THE END OF THE PRIVATE PRACTICE OF MEDICINE — Economic Consequences to Us All

A recent Wall Street Journal article http://online.wsj.com/article/SB10000872396390443713704577601113671007448.html?mod=WSJ_hp_mostpop_read described an increasing and frightening trend in health care today–the purchasing of  physician's practices by hospital chains. 

 This is not merely the end of private practice medicine as we know it–it actually is resulting in increased health care costs.  As a private practice physician I fear the day when medical care in this country will be accessed only through such large organizations.  The motivation for physicians joining up with such hospital mega-groups is multifactorial.  There is an increasing fear among physicians that they will be marginalized in the onslaught that is occurring. 

ACOs (accountable care organizations) are the legacy of Obama care.  They act as giant purchasing organizations in which Medicare and insurance payments will be bundled and directed to them.  Distribution to the hospital, nurses, physicians and administrators will come out of this pot.  Small private practice doctors fear they will be left out of the game if they don't join.  But more significant and pernicious is the reality that hospital-based organizations can charge MORE than private docs themselves. 

 The article describes the increased costs of procedures that were formerly performed by private practice medical practitioners.  The cost of cardiac catheterization and testing may becomes enormously higher under such settings.  I am sure the cost of what I do–upper endoscopy and colonoscopy are likewise inflated by such arrangements.  Then there are the intangible aspects of losing small privately run practices–the ability to provide individualized care in a small, compassionate setting.  When institutions take over, there is a different mind-set among workers and patients.  They become a number.  They will deal with the employees of a large company who have little concern whether that patient/client is satisfied or not.  This is not a slam on any one individual.  It is the nature of business.  Small (mom and pop) businesses just provided more personalized care.  The small practice strives to satisfy their patients because they cannot aford not to!  It is not that complicated. 

Adding layers of bureaucrats to the practice of medicine inevitably slows down the process, de-humanizes the process and leads to dissatisfaction for patients and practitioners.  Add to that the cost increases that are now emerging and you have the perfect storm–for disaster in the practice of medicine.

SEEKING SOLITUDE — The Mind Vacation

Do you ever find yourself just sitting and being still?  Rarely, I will guess, unless you meditate on a regular basis.  On the contrary, most of us find our minds bombarded by constant thoughts and feelings and our actions often paralleling this frenetic  activity.

And I am as guilty as the next guy.  I barely sit down to eat and find myself reading or glancing at a TV when I should be "sitting down" to breakfast. 

My private life seems to reflect the intense atmosphere of my office life.  Phone calls intrude on my personal time, charts are thrust in my face, letters are being read–as I'm attempting to wolf down my lunch.  Dinner time is different.  I actually sit down to eat.  And by the way when is my next vacation?  My wife has to set one up for us or I'd be too wrapped-up to ever plan or take one.

 In a universe of constant doing there seems to be no place for just being.  We seem to fear that we must multitask or risk loosing out on something. Exactly what that is we find hard to define.

 Ironically, the faster we move, the more we feel inadequate to accomplish what we believe is so important.  The continuous treadmill metaphor is appropriate. The perception of accomplishing more is associated with the feeling that we are falling further behind.  It is the Promethean task lived out on a personal level.

I recall seeing a series of statues of  Buddha in the Metropolitan Museum of Art.  These enormous works of art portrayed the Buddha in a sitting position with legs folded and arms and hands in their typical repose.  His eyes were closed and most importantly—there was a gentle smile on his face.  It was a picture of complete peace and serenity.  The last time I looked like that was when I sitting on a beach in the Mayan Riviera

The truth is simply this–the ONLY place where serenity and peace exists is within ourselves and THAT  place is our minds.   It is necessary to slow ourselves down, to attempt to empty our minds, to stop doing and just be present in that sacred space. 

This is not to imply that we should or could drop out of our hectic lifestyles.  Many of us actually  enjoy the many activities we embrace.  But we would all be better off by taking a mind vacation on a daily basis.  

Put aside our smart phones, I-Pads, laptops.  Rest in the present moment.  Empty our minds of thoughts and feelings. In essence–its OK to "be out of your mind."

 Focus on a mantra or the sensation of the breath entering and exiting our nasal passages.  Just stop in order to re-charge our batteries. 

 Rest in the emptiness of no-thought. Just be present with the joy of possibilities.  Take a mind vacation.

ON FINDING INNER JOY– CHOOSE WHAT WORKS FOR YOU

Do you know anyone who is not seeking more peace and contentment in their lives?  Unlikely. And in many ways  the term serenity best encompasses this concept.  

Buddha understood that all sentient beings suffer.  It is part and parcel of being in this physical world having attachments to that which will, by necessity,  change and pass away.

Practicing non-attachment is difficult if not impossible for most of us.  What does it actually mean anyway?  Perhaps it refers to the obsessive, even neurotic belief that we can change others, make decisions for them, prevent them (and ourselves) from suffering in the end.

What I have observed is simply this–people who seem content live in a universe of their own in which their suffering seems somewhat limited and controlled.  They understand the rules of the society in which they inhabit.  They are comfortable with their associates and their environment.  They are not seeking radical change, nor are they unhappy or in conflict regarding the conditions of their lives.

These people may live under circumstances that others might even find intolerable–trailer parks, low income, small towns without the cultural, culinary, intellectual sophistication of large cities.  And yet they may be more content that a more affluent city dweller  or suburban dweller who is never satisfied with the state of their existence.

Very often serenity is associated with our personal connections with others. Loneliness sucks.  On a primal level, we all need personal interactions with human beings  we feel comfortable being with.

There is the stereotypical example of the  overtly wealthy couple with enormous material possessions who remain miserable because they cannot "keep up" with their even wealthier friends.  To outsiders this seems completely absurd.  Yet serenitiy is an inner subjective perception. If individuals inhabit a universe which doesn't quite fit—they suffer.

I believe that it is possible to "feel" your way into the universe that suits you best.  Be truthful to your own values.  Be honest and introspective.  What do you need to make you happy or serene.  It will be unique to you.  Don't "borrow" someone else's universe.  You won't fit in. 

SERENITY — THE PATH OF GRATITUDE

Serenity is a state of mind desired by most of us.  But considering our chaotic, stress-filled lives, how is this possible?  The Serenity Prayer quite brilliantly asks us to accept what we cannot change.  Easier said than done, we reply.  Acceptance is the way of the Buddha.  We "nonattach" to the suffering of those around us.  We distance ourselves emotionally from those we love.  We face our own obstacles, disappointments, rejections, failures and view them as life's lessons. 

Is that possible?  Do we need to meditate 24/7 to achieve that bliss in the midst of all that bombards us?  What about another path to serenity? 

What if we focus our awareness on gratitude?  It doesn't require that we de-tach from the suffering of the world.  It doesn't encourage us to accept the disappointment, frustration, anger, despair that we all experience with passivity and inaction.  It essentially re-directs our attention, our awareness away from pure acceptance /non-attachment to a mindfulness of what we can hold on to, what we can be grateful for.  It is the old-fashioned "count your blessings", focused on a personal yet metaphysical level. 

We can "count' our blessings.  We choose to look at what is working in our lives.  This will be a completely personal examination.  It is unique to each one of us.  We don't list the negatives in one column, the positives in another–not in this exercise.  We ignore the negatives.  We fixate on the positives, they become our personal gratitude list. 

 If we  have difficulty releasing the negative column and finding the positive it might help us to recall the quote from French Jesuit paleontologist  Pierre Teillhard de Chardin, " we are not human beings having a spiritual experience, but spiritual beings having a human experience".  This is an experience that requires problems, difficulties, suffering as the source of learning, overcoming, transcending. 

Gratitude removes us from this evaluation process.  We don't have to compare ourselves with anyone else in the universe.  We need to simply and directly meditate on that which is working in our lives.  It may be an expansive list, it may be as narrow and restricted as this–we are alive.  We have an opportunity in the next moment to transcend our suffering.  We can become a beacon of light for some other soul, suffocated by darkness.

By being grateful for one thing only–the gift of life, we can detach from all the negativity which weighs us down.  As it has been said, if you question whether your spiritual journey is over, ponder this–if you're still alive, it isn't. Our incarnation here is for one reason–to challenge our true self–our soul.  Every challenge requires stress.  We did not incarnate here to have an easy time of it.  We are all here for one grand reason–to face adversity and do our best to overcome it.  In doing so we expand our karmic duty–to those around us.  We can become an example to others.  Gratitude is a powerful tool to assist us in this task.

DOCTORS CHOOSE DEATH FOR THEMSELVES WHEN THERE IS NO LIFE

Death with dignity.  Is that merely a hollow phrase, or is it possible to obtain even under the most dire circumstances. 

In a NYTimes articleby Katie Hafner http://www.nytimes.com/2012/08/12/health/policy/in-ill-doctor-a-surprise-reflection-of-who-picks-assisted-suicide.html?_r=1&hpw the issue is discussed once again.  It touches on Washington states's Death WIth Dignity act which allows prescriptions for lethal doses of barbiturates under certain circumstances of prolonged suffering. 

 Dr. Richard Wesley who suffers from ALS (known as Lou Gerhrig's disease it is a progressively debilitating disease in which muscular activity degenerates) is specifically discussed as is the issue of physician-assisted dying.  The fears that Oregon and Washington would be inundated with individuals seeking such assistance in the dying process has not materialized. 

The article quotes several physicians who represent different positions on this issue. While Dr. Steven Kirland, Dr. Wesley's pulmonologist is in support of Dr. Wesley's right to choose the time and place of his own death, other physicians such as Dr. Kenneth R. Stevens, emeritus professor of radiation oncology do not.  "I didn't go into medicine to kill people" was Steven's quote regarding this topic. 

Sadly there are many physicians who agree with Dr. Stevens.  To me this is a pathetic response to one of the most important issues facing our society today.   My response to him would be–Of course, doctor, no physician is empowered to "kill" people.  But what about keeping patients free of suffering.  Isn't that the highest mandate of our profession?  And what about healing?  Dr. Stevens, as is true of many of my colleagues fail to understand the deeper meaning—healing means to "make whole".  In the dying process, healing means making someone comfortable, reducing pain and suffering. If that process facilitates death itself, so be it.

 In metaphysical terms, dying may be the highest form of healing.  Whether or not one accepts survival of consciousness after death or not–the highest degree of human to human interaction is compassion and empathy.  How would each of us choose to die?  It is not through suffering, I can assure you. 

It is interesting that the article fails to mention the work of Dr. Kevorkian.  Although vilified and demonized by many, he was a pioneer in a field that still makes most of us uncomfortable.  But such a reaction should not dissuade us from further discussion and debate. 

But this discussion is belongs as part of a broader debate–how do we treat patients at the end of life?  Just because we can order tests, do procedures, perform surgery….should we?  Why do so many of still die in hospitals, in ICUs and not at home with Hospice and home care?

None of this is easy but that doesn't mean it isn't important.  It is of paramount concern.  Billions of dollars are spent at the end of life when there is no realistic chance of altering what is inevitable and imminent.

THE SIKH MASSACRE IN WISCONSIN– Turning Tragedy Into Awareness In Two Parts

The horrific crime in which six Sikhs were ruthlessly murdered in the their temple by neo-nazi Wade Page is a tragic wake up call to those of us who fail to recognize the inherent danger of all hate groups. In a democracy in which free speech is tolerated, those whose rhetoric supports hatred of others must be closely monitored. It only takes one such demented individual, armed with assault weapons (for which there is never an excuse to be legal) to take innocent lives and inflict unspeakable suffering. Groups which have promoted hatred and intolerance of others need our special attention. Darkness and secrecy allows their power to grow.  Shining the light of public awareness on them can make us all aware of their danger. 

This is part one of the awareness.  There are groups such as the Anti-Defamation League and others which do monitor hate groups.  Jews know better than anyone the power of insidious hate-mongering and the real effects it has on innocent human life. Other groups both public and private do the same.  Is this an invasion of privacy issue?  Is the free speech of hate groups being compromised?  Ah, the conundrum that will always exist.  There must be a balance between protecting individual right of expression and the danger to innocent citizens.  Monitoring is mandatory because the innocent cannot defend themselves against violent extremists.

And now the second area of awareness to arise out of the suffering.  An understanding of the Sikh religion. With their colorful, prominently displayed turbans, Sikhs  have been accused of being militant Muslims and frequently attacked.  Their children are called Osama, their places of business trashed.  In truth their religion is not well known or understood in this country.  The world's fifth largest organized religion, Sikhism is a relatively young religion.  It originated in the fifteenth century in the Punjab area of India and has nearly 30 million followers.

 Their belief system may be of interest to those who are fascinated by how human beings seek to understand the divine in a multitude of ways.  They are monotheistic, reject the caste system of their native land, believe in revealed truth by a series of Gurus, are peace-loving, believe in karma and do not aggressively proselytize.  They are not terrorists.  

There has been an outpouring of support from non-Sikhs in the Wisconsin area.  As an article in MercuryNews.com pointed out "People of a range of races and faiths wore colored headscarves our of respect for the Sikh religion."  This is the power of the American experience.  The dynamic challenge of a democracy is to allow free speech of all varieties and yet protect those who may sadly become its victims. We need to defend the rights of those who differ from us in practice and belief to enjoy the freedoms we all take for granted.  

INCENSE & ADC

After-death communications (ADCs) imply two controversial but metaphysically paramount concepts–1) there is survival of consciousness after physical death, 2) communication between this discarnate consciousness and living beings is possible. 

Coming from what was a strong skeptical /atheistic belief system I believe that the evidence supports both contentions. 

The following is a simple but profound example of an ADC via the sensation of smell.  This is not unusual in the world of ADCs but not the only kind. It involves someone I know and respect.  This topic of credibility is necessary in discussing paranormal activity.  Is the individual believable?  Do they have any motive for making it up?  In almost every case involving a personal connection/friend/acquaintance the answer is a profound NO.  On the contrary, ordinary individuals are reluctant to discuss such experiences with anyone.  The fear of appearing naive or foolish often trumps the desire to share a profound personal transformative experience. (as with NDEs). 

So in brief Dr X is a retired anesthesiologist, a practicing Buddhist originally from Thailand.  He had  previously described a personal experience in which he was visiting his dying brother there.  He had sat by his bedside for quite a while, then took a walk with his niece (the brother's daughter) outside. While walking and speaking of the brother the daughter received a call on her cell phone.  It was her father's number.  She showed it to her uncle.  They were both shocked knowing that he was in a deep coma and that her uncle Dr X was carrying his phone.  Simultaneously Dr X smelled incense.  He asked his niece if she smelled it.  She did not. They quickly returned to the hospital room to discover that the brother had died while they were out walking. 

Just recently Dr X was playing golf with another anesthesiologist who I work with on a daily basis.  Dr X began to sniff the air.  He asked if the other fellow smelled incense.  He did not.  Dr X recalled the prior time he smelled it.  Later that night Dr X received a call from Thailand.  One of his cousins  whom he had been close with had died.  Most interesting is the cultural connection with incense and death. 

This sign had enormous meaning to Dr X.   These experiences are not unique.  When they occur they bring a sense of a connection with transcends death.

THE GLASS HALF…….–On Balancing Negative with Positive Thinking

The recent NTimes article by Oliver Burkeman  http://www.nytimes.com/2012/08/05/opinion/sunday/the-positive-power-of-negative-thinking.html offers an interesting response to the rush to embrace unquestioning optimism and positive thinking that permeates pop psychology and  New Age spirituality.  Now I have personally promoted the optimistic approach to life–but with a  robust degree of  moderation and balance.  

There is no question that optimistic individuals are happier than pessimists.  They live longer, have more friends, have stronger more potent immune systems.  Research in the field of Positive Psychology also have helped define who the optimist is.  There is perhaps a genetic contribution of nearly 50 % to one's basic outlook on life.  Life experiences contribute to the other 25% and there is at least that much left which becomes our choice.  So optimism can be learned and acquired.

But there is also a danger in too much optimism, in blind optimism–the kind that ignores danger and the reality of negative outcomes.  The article describes some of Tony Robbins' followers who burnt their feet walking across hot coals. While a light quick walk on hot coals will probably burn no one, those true believers who did get burnt blamed themselves for not being positive enough.  

Some of us underestimate our own potential.  For a variety of reasons including early life negative experiences or lack of parental support, we have developed a life script which tells us that we cannot achieve lofty goals.  That element of negativity will prevent us from reaching our highest potential.  On the  other hand, blind unrealistic expectations which have no hope of being realized is a recipe for repeated failure.

I have previously criticized the strong advocates of "The Secret" who believed that deeply wishing and visualizing an outcome would bring it into existence.  I used the Kabbalistic analogy of different worlds.  In the universe of pure thought (yetzirah), the desired outcome immediately comes into being.  Unfortunately, we all live in the world of action (assiyah) and are compelled to live by its rules.  While creating goals are important and visualizing positive outcomes necessary, the hard work of making them come into existence cannot be bypassed.  

Also, for many, the fear of failure can be tremendously motivating.  Worrying may alert us to potential dangers and prepare us to avoid them. Being aware of possible failure allows us to pick ourselves up when it happens and not be devastated to the point of paralysis. That does not mean being trapped or weighed down by fear, but using this "negative" energy to seek a positive outcome.

Once again the magic ingredient is balance and continuous feedback.  Observe your own thoughts and feelings.  Be a realist about possibilities.  Positive expectations are great but if we are not realistic about our plans we will be continuously disappointed. And constant failure is difficult to overcome, even for the most committed optimist.

Be the witness of what goes on in your mind.  This is the Buddhist approach via meditation or bare awareness.  

You will understand the power of the mind to motivate, empower or to impair success.  Being aware will allow you to use the power of negative thought in balance with an underlying optimistic attitude and achieve as much in life as is reasonable based on hard work and talent. It will also assure a degree of equanimity and serenity which is everyone's ultimate goal.

THE ARAB SPRING — 21st Century Technology Does Not Mean 21st Century Liberation

For those readers who naively believe that technology will promote the greater good, just examine what has occurred since the "Arab Spring".  There were high hopes among Western progressives who passionately believed that the internet, Facebook, Twitter would bring the longed hoped-for breath of freedom and liberty in lands long oppressed by dictators.  21st century technology does not guarantee 21st century mentality or free expression.

Unintended consequences and the reality of a morally ambiguous technology has led to completely different outcome. The rise of religious fundamentalism merely supplanted those of prior dictators. For in fact modern technology was utilized by the religious fundamentalists to promote their agenda. 

In her article in September 2012 Discover Nina Burleigh clearly demonstrates this reality.  The hope of the more naive among us that democracy, personal freedoms, liberation of women would necessarily emerge along with 21st century technology were sadly mistaken. Instead Muslim fundamentalists embraced this technology to promote their religiously conservative positions.  As Burleigh states, "the Internet is poised to drop-kick Arab society back centuries in terms of women's rights and free speech".

The lesson here is clear–technology is morally and ethically neutral.  The same technology that printed the Bible printed Mein Kampf.  Perhaps this should alert those among us who live in the world of wishful thinking to be less gullible when it comes to technological advancements and seek to understand the underlying philosophy of those who utilize them.

NDE— Scientific American Tried (In Vain) To Explain It Away

I didn't see this article when it first came out but my recent re-visiting of the NDE experience coincided with finding it online.  Entitled PEACE OF MIND: NEAR-DEATH EXPERIENCES NOW FOUND TO HAVE SCIENTIFIC EXPLANATION comes from Scientific American by Charles Q. Choi http://www.scientificamerican.com/article.cfm?id=peace-of-mind-near-death&print=true  

It is a rather pathetic rehash of other skeptical attempts to de-legitimize the experience as being nothing more than the result of lack of oxygen to the brain or the accumulation of toxins. This approach seems to profoundly threaten the scientific/materialistic metaphysical view of reality.

Even the suspicion that the NDE might reveal something of a paranormal / spiritual experience is so threatening to this community that they defy rational thinking in their desperate attempts to demean it.

The article (as so many others like it) attempts to simulate the NDE by stimulating different areas of the brain, particularly the right temporoparietal junction.  It also offers the locus coeruleus of the midbrain as another brain source of the experience.  Once again it offers lack of oxygen to the brain as producing the tunnel of light phenomenon. It also explains how certain drugs including the anesthetic ketamine can simulate an out-of body experience

The problem with all these explanations is simply this–they do not account for the powerfully salient features of the NDE.  They create a weak and inaccurate version of the NDE and then attempt to debunk it. 

There have been many fine, detailed investigations of the NDE which have effectively countered each attempt to offer scientific explanations for what truly happens.  The best analysis and summary I have read comes from cardiologists Pim van Lommel, M.D. in his book Consciousness Beyond Life: The Science of the Near-Death Experience.  Lommel systematically brings a reasoned and detail analysis of the NDE and explains rather convincingly why it is NOT the product of lack of oxygen, a particular area of the brain or some drug reaction. 

In fact as I have discussed in earlier postings, the features of the NDE which are most compelling cannot be explained away.  Individuals who are essentially "brain dead" with profound lack of oxygen to their brain describe vivid, coherent experiences in which they not only encounter deceased loved-ones who they did not know in life but later recognize in pictures, but can visualize real life events that take place when they are unconscious and comatose.  These can be confirmed by other observers.  They are so profoundly affected by these experiences that they are often life-changing. There is a nearly universal loss of the fear of death.  

Such a profound, life-altering transformation of basic values with an emphasis on spirituality over materialism cannot possibly be the result of a delusion or hallucination.  In fact when asked to compare this experience with a dream, hallucination or even waking consciousness, they will uniformly state that the NDE was "more real" than any of these.  The common features of the NDE across countries, times and cultures unequivocally point to a deeply powerful, real and enlightening encounter with a deeper reality. 

It is unfortunate that such a well-respected magazine such as Scientific American did not truly explore the essence of the NDE.  It reflects the general bias of the scientific community to be closed-minded about experiences that challenge their "faith-based" belief that nothing can exist without a scientificc explantion.  And, therefore, closes itself off to the real investigation of the NDE. That attitude only inhibits the full exloration of new frontiers in human consciousness studies.