impulsive decision making is apt to lead to errors. The production processes of assembly line manufacturing Henry Ford developed may be advantageous for manufacturing cars, but completely inappropriate for treating human beings, especially those who are sick, in pain and in distress.

The lost art of LISTENING
One of my professors from medical school once said: “if you listen carefully to your patients they will make the diagnosis for you 80% of the time.” As I mentioned previously many of my patients complained that their doctor was not attentive, and always seemed in a hurry. Since there is a shortage of physicians, there will be a need to see more patients; consequently less time is made available to talk, and the doctor seems remote and uncaring. The patient may leave with unanswered questions and harboring a great deal of anger. When called upon to consult with hospitalized patients as a psychiatrist, I often found the problem to be the result of a doctor patient relationship gone bad. To the physician, the patient seemed unruly and uncooperative when they just didn’t feel they were being heard.

Litigation
Another downside of failed communication between a physician and patient is litigation. As a matter of fact, insurers report this scenario is a major cause of malpractice suits, and that the best protection from malpractice suits is a good doctor patient relationship. Of course the cost of these suits, which are less prevalent in other countries is also said to be a major cost factor. Some states have initiated procedures to help reduce the number of suits and to limit the amounts which could be paid; meanwhile refusing to search for reasons for why there are so many suits filed.

The Conundrum
A few years ago, after retiring from private practice, I began working part time at a public facility that had a very long waiting list of people needing to be seen. I was asked if I would be able see a patient every 10 minutes. I replied haughtily that I was not a prescription technician, yet afterward wondered how many of the people on that waiting list might be suicidal. These are the kinds of dilemmas facing doctors, especially those in primary care settings (i.e., if you spend adequate time with each patient, how many won’t be seen at all). In my small town, there are very few primary care physicians who are currently accepting new patients leaving many people to seek care at our ER which of course is much more expensive. The solution, which is currently underway, is to license those with lessor training to diagnose and treat. I am sure there is also the thought that these nurse practitioners, physician’s assistants and such will demand lower fees, although that may not have work out as expected. I also question the wisdom of solving the doctor shortage in this manner, especially during a time when the increasing complexities in medicine demand more knowledge than ever before.
Fee-based vs. appointment-based physicians
There is also, in my opinion, a maldistribution of physicians, with the shortage most acute among primary care doctors. Family doctors have always been the grunts in the healthcare domain, with the specialists commanding the most respect especially the surgical specialties. Those who do procedures are reimbursed based on a fee schedule while primary care docs are essentially paid based on time spent with the patient. This can lead to serious inequities in incomes. The days of the solo general practitioner are past, for most find they cannot generate enough income to pay their overhead. It requires a considerable staff to do billing, get authorizations from insurance companies, fill out forms, deal with managed care, medicare, medicaid, pharmacies etc. He is forced to accept insurance company fee schedules if he wants to be “on their panel”. Add his malpractice insurance to the mix and soon he will be looking for a salaried job or a group to join. Young doctors may be saddled with hundreds of thousands of dollars of student loan debt which can be a powerful motivator in choosing a career choice as he may look toward the more lucrative specialties.
Living History
In 1965, I had been doing general practice for a very few years and when medicare came in to being that year I was convinced that this was the beginning of the end, and Joe McCarthy was right when he said we were well on our way to being taken over by the communists. The precedent of connecting healthcare to employment had already become entrenched by corporations who used that fringe benefit to attract workers during the labor shortages of world war II, but in the 60s Blue Cross and Blue Shield were the only significant players and all that was necessary was to send a bill and receive payment. Of course it made no sense for health insurance to be tied to employment, but the labor unions were not about to give up that goody, and it remains in ObamaCare, which is one of the reasons why although better than nothing it is not by much.

Eating crow
Now, 50 years later, I have eaten so much crow that I regurgitate black feathers as I have become an unabashed promoter of a single payer system, that is medicare for everyone. Such an idea is certainly not new as it was first proposed by Teddy Roosevelt in 1912. I have dealt with a system that has become increasingly complex each year, and have done battle with giant corporations whose major function appears to be to find ways to deny treatment to those whom I feel are in need. I have this perhaps naïve view that with the insurance companies out of business and their lobbyists gone maybe our do nothing congress might do something beneficial for their constituents.

One frequently hears that socialized medicine would bankrupt the country due to the inevitable inefficiencies that would result. The reality is that medicare may be the only efficiently run federal program in existence with an administrative overhead of less than 3%. The affordable care act only allows health insurance companies 20% in administrative costs, whoopee. Of course this does not take into account the millions of dollars spent by hospitals and doctors which would be greatly simplified if they only had one entity with whom to deal. Even without taking this into account, we would reduce total health care costs by at least 15% if not more.

More savings could also accrue were congress to repeal that ridiculous law prohibiting medicare from negotiating drug prices. In addition to the effect on total costs, I find it repugnant that populations all over the world pay less than I do for my medications. This seems unlikely to change since Pharma seems to be especially adroit with their lobbying efforts. I would be very interested to hear from Congress their rationale for this law. It must be a dandy.
There is also the economic effect on businesses to be considered. Many industries report that providing health care for their employees is a rapidly rising expense that makes it difficult for them to compete internationally. One would think they would be busy lobbying for a single payer system. The digital movement in healthcare has spawned new departments in most institutions. In the mental health center where I had recently worked one person managed to keep all the computer stuff running, until the introduction of an EMR. It soon became necessary to hire 2 more people, and an IT department was born.

Longevity has its advantages, and in my case it has allowed me to witness and in a small way be part of the profession of medicine during a period of momentous discoveries. The 60 years of my involvement saw the virtual elimination of many illnesses which had been responsible for millions of deaths and untold suffering. When I began practicing medicine, if someone told me that it would one day be possible to transplant a human heart I would have laughed in their face. To confirm the suspicion of a brain tumor would require two or three days of tests some of which were dangerous, now an in depth picture of the brain is available in a matter of minutes. Even in my own field of psychiatry the study of the mechanisms underlying brain functions has revolutionized the field, and the complexities described often leave me wondering what the hell they are talking about. This paper is in no way meant to denigrate these accomplishments; rather it is an attempt to expose some of the factors which have resulted in an inefficient and costly system of providing them to the masses.

At the outset, I listed three goals that were hoped to be accomplished by the digitization of our medical records. The first was to decrease cost. From what I was able to glean from my research and personal experience I have concluded that the attainment of such a goal is unlikely. As for the other two, I am convinced that an all-encompassing computerized system has the potential to improve treatment outcomes and reduce errors. Unfortunately, the systems in play are too fragmented for that potential to be realized. It would appear that fixes are readily available. It remains to be seen if they will be applied.

Reminisces
As with most old guys I like to end my conversations with reminiscences of the good old days even though the current ones may be better. In spite of a lifetime in which I have witnessed the most exciting time ever in medicine, a time of more discoveries and progress made in the alleviation of suffering than had occurred in thousands of years, I sometimes feel nostalgic for the way things used to be even though without the miracles of modern medicine I would probably not be here today. I recall a time when the doctor patient relationship seemed much more personal than it does today, when doctors saw themselves as healers rather than fixers or technicians. I remember a time when one could even talk to one’s doctor on the phone. Now if I have a question for my doctor I must answer to the receptionist regarding my reason for calling, and if she considers it worthy of note, she will post a message to the doctor’s nurse or direct the call to the nurse’s voice mail, and if the nurse considers the question worth consideration she may consult with the doctor, but if not will devise her own answer. If she is not too busy, I may be fortunate enough to receive a call back with either the doctor’s or her answer to my question. In any event the doctor will be insulated from the stupid patient with his stupid questions. You might think that since I am a physician I would be more readily granted access, but you would be wrong for the fellowship of physicians is no longer a strong tradition.
How it used to work
I remember a time when most people had a personal physician, and usually their relationship was indeed personal. If admitted to the hospital your personal physician would see you daily even if he had referred you to a specialist, now you are apt to be followed by a hospitalist whom you are meeting for the first time. Were you to have surgery, your doctor would assist if possible. A visit to the emergency room would prompt a call to your doctor. If you were unable to come to his office, he would come to you. In short your doctor was in charge and responsible for your treatment. He would likely know your strengths, your weaknesses and usually knew most of the members of your family. In short the doctor patient relationship was very personal.

There have always been those dedicated to healing their fellow man even in prehistoric times and in the most primitive of cultures. Much of the science has been off track; however, there has been much learned about the art of medicine. It would be a great loss if that knowledge were abandoned in favor of purely digital solutions.
1. Health Affairs: Study puts a price on EMR implementation in small practices
2. Info World: tech’s bottom line May 2, 2013.
3. Healthcare IT News: Nurses blame interoperability woes for medical errors. March 15, 2015
4. FierceHealthIT: The cost benefit calculation of electronic health records systems.
5. Mother Jones: Epic Fail, November/December 2015.
6. PBS Newshour: Health Costs, How the U.S. compares with other countries October22,2012.
7. The Dartmouth Atlas of Healthcare: Reflections on Geographic Variations in Healthcare, May 12, 2010.

SUCCESS

carterThe other morning I awakened to a pleasant surprise. CNN had someone on the screen other than Donald Trump. Jimmy Carter was holding a news conference about his illness and plans for the future, a future that one could safely assume was rather limited since he acknowledged that he was about to undergo treatment for a melanoma with cerebral metastases.

As a cancer survivor myself (see: THE BIG C AND ME) I felt my admiration grow even more for this man who had always been my hero. This 91-year-old man of unshakable faith, showed no bitterness or self- pity, but was determined to carry on with his life’s work as long as he could function. His response to questions about how he felt about his illness was typical Jimmy Carter: “I will hope for the best and accept what comes.”
As I considered the accomplishments of this person who had come from inauspicious beginnings as a peanut farmer in a small town in Georgia, a feeling of awe came over me. As a young man he left the small town of his childhood to attend Annapolis, bent on a career in the Navy. Subsequent to that, he attained an engineering degree and was involved with Admiral Rickover in the development of nuclear submarines. After returning home, he not only was elected governor of his state and then to the highest office in the land, but won a Nobel Peace Prize after negotiating a treaty between Israel and Egypt that may have saved thousands of lives. It would also seem unlikely that a son of the deep south would become an outspoken foe of bigotry and a strong supporter of human rights throughout the world, but he did. A failed attempt to rescue American hostages in Iran is said to be responsible for his defeat for a second term as president.

Mr. Carter’s presidency was labeled by many as a failure, and his many achievements in economic and foreign policies have been largely ignored. His integrity however has never been challenged. His fulfillment of his promises to “never tell a lie” and to “never avoid a controversial issue” did not enhance his popularity, for as any successful politician will admit, truth telling is not a winning strategy in the political arena. His successor however could have used the tune “don’t worry, be happy” as his theme song.

The loss of his presidency would prove to be the beginning of even greater exploits. Most ex-presidents build libraries which are more like monuments to themselves. They seem to be very concerned about their legacy, which shouldn’t surprise us, after all those with weak egos are unlikely to ever make it to the top spot. Mr. Carter; however, used his monument as a platform on which to establish a center to “wage peace, fight disease, and build hope.” He did confess in his news conference that he has cut back his schedule somewhat, but still plans to remain involved in The Carter Center’s operation. When asked about his most fervent wish, he replied “to outlive the last guinea worm.” For those not familiar, the guinea worm has been a prevalent cause of much suffering throughout many parts of the world and has been almost totally eliminated through the efforts of the Carter Center.

Not only was I impressed with his vigor and enthusiasm, but by his abiding concern for issues he obviously considered more important than his own. Now I ask you, how could you not love a guy like that? For me, listening to him was very emotional. I experienced an intense feeling* of respect. A few days later, a grandson happened to be visiting and we were discussing my blog. As reigning patriarch, I have issued a hard and fast rule that all family members must read this stuff whether they like it or not. Accolades are appreciated, but not required. On the other hand, those who are critical should expect to move down a notch or two on the Christmas gift list. After successfully passing the quiz on the contents of my last blog (although not a fan of Ronald Reagan, I do subscribe to the trust but verify policy) he went on to suggest that I do an essay on success.
Since both my grandsons are beginning their senior year in college, I could understand why such a topic might be on their minds. I also felt the topic particularly serendipitous due to my recent encounter with Jimmy Carter. An analysis of his career brings up the problem of defining exactly what we mean by the word success, and how do we make that judgment? What do we mean when we say a person is a success or a failure? Does it make any sense to make such all encompassing judgments about people since the inconsistent conclusions arrived at by those who are judging would seem to prove that such distinctions are quite subjective. Is success like many other things in life in the eye of the beholder?

There generally seems to be a consensus that Carter was the most successful ex-president in our history, but the agreement ends there. As to the rest of his life, there are those who applaud and those who consider him a failure in many ways. One could say that his political career was a mixed bag. He lost his first bid for governor of Georgia, and his Camp-David_wareelection for president. His presidency was mired by so called “stagflation” for which he was blamed by some while others gave him credit for initiating policies that got the economy back on track. I believe most historians would agree that the negotiated peace treaty between Israel and Egypt was his most laudable success. In spite of this, he was accused of anti-Semitism for his book on Israeli politics: “Palestine Peace not Apartheid” in which he presented the Palestinian side of the story.

With this in mind one must conclude that the distinction between success and failure very much depends upon one’s values. Those of us of a more liberal position are more likely to judge Mr. Carter as a successful person than those of a different political persuasion. Our success in competitive activities such as sports can be more easily determined by winning. We also have developed tools, even though crude, to help us measure academic success. In business, success is generally measured in terms of profits generated, but we have no way to assess the most important facets of life such as honor, compassion, fidelity, fairness, integrity, parenting, and citizenship to mention a few.

The term success is usually viewed favorably by society, but can also have negative connotations. The most succinct definition I could find was “the accomplishment of an aim or purpose”. Obviously if that goal is nefarious in nature the accomplishment will not be viewed in a positive light. For example there are successful criminals, con-artists, and other asocial people. There may also be an issue with the means of accomplishing the desired goal. There may be not only illegal but unethical factors contributing to an individual’s success. Unfortunately such behaviors are many times ignored as successful people are often idealized.

Is the Key to Success Linked to the Courage to Fail?

With all this in mind I have come to the conclusion that each individual is the only one who can judge his success. Of course we need to set goals if we want to be successful in reaching them, but if the goal is to leap tall buildings in a single bound our chances of success are diminished. I have known people who are reluctant to set goals for themselves presumably due to fear of failure. I can only assume their life must be very boring. Success requires risk, and one must be prepared to accept failure for in spite of our best efforts we will not always succeed. It is said that many of the most successful people throughout history have had multiple failures prior to achieving their goals. In my own case, although I have never aspired to lofty goals, I figure my success rate to be about one success for every 10 failures. It is therefore logical that success usually requires a certain amount of determination, and the ability to not be dissuaded by failure. It also lends credence to the age old admonition: “If at first you don’t succeed, try try again.”

Flexibility in interpreting results may also be helpful. At times it may be necessary to revise or reframe one’s expectations. There may be unintended consequences of reaching one’s goal which may exceed or diminish expectations. If a goal is not attainable, it may be possible to modify it in such a manner that one can still enjoy the feeling of success. I have a brilliant close friend and colleague who has written much about psychiatry both for lay and scientific consumption, most of which has remained unpublished. I sense that he thus feels as if he is a failure even when I point out to him that he has been successful in producing thoughtful extremely well written material, and further remind him that his judgment is at least as good as the editors who reject his writings. It is always dangerous to allow someone else to be in charge of one’s self-esteem.
Most successes go unnoticed so it is important that we acknowledge our successes to ourselves. Patting oneself on the back does not necessarily denote arrogance, and will help us develop the confidence needed to pursue more successes. Failure sucks, but even an occasional success will rid us of that feeling. Mankind has undoubtedly been motivated by the search for that feeling one associates with reaching a goal.
At this point in my blogging career, I find it necessary to modify my goals for success. I have come to accept that my writings will not be appearing in the New York times, be going viral or be considered for a Pulitzer Prize; consequently my quest for fame and fortune must end. To that end, I will reread this thing and convince myself that it is worth reading, and crown myself a success.

*One of my friends who reads this stuff has questioned my definition of respect as a “feeling” in my last blog . The highlighted word is for her.

Separation Anxiety + Mental Health

LincolnLincoln is a very large black Labrador retriever, who has bonded to my son-in-law. Bonded does not adequately describe this relationship for it is as if Lincoln is attached to Jim by a very short invisible rope. Recently, during a visit to my daughter’s home I had the opportunity to witness a hilarious demonstration of this attachment. Jim was mowing his yard with Lincoln at his heels, and when he turned to push the mower in the opposite direction Lincoln followed. This continued with Lincoln following back and forth until the job was done. In a similar manner, he is rarely separated by more than a few feet from his master. When Jim leaves he is frantic, constantly watching the door, pacing back and forth, obviously quite agitated. Lincoln would seem to be the poster child (excuse me, poster dog) for the diagnosis of separation anxiety.

According to the ASPCA web site, the condition is not uncommon among dogs, and is most common among those rescued from kennels, and those who have been moved or have lost their major guardian. In other words, it seems that dogs know when they have a good deal and worry that they might lose it. Lincoln fits that category as he had been given up by his family and given to Jim. Watching Lincoln started me wondering if we humans are all that much different from him.

Most of us can recall at least one incident when we experienced “homesickness.” In my own case I remember vividly very intense feelings when left to stay with my Grandparents.   I never have been able to find words to adequately describe those feelings, but have likened it to a kind of psychological amputation in that a part of one’s self is missing. Those who have experienced it will understand how painful it can be.

Leaving for college is a common precipitant for it represents an abrupt breaking of many of the bonds attached to things familiar and to those upon whom we are dependent. My youngest daughter Maggie (currently my editor and the one who bears total responsibility for talking me into writing all this stuff) was the most memorable example of this phenomenon; although, her siblings also experienced it to some degree. Maggie was eager to fly away from the confines of a boring small town to gain freedom from parents who continued to treat her as if she were a child and to subject her to all kinds of stupid rules. As a matter of fact she was so convinced that geography would be the solution to her discontent that she refused to consider any school within her home state.

The vision of that skinny little girl surrounded by huge limestone buildings gently sobbing and feebly waving a goodbye as we pulled out of that parking lot has never left me. Little did she know the effects her mother and I felt from that poignant scene, for we were heading home to an empty nest. Nothing would ever be the same. Maggie was a prime example of the wisdom of the admonition that one should be careful what he/she wishes. She lost nearly 20 pounds during her first two weeks, and was barely able to function according to her roommate who called us to express her concern. Barb and I resisted our impulse to go save her from this horrible fate, and as one would expect she soon had a spontaneous remission, and went on to excel.

Homesickness vs. Separation Anxiety Disorder

What Lincoln and Maggie have in common is that they have both experienced separation anxiety; although in Maggie’s case the condition was temporary but for Lincoln it became chronic, which qualifies him for a diagnosis of separation anxiety disorder. Although they share the same symptoms, Maggie’s reaction would be viewed as homesickness; therefore, benign in its implications while the same problems if persistent are characterized as mental illness.

In like manner, one could make a case that mental illnesses are largely due to quantitative rather than qualitative variations from the norm. Who among us has never experienced an irrational fear, a fleeting suicidal thought, unwarranted suspiciousness, unreasoned feelings of despondency, or a spontaneous episode of anxiety without obvious cause? Such short lived experiences are usually shrugged off, but the realization that these feelings differ from those of a mentally ill person only in their duration can result in self-doubt and feelings of insecurity about one’s mental stability.

The mechanisms we use to deal with these feelings of mental insecurity and self-doubt are all apt to contribute to the isolation and discrimination so often seen in our relationships with people who are mentally ill.

Denial

Denial is a powerful mental mechanism characterized by statements such as: “pull yourself together, stop worrying, quit being so sad, or stop acting so crazy.” Such statements deny illness and suggest he only needs to “buck up,” thus, perpetuating the time honored tradition of blaming the victim for his troubles. Of course kicking a person while they are down is not very therapeutic, but it may help us feel immune. Some naysayers even insist that the whole idea of mental illness is a fable.

Avoidance

Avoidance is another method of dealing with one’s insecurities. It operates under the out of sight out of mind premise. When I was practicing there were some people would not visit friends or relatives in our psychiatric ward. Many others were obviously uncomfortable in that environment, and would avoid eye contact with patients. The usual response to someone exhibiting bizarre behavior is for observers to look away after a furtive glance. Avoidance in its extreme form is to be shunned, which is guaranteed to exacerbate most any mental illness.

Ridicule

Ridicule is a tried and true method to avoid ownership. It is said that those operated Bedlam (which was actually named Bethlem Royal Hospital), the infamous insane asylum in England that charged admission for visits to the facility where one could make fun of and taunt the patients, felt it was quite progressive because the fees collected helped fund the “hospital’s” operation. I imagine the taunters felt safe since most of the patients would have been chained to a wall. We are of course much more sophisticated than the residents of jolly old England, yet when we joke about mental illness, are we not engaged in a similar coping mechanism? For the patients and their families, there is certainly nothing humorous about mental illness.

Words

The way we speak often illuminates thoughts buried so deep that we may lack awareness of them. This appears to be true when we discuss mental illnesses, especially the more serious variety. For example when we say a person is schizophrenic, where schizophrenic is an adjective, we seem to be saying what he is, but when we use the term as a noun as “he is a schizophrenic” we are saying who he is. He is no longer a human with the disease, but he is the disease, and his humanity is diminished.  People with schizophrenia have this in common with those suffering from leprosy, who are usually referred to as “lepers.”

The plight of those who suffer from mental illness

The parallels don’t end there for those afflicted with either diagnosis, leprosy or schizophrenia, have suffered the same punishments including: torture, execution, imprisonment, denigration, ridicule, and shunning. Both have been thought to be caused by demonic possession, curses, divine judgments, witchcraft, etc. They have been with us throughout recorded history and probably longer. You may be thinking, “Yes, but we have become so much more sophisticated, enlightened and compassionate.” Yet, thousands of severely mentally ill people are imprisoned. Only recently has there been a movement to mandate psychiatric care reimbursement by third party payers to be equivalent to that provided for treatment of non-psychiatric illnesses. An estimated 70% of the homeless who live on our streets are mentally ill. Our government has diligently worked to deny benefits to veterans suffering with post-traumatic stress disorder, and the list goes on. Incidentally, the last leper colony in the U.S. was not closed until 1999.

The stigma of mental illness

I contend that ignorance is fertile ground for the development of stigmata. We are often most fearful of those things which are mysterious to us. A diagnosis of separation anxiety does not promote much fear in us. We all have some familiarity with and empathy for that problem, but mention psychosis and there will be a different reaction. There are abundant myths regarding psychotic illnesses, and for many that term belongs in the same category as axe murderer. Since early childhood we have been taught to avoid people who are acting strangely, and what we don’t understand is always strange.

Behavior Health vs. Mental Illness / Patient vs. Client: Renaming and Reframing

Another way of dealing with uncomfortable problems is to reframe them by renaming them as something less threatening. In the mental health field this mechanism is used by mental health advocates in a way that I feel undermines their stated goal of de-stigmatizing mental illnesses. One such term which I find totally repulsive is behavioral health which has found its way into the vocabulary of not only the general public, but those charged with treating the mentally ill. While espousing the need for acceptance, they choose to call the condition by a different and totally inappropriate name. A mental illness is no more a behavior than is cancer, but since there is a type of treatment used for less serious illnesses called behavior therapy, the term has now been co-opted to encompass all psychiatric illnesses.

In their zeal to demedicalize mental illnesses, the powers-that-be have successfully substituted client for the word patient when describing people in treatment. This is an issue which sometimes leaves me wondering if it might be time for some more therapy for myself. I have fought this one unsuccessfully for at least 20 years. The word patient is from the Greek meaning “one who suffers” while the word client has to do with a business relationship. Call me a snob, but I feel a doctor patient relationship is more than a series of business transactions. As I have pointed out repeatedly to all who would listen and even those who would not: Accountants, lawyers, and hookers have clients. Physicians have patients.

Shortly before my retirement, I penned a letter on the subject to all the nurses with whom I worked, expecting them to be a bit more sympathetic since they had been medically trained. When I asked one if she had read my letter, she answered in the affirmative, then said “Your next client is here.”

Sadly, the previously described types of reactions to a diagnosis of mental illness occur at a time in a person’s life when he/she is in most need of support and relatedness. Admittedly there has been some progress in educating us about mental illness, and research is opening doors toward more understanding, but society remains relatively uncommitted to dealing with one of our most pressing problems. Hopefully there will come a time when patients will not fear being seen going into their psychiatrist’s office.

From Eshrink’s Editor: What can you do to help?

Get informed. Volunteer.

(Side note from eshrink’s editor: If you think about it, all of the big issues that face our society are just symptoms of a society that has yet to address mental illness and the plight those who are the caretakers for the mentally ill face. As the election cycle gets in full force, pay attention to how few candidates address mental health and mental illness.)

Below are some resources I found helpful.

http://www.nami.org/Get-Involved/Raise-Awareness/What-You-Can-Do

http://www.nami.org/get-involved/raise-awareness

Helpful Tips for Family and Friends

60 Tips

Life

There was a fly on my bathroom window this morning.  As I prepared to swat him, I was reminded of my mother saying “He wouldn’t hurt a fly,” a complimentary phrase used to describe a person of gentle character. Although my mother was a gentle soul herself, that saying did not apply to her as she was an avowed hater and ferocious killer of flies.  Her swatter was always within reach and during times of heavy infestation, she would hang a fly catcher from the ceiling light.  The latter was in the form of a sticky tape which would attract flies and then hold them until they stopped fluttering, a sort of weapon of mass destruction.  The flies did not appear to be very smart for they continued to land on the fly paper in the midst of hundreds of their dead buddies.

As I stood poised to murder that poor little guy with my bath towel, it also occurred to me that to see flies in the house is now rather uncommon, compared to my childhood when it seemed they were everywhere; undoubtedly a testament to indoor plumbing and pesticides. A frequently heard admonition delivered in semi-panic mode was: “Close the screen door, you are letting in all the flies,” and believe me there were often a lot of flies to let in.  Once in the house, the only solution was death by whatever means available.

We are a culture which professes a reverence for life, but I doubt even the vegans among us would feel much compunction about swatting that fly. The rest of us find only the lives of our own species or perhaps those of our pets to be important.  I am told there are some eastern religions which forbid the taking of any animal life no matter how small or insignificant, which leads me to believe they find life itself to be a holy condition.

As I grow older, I find that I no longer take life for granted.  This shouldn’t be surprising since economists explain that as a commodity becomes less plentiful, it accrues more value. I suspect that is one of the factors which has inspired me to write this little ditty.  Life is one thing that fly and I have in common; although, our experiences with it obviously differ considerably.  Much has been written about the mystery of death, which is understandable since we have not experienced it personally, but I submit that life is much more complicated and mysterious.  As a matter of fact, when I consult my favorite reference (Wikipedia), for a definition I become even more confused until I find it defined as the opposite of death.  That was not very helpful as I think I already knew that.  I believe my tenth grade biology teacher did a better job when she described life as the ability of an organism to respond to its environment, and to reproduce itself.  Using these criteria one must conclude that Mr. Fly is indeed alive.

Life and Consciousness

In the midst of plotting my strategy as to how to take him out without breaking the window, I found myself wondering if the fly knew he was alive, or if he was even aware of his own existence. Recently I have been reading about some exciting research that attempts to understand how our brains work, but there still appears to be a lot of questions about consciousness.  In addition to the imponderables of why am I here and how did I get here, man is also faced with the even more vexing question of how do I know I am here?

The earliest recorded writings on the subject of consciousness were contained in an essay by John Locke in 1690 (side note from editor: this connection won’t be lost on devotees of the television show Lost).  He defined it as “The perception of what passes in a man’s own mind.”  There has been much disagreement even in the description or definition of the word.  The one I liked best was the translation from the original Latin namely: “knowing that one knows,” but then I have always been a sucker for simplistic answers to complex questions. Not so with the world’s greatest philosophers who have found the subject fertile ground for their speculations and opinions.  I tried googling some of that stuff and found that I had no idea what they were talking about, but felt a great sigh of relief when I stumbled upon a quote from Stuart Sutherland in the 1989 Macmillan Dictionary of Psychology where he wrote “Consciousness is a fascinating but elusive phenomenon: it is impossible to specify what it is, what it does, or why it has evolved. Nothing worth reading has been written about it.”  That last line made me feel much better.

With the marvelous advancements in discoveries about the brain, and the ability to actually witness its functions via scanning techniques, neuroscientists have now thrown their ideas into the mix; however, they are limited by the problem of objectively measuring a subjective experience.

Recently I wrote a spoof abut a future in which robots populate an earth where the human race has become extinct.  My wife thought it was crazy, but I now feel vindicated after discovering that Alan Turing (credited with inventing the computer) had written a paper on the subject of computer intelligence in 1950.  Now there is much discussion about artificial intelligence, but one wonders, “What is the difference between artificial intelligence and the genuine article?”  There is some debate as to whether computers can actually be programmed to be conscious.  Many learned people dismiss this idea as preposterous, but then people shared that same attitude about going to the moon.  After living on this planet long enough to witness many “preposterous” discoveries, I have learned that the adage “never say never” makes a lot of sense.

What about the fly?

Those of you who are still reading this may wonder what this has to do with the fly on my window, and I don’t have a very coherent answer, other than I have a tendency to wander off on tangents when I am thinking “great thoughts”.  This is a phenomenon we psychiatrists call loose associations often found to be a harbinger of impending psychosis.  I prefer to think that I am perfectly sane; however, if I am suffering from an altered state of consciousness I may be totally unaware of my mental problems, and as a matter of fact this is one of the factors which often makes it difficult to treat the more serious mental illnesses. After all, it would make no sense to undergo treatment for an illness that does not exist; consequently, should we be surprised that many seriously ill patients resist treatment as have I?

Consciousness and animals

Consensus among the experts regarding consciousness in animals seems to be lacking.  Some are convinced that this is an exclusively human function while others feel that some mammals and birds are so endowed.  Others believe that only subhuman primates, chimpanzees in particular, exhibit consciousness, and that other creatures including insects like my fly friend operate on instinct.  Of course we don’t know much about instincts either.  Although instincts are thought to be encoded on the organism’s DNA, we still face the mystery of how that process occurred. The limited research I performed to help me answer my housefly question has convinced me that the fly in the window, although satisfying the criteria to be called alive, almost certainly could not experience consciousness.  I did learn a lot about flies for example: 1) they only live from two to four weeks, 2) they undergo a complex life cycle as maggots, pupae, etc, 3) they have large protruding eyes with multiple lenses which allow them to see in all directions at once which explains why you can’t sneak up on them, 4) they have been aggravating us humans throughout history, 5) they can carry a variety of diseases from the garbage and feces on which they feed, 6) enlarged photographs show them to be truly ugly.

Obviously, in order to be conscious we must have a functioning brain, an organ of such marvelous complexity that it defies our total understanding. Most experts agree that the ability to experience emotions is essential for consciousness, and this is what sets us apart from other life forms, yet we know that elephants for example go through an elaborate period of mourning at the loss of a family member, and many of us remain convinced that our pets demonstrate all kinds of feelings based on their behaviors.  The idea that the brain is the seat of emotions is fairly recent, and for most of our history had been ascribed to the heart.  The tradition lives on; however with phrases like; “my heart goes out to you” or “her heart is broken.”

Consciousness and theology

Discussions of consciousness are almost certain to lead to theological considerations.  Indeed some philosophers would contend that the soul is simply the state of being conscious. Throughout history, man has left evidence of his belief in a spiritual component to his being, which is separate from and survives his death. Such a belief has crossed all boundaries and cultures throughout the world; although with different versions of the same theme.  Of course without consciousness, man would have been incapable of conceptualizing a spiritual aspect to his being or for that matter even the realization that he was mortal.   One might ask, is it not possible that our conscious mind is incapable of perceiving the “soul within us,” or as some insist, is this idea simply a fairy tale devised by man to deal with the awareness of his mortality?

There are those who operate under the assumption that if you can’t see it, hear it, smell it, taste it or touch it; it doesn’t exist.  I submit there are many things which we cannot perceive which are known to exist.  Gravity for example, does not pass that test for we cannot perceive it directly, although we are certain that it exists because we can witness its effects.  We even have an equation to describe it.  As a matter of fact our universe is so well ordered that theoretical physicists insist that everything can be explained by mathematics. By making use of these principles, they have been able to predict the discovery of many things in our universe both in the field of particle physics, and the other end of the spectrum namely, astrophysics.  One of the more famous examples of this was the discovery of black holes in the universe 55 years after Einstein had predicted their existence based on his calculations. It is little wonder that a guy like me who struggled with ninth-grade algebra has difficulty understanding these guys.

If you thought Einstein and his relativity theories containing terms like a fourth dimension, space time continuum, and how straight lines are actually curved  strange, take a look at quantum mechanics which is really weird.  Among other weird things, devotees to this line of thought explain with a straight face that an object can be in more than one place at the same time.  In an earlier time if someone presented me with a story like that, I would probably have suggested he come with me and spend a few days in the psych ward.  Some also postulate the existence of parallel universes.  While all this is going on subatomic studies are turning all we learned about the atom and the nature of matter on its head.  We were taught that the atom had protons, neutrons and electrons, now we are told there are quarks and leptons and other kinds of things in there doing weird stuff.

You may be thinking “here he goes off the deep end again” but the point I am attempting to make is that there are many things going on which our brain can’t contemplate due to the limitations of our special senses.  With that in mind it doesn’t seem like a big leap to think there may be spiritual stuff going on both within and around us of which we are totally unaware.   I would not be shocked if some modern day Einstein would not come up with an equation some day that would confirm the existence of a spirit world, God included.  In the meantime we are left with the admonition to believe.  This has always been difficult for me as I have always been a skeptic by nature and like things to be proven.  In spite of this, I try to believe as I am told that only believers will get their tickets punched to the pearly gates and the other option does not sound good at all.

Meanwhile the question remains unanswered as to what all is involved in consciousness.  Is it simply a byproduct of life, the end result of the evolutionary development of the human brain?  Is the condition unique to humans?  Is there a mystical component involved?  I know these are all questions I raised early in this writing, but did you really expect answers?  As I have said in a previous blog, more wisdom is usually found in questions than in the answers.

By the way, in case you are wondering about the fly, I swatted him.