It was a bad week. I know a lot of other people who felt the same. I happen to be fortunate enough to live in an area where the vast majority of the population shared my dismay, but it was still difficult. Not much sleep. No appetite. Hard to concentrate. Anhedonia.

I had to keep going, though, so this morning I went downtown to work at one of my side gigs. Actually, I was there last week, but someone called out so they asked me to fill in this week as well. So I went.

It’s a Suboxone clinic*. A crazy-busy place where people struggling with addiction come to get a prescription medication that allows them to lead a normal life — their words — in conjunction with psychotherapy and close drug monitoring. They are probably the only buprenorphone prescribers in Pennsylvania who take insurance**. They average 200 patients per session, but because of the SEPTA transit strike last week, there were lots of folks who had to re-schedule.

I’ve been working there since June, and I love it. Don’t get me wrong: I love my practice, but reassuring yuppies that their back pain will go away in a few weeks and trying to explain why they don’t need antibiotics for their bronchitis doesn’t exactly feel like the cutting edge of saving lives and easing suffering. But this place does. These are people who have struggled with demons more malignant than I can imagine. They have seen loved ones murdered, lost others to overdoses, suffered rape and abuse; the entire gamut of human suffering. Yet they are the ones who have chosen to fight. To come and ask for help.

Many doctors don’t like addicts, an understandable attitude given many of the experiences we’ve had with them. The manipulation, the lying, the untrustworthiness; we’ve heard it all, and we’ve all been burned. But this is an extremely structured and protocol-driven setting. Every patient must have a urine drug screen after every visit. Dirty urines prompt a Probation program, with increased therapy and more intense followup. As long as a patient is working the program, we’ll write their refills.

It’s downright inspiring. There’s a real sense of making a difference in someone’s life; one that could literally be the difference between life and death. I don’t think there’s a single patient in that clinic who hasn’t lost someone to drugs. They know all too well how important this medication is to them. And I feel privileged to have the opportunity to help them.

And you know what? Thirty patients and four hours later, I felt better. Still worried sick about the future, but not quite so down. An unexpected benefit of helping others.

*Suboxone is the brand name for buprenorphine/naloxone, a “replacement” drug for opiate addiction that doesn’t produce the high of heroin (actually blocks its effects) but blocks the symptoms of opiate withdrawal. Whether someone on Suboxone instead of heroin is really “clean” or not is a matter of semantics. Medication-assisted treatment of opiate addiction has been shown over and over to be more effective than “total abstinence.”

** Many if not most doctors who prescribe Suboxone privately charge cash for the visit, often exorbitant amounts, including monthly returns.

I feel like a cell in a body. A tiny little cell that’s part of something far bigger and more complex than myself.

It’s a body that has cancer. Not a terrible cancer. Something curable with appropriate treatment. The treatment wouldn’t be pleasant, but it wouldn’t be crippling. But it has to happen, because without it, the body really would die.

But the body has somehow inexplicably rejected conventional treatment, and decided to go with alternative medicine. Woo. Nonsense. Fantasy-based care.

“That chemo is poison!”

“The drug companies are all in cahoots, trying to keep me sick so they can make more money off me.”

“My doctor has orange hair and small fingers, and although he’s never been to medical school, he says he can make my body great again. So what do I have to lose?”

I am trembling in fear, because as a tiny isolated cell in this sick, sick, sick body, I could very well die. And there’s not a damn thing I can do about it.

It’s that time again. As the year draws to a close, various insurance plans try to finish collecting data to calculate bonus payments as “incentives” for “Quality” care. The only problem is that, as I’vewrittenbefore, all of their “Quality” measures are in fact nothing but proxies for cost, most of which I have no control over.

Back in the 1990s at the beginning of the Managed Care era, the model of the primary physician was that of gatekeeper. Twenty years later, the last vestiges of this model is the wretched “Referral,” a word which used to mean something but was co-opted by the insurance companies to become the magic key to unlock the door to specialty care. The original idea was that I could control where patients went; preferably to cheaper (sorry; more “cost-conscious”) places. Couple of problems with this:

I have no idea how much any given doctor or group charges for any particular procedure, and even if I did,

I have no control over their negotiations with the insurance plan.

If a patient wants to go to Hospital A for their procedure, the idea is that I can save the insurance company money by steering them to (cheaper) Hospital B. Good luck with that! Oh, I still refer patients in the sense that I make specific recommendations about what doctors I think would best be able to help them, but the vast majority of the electronic referrals we put in for patients are basically self-referrals. Patients choose; we type. That’s just how it works.

Some of the other “quality” measures I fall short of include:

Colonoscopies: Face it. There are a certain number of patients who just are not going to do this. (They actually say so: “I am just not going to do that.”) My panels are very small and very stable, which means that by now, I’ve talked just about everyone into it who is going to do it. All that’s left are the holdouts, which makes me look bad. Granted there are new kids on the block, technologies that rely on stool testing, which is marginally more acceptable to patients. Perhaps over the next few years, I may see my numbers on this measure turn around. But in the meantime, on paper, I’m a terrible doctor.

Mammograms and pap tests: same basic issue as colonoscopies, except that few of the insurance plans have factored in the latest evidence-based guidelines on screening frequencies. This means that while my patients may be waiting until 50 to have mammograms every other year and getting paps every 3-5 years after decades of normal tests, I fail because everyone everyone over 40 doesn’t have an annual mammogram or biennial pap.

Adolescent well visits: Guess what! Did you know that adolescence isn’t over at age 18? It goes well into your 20s, at least according to various insurance plans. Once my patients go off to college, I don’t necessarily get to see them every single year. I’d like to, but they can’t always make it. And I get dinged for not providing “quality” care.

I’m not a registered PCMH (“Patient Centered Medical Home.”) Why not? Because, as I’ve written before, a PCMH is a series of policies and behaviors to make a large practice work for the patient like a solo doctor’s office. Which I already am, and which I already do.The PCMH is something else too, though: it’s a revenue stream for the AAFP via TransforMED. My problem is that upon crunching the numbers, I don’t think I can get paid enough in bonuses and incentives to offset the (considerable) cost of achieving and maintaining the formal status of a “Medical Home.”

My generic drug prescribing rate is over 94% though. You’d think that would count for something, but somehow the fact that all my other “quality” measures bring me out almost at the very bottom of the list means I’m not holding my breath to see any “incentives.”

Whenever I get these “Quality” reports in the mail I read them over, gnash my teeth, and see if there’s anything I can realistically do differently. Then I put them away, and struggle to forget about them.

All I care about is taking care of my patients. My patients seem to think I do this pretty well. I try very hard not to spend their money if I don’t have to, which they also appreciate. I return their calls as promptly as I can, and am available 24/7 by phone, text, email, Facebook, whatever. I pick up my fair share of cancers and diabetes, and I work really hard with patients to control their blood pressure, cardiovascular and other risk factors. I think I’m doing a pretty good job. They’re not dropping dead around me. (Then again, I’m pretty aggressive at pushing palliative care, including hospice when appropriate. So when they do die, it’s as comfortably as I can manage.)

So if you look at the meaningless “Quality” indicators generated by various insurance companies, I look like a terrible doctor. But it’s because I work so very hard to ignore them. Trying to put a few more dollars into my pocket is not going to result in better care for my patients, and that’s what really matters to me.

So yes: the insurance companies say I’m a terrible doctor. And I’m proud of it.

One of the staples of the holiday is round challah, a rich egg bread in a round shape. Yesterday I experimented with creating a recipe for it on my own.

Well, not entirely all on my own. I had a ration to work with: 5:3. Five parts flour (by weight) to three parts liquid. That, plus the fact that I already know how to make bread (i.e. techniques for mixing ingredients, kneading, etc.) and away I went.

I also took pictures:

First I measured out 40 oz of flour:

That meant I needed 24 oz of liquids. I had 5 eggs left in the box, so I took one of them, separated it, and saved the white to brush over the loaves before baking. Then I threw the rest in. That added up to about 8 oz. Next I added 4 oz of honey, and 4 oz of shortening. Just for the hell of it, this time I decided to try coconut oil. I usually use butter, but this way the bread would be pareve; neither meat nor dairy, if anyone who cared about keeping kosher happened to eat some.

That left 8 of my 24 oz, so I used a cup of water which I heated in the microwave, and then dissolved the yeast in it. I mixed the wet ingredients up really well with a fork, then threw about a teaspoon or two of salt. Then I started stirring in the flour:

See that plastic yellow thing the size of a miniature painter’s pallette? That’s my secret weapon that I use to mix in the last third of the flour; it’s really more like kneading than mixing, and it works great. As it turned out, I didn’t actually use all the flour I’d measured out, because I didn’t need to. That’s where the experience came in, knowing when the texture was just right.

First rising was about an hour until doubled in bulk. Then I punched it down, and finally I shaped it into a cool round braid:

let it rise again, then brushed with the reserved egg white, baked at 350 degrees for about 25 minutes. And voila:
The end result: it smelled heavenly while baking. The crumb (texture) was perfect. I thought the taste was set enough to, but just the slightest bit bland, likely because of the coconut oil. Next time around I may use peanut oil, unless I know butter will be okay.

Twenty-seven years. More than a quarter of a century. Maybe not much in terms of a tree, but rather a long time.

Time for a babe in arms to reach adulthood, complete with a condo, live-in girlfriend, three cats, and a PhD within spitting distance.

Time for a medical practice to begin, grow, expand, and contract again until it is just the right size for a solo dinosaur.

Twenty-seven years ago today I hung out my shingle in front of a tiny basement office. I saw three patients that first day but only three more the rest of the week. I’ve had my ups and downs; overall, more of the former than the latter. Paper charts have turned electronic. Guidelines have come and gone. We’ve stopped prescribing antibiotics for bronchitis but begun using them for stomach ulcers. Open heart surgery for coronary artery disease has given way (about 90%) to balloons and stents. Too many other changes to catalogue on the spur of the moment.

And yet so much has stayed the same. Parents of newborns are no less terrified at the awesome responsibility of a tiny human. Pain, fear, grief, loneliness, and anguish haven’t changed. People who are hurting darken my door, and I consider it a victory to lessen their load, however slightly.

It’s been a helluva ride. And the best part is that it’s not over. Far from.

Twenty-seven years, and I’m still having fun. What more could anyone ask?

In an alternative line of history, I’d most likely be going down to Washington DC this weekend for a party. In this alternate history, today would have been my parents’ 60th anniversary. Falling on a Friday, dollars to donuts says we would have partied on Saturday. And what a party it would have been. 60 years is quite a long time; worth celebrating.

But my mother died thirty years ago, when she was younger than I am now. She never saw my kids or any of her other grandchildren. She never made it to the 21st century; never used an iPad or a smart phone. How she would have loved the Internet, early adopter that she was.

Then again, if that alternate history had come to pass, I’d only have four sibs instead of six; six nieces and nephews instead of nine. If I even had a daughter, she’d have a different name.

And in this timeline — which is really the only one that matters — I got to go to Washington two weeks ago for another party: my step-mother’s 80th birthday. And what a party it was! Well worth celebrating.

But for today, I’m allowed to think of that alternate history. Because 60 years is quite a long time.

For a much longer time than I’d like to admit, my dietary advice to patients was squarely in the “Do as I say, not as I do” department.

I’ve never liked fruits or vegetables. Oh, I’d eat salads, but not with tomatoes. I can’t stand tomatoes. I love cucumbers, but not the seeds. Once I discovered the seedless ones, though, I couldn’t get enough. Potatoes, of course. Onions were okay, but only cooked. That was about it.

Over the years, though, I can’t tell if I’ve become more adventurous, or just less rigid. I started adding red peppers to my salads. Then I found a magnificent recipe for a Watermelo Gazpacho, which I now eat for lunch every day.

Just to prove it to my family (ie pix or it didn’t happen) here’s my grocery cart last time I went shopping:

The real reason doctors have begun “requiring” that patients undergo all manner of screening interventions is to enhance their compliance ratios. After all, the quickest way to get to 100% is to get rid of everyone who falls short.

Hospitals across the United States are throwing away less-than-perfect organs and denying the sickest people lifesaving transplants out of fear that poor surgical outcomes will result in a federal crackdown.

As a result, thousands of patients are losing the chance at surgeries that could significantly prolong their lives, and the altruism of organ donation is being wasted.

CMS’s latest push to revamp Medicare payment systems to reward “Quality”, a word never defined except in terms of dollars and cents, has an excellent chance of being the final straw that breaks the back of medical care in America.

What on earth do anti-vaxxers and Hillary-haters have in common? I’ll tell you:

They are terminally resistant to actual, verifiable FACTS.

As has been shown over and over by numerous scientific studies, vaccines have absolutely no relationship to the development of autism or autism-spectrum disorder. None. Zilch. Zip. Nada. That association has been debunked, disproved, laid to rest. It is false.

None of that proof stops people from continuing to believe it, though. Anti-vaccine drivel drips from every corner of the Internet. Why? Because certain people want to believe. They don’t trust doctors, or scientists, or drug companies, or anyone but themselves with the well-being of their precious offspring. The irony, of course, is that trying to protect their kids from the “evils” of vaccines exposes them to the actual scourge of vaccine-preventable illness.

This magnificent article, written and originally posted on Facebook by Michael Arnovitz of Portland, Oregon, details what is essentially the decades-long slander of Hillary Clinton. His bottom line: the root of Hillary-hate boils down to plain, old, garden-variety sexism.

The PolitiFact scorecard: Hillary Clinton

I get that there are plenty of people out there who disagree with Mrs. Clinton about her policies and positions, and that’s valid. Call her a bitch, a harpy, a shrew, whatever you want; those are opinions, to which everyone is entitled.

But just like the anti-vaxxers, because you are not entitled to your own facts, when you call Hillary Clinton a liar, I call bullshit. You don’t have to like her, but you’re not allowed to make stuff up. Hillary Clinton is a woman, a lawyer, a wife, a mother, a grandmother, a former First Lady (of both Arkansas and the United States), a former Senator, a former Secretary of State, and the Democratic nominee for President of the United States. But she is not a liar.

For the non-medical reader, the Chief Complaint can be thought of as the patient’s opening statement. It’s what shows up on the schedule as the only thing I know about why the patient is there. I’ve compiled a brief and definitely non-exclusive list of the worst chief complaints I’ve ever seen; the ones that make me sigh in advance, knowing that taking the history is going to be like pulling teeth and that the patient is probably not going to be satisfied.

Thirty years after I graduated from college, I wrote about taking my youngest child to begin his career there. Damn good piece, if I do say so.

2012 was a big year in my family. Multiple graduations, weddings, milestone birthdays and anniversaries got me thinking about my mother, who by dying in 1986 had missed out on the entire lives of her grandchildren. I wrote this poem and posted it that year.

I’ve posted other things on this date, my mother’s yahrzeit, in previous years: 2015, 2014, and 2011, in addition to the above link to 2012. But for some reason, today the words “thirty years” pack a special wallop. I re-read my poem (damn good, if I do say so) and decided to post it again. (Please don’t sue me for plagiarism):

Gone too soon, gone so long, a dozen lifetimes ago;
Blankets and booties to caps and gowns; seasons change, ebb and flow.
We pause; we think; we imagine; we recall.
Piano recitals, horses to show, Frisbee, hockey, ballet,
From the sidelines of soccer to the banks of the regatta,
We daydream; what if?
In moments of silence, alone with our thoughts,
Or gathered together in the raucous din that is our joy,
The light of remembrance shines on in our hearts.
Though we only light this candle once a year,
The memories we hold are always near.
Gone so long, gone too soon, a dozen lifetimes ago;
Seems like yesterday; seems like eternity;
Dozens of lifetimes to go.

Physician suicide is an enormous problem. We lose approximately 400 doctors and trainees annually to suicide. This is a tragedy, pure and simple. Not limited to the human carnage of the equivalent of an entire medical school class or more, but, to quote Dr. Pamela Wible, “Each year more than one million Americans lose their doctors to suicide.”

What does it mean, then, when physicians who are trained in medicine — defined as the application of scientific principles to the diagnosis and treatment of human ills — turn away from reality to accept the magical thinking of pseudoscience? I submit that it is intellectual suicide. It may not seem to patients as if they’ve lost their doctors, but when physicians stop practicing medicine and embrace magic, those patients are no longer receiving medical care. There is such a thing as being too open-minded; your brain really can fall out.

Currently known as “Functional medicine” or “Integrative medicine,” it was formerly referred to as “Complementary” or “Alternative”, sometimes “holistic” or “natural.” Quackery is still quackery, no matter how hard it tries to re-brand itself over the decades. It encompasses, amonth other things, Natuopathy, chiropractic, homeopathy, Reiki and other forms of “energy healing,” and acupuncture. (Yes, acupuncture. Check out the archives at Science Based Medicine. Although widely considered to be efficacious, studies on it are fundamentally flawed. When studied properly it doesn’t work any better than a placebo. And placebos are fundamentally unethical.) Speaking of Science Based Medicine, by the way, this recent article is exactly what I’m talking about. It’s called “The Harm of Integrative Medicine from a Patient’s Perspective.” It’s riveting.

Alternative medicine doesn’t work. If someone takes it and gets better, there are only three possible explanations:

They were going to get better anyway, and would have even if they hadn’t taken it.

They didn’t have the condition in the first place. (This is likely the source of many apparent cancer cures.)

The curative intervention was something other than the alt med one. Either conventional medicine was used concurrently, or the alternative medication was contaminated with actual active ingredients. Red yeast rice lowers cholesterol because it contains lovastatin, a recognized, well-studied pharmaceutical which happens to be much cheaper (on the $4.00 generic list) when purchased in drug form rather than as a supplement.

Why are supposedly intelligent, scientific physicians drawn to pseudoscience? I actually wrote about this back in 2008. (It’s a pretty good piece, if I do say so myself.) If you don’t feel like clicking through to read the whole thing, here’s the meat:

Far from gaining a new “faith” in alternative medicine (that requires magical thinking), I believe that these physicians have lost their faith. Faith that science and rational thinking are the best way to understand the physical world around us, including the human body. How easy it is to relieve the pain of not understanding by giving in to the idea that there are answers after all; energy fields; water with memory; the “mind-body connection.” That there is also an enormous, enthusiastic, welcoming community — cult-like — merely reinforces all the new “paradigms.”

Physician suicide is a tragedy. But so is integrative medicine and all its permutations of quackery, which push magical thinking and pseudoscience onto unsuspecting patients. Intellectual suicide is just as tragic for those who have entrusted their care to us.

Dr. Wible and her young colleague have responded to my previous post: [Cross posting with her comment section, to share the clicky love as we continue the dialogue]

A few corrections to your blog Lucy:

1) I do NOT have a subscription practice. I see all-comers and I take insurance.

2) I have never turned anyone away for lack of money. I don’t believe in a two-tiered health care model.

3) Diet and nutrition is not woo (and is certainly not taught in med school). There are HUGE problems with allopathic medicine which does not prepare us to care for patients in an outpatient setting when it comes to prevention, lifestyle, and common sense things people can do to prevent taking drugs for the rest of their lives.

4) PAs and NPs are providing primary care in an outpatient setting with a lot less training and most are doing a great job. Physicians who want to practice outpatient medicine should not be held hostage to 3-4 year residency programs. There are not enough residency programs to meet the needs of current med school graduates. These students with 300K+ loans should not be sitting at home twiddling their thumbs when they could be caring for people like NPs and PAs.

5) And yes, I believe that residency programs can be shortened. How does working in the NICU help me provide care in an outpatient setting? There are so many parts of residency that could be structured in a more personalized way to meet the ACTUAL needs of patients and docs who plan to open neighborhood family medical clinics. A tertiary-care hospital-based Pharma-heavy medical indoctrination is not appropriate for everyone.

I could go on . . .

~ Pamela

P.S. I allowed my community and patients to design and define their OWN ideal clinic (which I opened based on 100 pages of their submitted testimony) and what they want and what residencies deliver are not a great match. Patient engagement is important – in fact essential – so let’s stop holding everyone hostage to a one-size-fits-all medical education system (that need to be TOTALLY revamped).

1) and 2): My bad. I seem to recall you talking about your practice being “full,” having a waiting list and so on, meaning you manage a panel. (I don’t.) Most people who do that are DPC or otherwise subscription based. Apologies.

3) Diet and nutrition (may as well throw in exercise as well) are not woo at all. I never said they were, nor does any legitimate doctor I know. However they are often used by alt med practitioners as a bait and switch for their actual woo, like naturopathy, chiropractic, homeopathy, and so on. As for that old canard about nutrition not being taught in medical school (not true, BTW) what we do learn about biochemistry and physiology allows us to understand nutrition at a much deeper level than anyone else, if we’re paying attention. In fact, truly understanding the basics allows us not to fall for each new fad diet that promises instant loss of belly fat. The really exciting new stuff about nutrition has to do with the gut microbiome, and how different people respond completely differently to exactly the same foods. Real doctors are the ones doing that research, not the ones with books to sell.

Use of the adjective “allopathic” is another flag that you’re setting up a false dichotomy between drugs and non-drug treatment, where presumably doctors ONLY use drugs. I use lifestyle measures (like diet and exercise) and “common sense” for prevention and treatment every single day. The idea that taking drugs represents some kind of failure is, in my opinion, foolish. Many people still need medications for things like blood pressure and diabetes even after optimizing their lifestyle. They certainly don’t have to “take drugs for the rest of their life,” but their lives will likely be shorter. The ability to use drugs appropriately is one of the skills developed in training. Opting out of that education is very much throwing the baby out with the bathwater.

4) Yes, there are many people providing primary care who are not residency trained physicians. However I reject your assertion that they are doing a “great job.” Google the Dunning Kruger effect: the less you know about something, the more confident you are about your knowledge. I’ve written about this with regard to PAs and NPs before. Patients love their NPs and PAs, just like they love their naturopaths, which basically means that they’re either never going to realize what lousy medical care they’re actually getting, or that if something untoward happens, they’re not going to blame them. Is graduate medical education perfect? Hell no! But fix it; don’t forego it.

5) I disagree strongly that residency should be shortened. Re-structure it? Absolutely. Spending more time in various outpatient settings, possibly free clinics where trainees can experience true undifferentiated primary care while still under the supervision of experienced faculty, would be fantastic preparation for independent practice. But one year of postgraduate training is nowhere near enough time to become familiar enough with primary care to practice safely and effectively on one’s own. All the CME in the world doesn’t make up for treating patients with someone who knows more than you do looking over your shoulder, pointing things out to you, and providing guidance. No, tertiary-care based training isn’t appropriate for everyone. Guess what! I did mine at a community hospital. Again, you’re offering a false dichotomy of “indoctrination” vs “following the dream.”

PS I’ve read all about your clinic, and I’m happy for you. Somehow I managed to wind up in pretty much the same place, but without going through the burnout phase that you did. Believe it or not, NOT everyone is driven the brink of suicide by medical training and practice.

As for “allowing patients to design and define” their ideal clinic, you have to remember that patients are not customers and are not always right. All too often they want things that are not medically appropriate. I have patients who would say that their Ideal clinic would be a place where they could get antibiotic prescriptions called in without a visit. Trying too hard to please patients can also lead to inappropriate narcotic prescribing. Slippery slope, that. I stick to treating my patients the way I want to be treated: same day appointments, communication any way they want, all labs called back personally; friendly, attentive, thoughtful, medical care. They seem to like it.

“Patient engagement” is indeed important, but it’s just the new term for what I’ve always done; involving patients in their own care, soliciting their input to treatment decisions, and providing lots of patient education. Frankly, my patients are most grateful when I take the time to explain why all those alternative treatments they found on the Internet are a waste of their time and money.

Her disciple, Kat Lopez, weighs in too:

…Did you mistake the Institute of Functional Medicine for woo-woo? You may want to check into it. The IFM is run by highly experienced MDs who have become world-renowned for their success in healing difficult diseases; the Cleveland Clinic just opened a functional medicine program because the efficacy of the approach is unparalleled (addressing the underlying causes of disease using nutrition and approaches to decreasing inflammation in the body).

Have you heard of Dr. Esselstyn or Dr. Fuhrman, eminent cardiologists who reverse severe coronary artery disease with diet alone? They’ve written several books, you may want to read one, they’re amazing. I think it should be illegal for docs to NOT reveal to their patients that there is a failsafe nutritional method to getting off their cholesterol meds, antihypertensives, diabetes meds, and gaining radiant health. Try reading up on those guys.

Also, writing off Mind-Body Medicine (I trained with Harvard’s Center for Mind-Body Medicine) as woo is a mistake – their unique approaches to mental health disorders (which I now teach as ongoing classes at my clinic), such as severe PTSD, has been shown my extensive research to far exceed the success of counseling and medication combined.

Sorry, Kat, but yes, every last modality you mention is nothing but solid woo, magical thinking, and pseudoscience. I urge you to check them all out at Science Based Medicine, my go-to site whenever I need to sort out science from pseudoscience.

On the topic of mental health, by the way, check out the writings of a wonderful young psychiatrist named Maria Yang MD. I’ve been following her through training, board exams, and now practice. She avoids the stereotypical portrayal of psychiatrists as the ultimate drug pushers without ever invoking the kind of woo at Harvard (no, the name doesn’t impress me) and elsewhere. Food for thought, as you say.

I like Dr. Pamela Wible. I think she’s doing fantastic work bringing attention to the tragedy of physician and medical student suicide. We also have similar practice styles (solo, unhurried visits, total communication) although hers is a subscription practice and I still make do with insurance. Also, she’s monetized it with the title Ideal Micropractice, an organization which costs $250 a year to join. After 26+ years, I’m pretty comfortable with my version, which is ideal for me, and can’t see paying for the privilege of sharing what I’ve learned. (I just offer it for free to anyone who asks.)

But her latest blog post, titled “Yes! You can open your dream clinic — without completing residency” crosses the line.

A video of a frustrated young resident, complaining that her residency was just training her to become a “robot doctor”, waxes rhapsodic on the joys of dropping out and opening her own practice. Complete with naturopathic medicine, acupuncture, “body work” (whatever that is; massage?) and “functional medicine” of course. All with the approval and support of her marvelous mentor, Dr. Wible.

Granted Dr. Wible lives in Oregan, where the woo flows deep and fast (ie, “alt med” is widely accepted.) But just because lots of people believe in unscientific nonsense dressed up as “medicine” doesn’t alter [see what I did there?] the inconvenient realities of science, human disease, and medical treatment.

Why stop at dropping out of residency? Medical school is dehumanizing and abusive. Why bother with it? Just take a few online courses and open up your Alternative Wellness Center right out of college. In fact, why even bother with college. Or high school. Wisdom from the mouths of babes, you know. Harness the healing power of innocence!

More from the dropout:

I started to realize that I have all of the emotional intelligence, the educational prowess, the passion and the drive to truly live my personal dream…

Sure, you can drop out of residency and open your own clinic. But no, you are not qualified to do so as an actual doctor. I’m sorry, but being a doctor takes more than emotional intelligence, educational prowess (whatever that is), passion and drive. It takes training and experience — more than you can get after only one year and a medical degree.

And by the way, those 1-year DO internships “intended to be adequate training for primary care” are a long gone thing of the past. Even DOs recognize the need for at least 3 years of postgraduate training. And some very good cases have been made that maybe even that isn’t enough.

Real medicine is hard. You’re not going to be able to cure everyone, or give everyone what they want, or make everyone happy all the time. Too often people come to us with unrealistic expectations. Alt med feeds into this by providing unrealistic solutions. Until you actually get sick with something that needs real medicine to treat. And if your alt med practitioner can’t even recognize that, you’re basically dead. When you didn’t have to be, that is. Sadly, I know lots of people who have heeded the seductive siren call of alt med — and most of them completed residency. Intellectual integrity is really really hard; maybe harder than medicine. But there is no excuse for turning away from science, AKA “reality” in our quest to help.

Humanize medical school and residency training? Absolutely! But don’t try to pretend that they’re unnecessary.

More than half of all doctors in this country are saying, “I really feel that some aspect of my work as a doctor is making me feel burned out.”

This is really trouble. It’s trouble because a doctor who feels this way can commit more errors. They suffer from compassion fatigue, or just not being able to empathize with others because they have their own emotional issues. They may retire early, thereby reducing the workforce. They may have problems managing their own lives; 400 doctors committed suicide last year, which is double the rate of the population average. There’s trouble for patients in having a workforce that’s burned out. There’s trouble for doctors in terms of their own health and well-being. We don’t talk about it much. We like to think that doctors can handle everything, but it’s clearly not true. It’s a problem and there ought to be some solutions.

Sing it, brother! Couldn’t agree more.

Unfortunately, he offers some “solutions” that frankly cracked me up:

One type of fix is to make sure that hospitals and other healthcare environments try to create better conditions for a happy workforce and for happier doctors. This might include yoga, mindfulness training, having more therapists to talk to, encouraging people to come forward when they feel this way, peer groups, and better mentoring.

Are you kidding me? Physician suicide is out of control and you’re suggesting yoga? Seriously, Art??

Want to fix physician burnout? It’s a ridiculously simple process with only two components:

LET US DO OUR DAMN JOBS.

PAY US APPROPRIATELY.

That’s it. As professionals, internal motivations far outstrip external ones. We became physicians to help people, not to enter data into computers or check off boxes for billing clerks. Let us get back to doing that without administrators and bureaucrats breathing down our necks, compensate us fairly and transparently, and watch burnout disappear.

I was showing off my phone to a friend who isn’t quite a Luddite, but who only carries a “dumb” phone. He was impressed with all the things I could do with Siri, even though I don’t really use her much at all in my day-to-day life. However, there are other voice-controlled features that I do use sometimes, with particularly amusing results in this case.

DDS was out to dinner (yes, without me; it happens) and I wasn’t sure if he’d given the dog his second dose of medicine before he’d left. No biggie, I thought; I’d just shoot him a text. Just to save some time, I decided to use the dictation feature.

However what my friend saw was me speaking into the phone saying, “Has the dog gotten his pill yet tonight?”

There is no conflict between science and religion (or at least there shouldn’t be) because they have fundamentally different purposes.

Science is the word we use to describe the process of discerning the physical world around us. We use our senses to make observations, which we then use to make hypotheses, which we then test with further observations, which we call experiments. Gravity, temperature, microorganisms, photosynthesis, and many other things and processes that exist can now be described with great accuracy thanks to science. Science is the only way to understand the universe around us; what it is and how it works.

Religion isn’t really about understanding. Religion is about emotion. Religion can (or should) provide hope in times of fear, comfort in times of grief, and even greater joy in times of happiness. Religion provides an emotional context to the world around us, and helps us come to terms with the unknown.

Ah, the unknown. That’s where science and religion come to blows.

Science says there is no such thing as “the unknown,” only “the not yet known.” Religion butts in where it shouldn’t by claiming to know “everything,” even when most of it consists of making stuff up. This is the opposite of science, but when you don’t understand or refuse to believe science, it’s all you’ve got.

Science steps on the toes of Religion by discounting its importance to very large segments of humanity. The definition of faith is “not requiring proof.” Whether or not I understand how sunlight is refracted by atmospheric water vapor, seeing a rainbow still feels holy.

Intellect and emotion are the yin and yang of the human psyche. As humans, we do ourselves a disservice when we try to divorce ourselves from either. I have no qualms about considering myself a scientist into the very fiber of my being, while still lighting a candle and reciting ancient Aramaic words on the anniversary of my mother’s death.

There seems to be a great deal of misunderstanding about Medical School. There are valid questions about curriculum, defined as what should be taught, and when, and who should teach it. But recent calls for students to “gain fluency in [health] systems” are completely misplaced. Here’s why.

What do you need to know to be a doctor?”

IT DEPENDS.

What kind of doctor are you going to be, and what kind of setting are you going to practice in (if you’re going to practice at all)? Because what you need to know to be a self-employed general surgeon in a rural area is completely different from what you need to know as a hospital employed pathologist. Or a suburban solo family doctor. Or an urban pediatrician. Or an academic rheumatologist.

It’s neither possible nor appropriate for medical school to claim to teach everything every kind of doctor needs.

The good news is that actual medical schools and other institutions involved in medical education really do understand this. As always, it’s the suits, bureaucrats, consumers, politicians, and policy makers who stridently insist that this or that “needs to be taught in medical school,” when most times all they’re doing is taking valuable time away from what really needs to happen in medical school.

What is medical really about? Two things.

First, you need to learn a huge volume of basic information about the human body, how it works, and how things go wrong with it. That includes anatomy (gross and micro), biochemistry, physiology, pathology, microbiology, and pharmacology. That’s your first two years right there. Most of the other stuff (statistics, sexuality, ethics) is to keep you from going crazy, but the firehose of information is the whole point. Although the testing process makes it seem as if you need to memorize it all, you really don’t. There’s nothing wrong with knowing where to look things up. BUT you need to know about it. That’s the main difference between PA and NP training (and what leads to the not-knowing-what-you-don’t-know debacle).

Next, you need to learn to apply all this information to the process of dealing with actual humans. This includes learning how to elicit information from your patients (how to take a history, a skill you then spend a lifetime refining), performing a physical exam, and interpreting diagnostic tests and imaging.

Notice that you don’t learn a whole lot about treatment. That’s because treatment is what you learn AFTER you are technically a doctor, in postgraduate (residency) education. That’s where people learn to be whatever kind of doctor they’re going to be. Each specialty uses the material from medical school in different proportions. Surgeons use their anatomy knowledge a hell of a lot more than psychiatrists. Pathologists don’t use as much of their pharmacology as pediatricians. And so on.

I like to say that undergrad teaches you what you need to get through the first two years of medical school. The first two years of med school teach you how to get through the second two years. And medical school teaches you what you need to know for residency, which is where you actually learn to be a doctor.

All this other crap, like “systems” and contracting and payment models are important to know about, but not in medical school. Valid concerns have been raised about the current structure of med school curricula, but losing sight of its primary aim — learning what you need to know TO BECOME a doctor, not TO BE one — isn’t going to help.

There’s a proposal in Philadelphia to tax sugar, specifically sugar in beverages like soda, sweetened iced tea, energy drinks, and other sugary beverages, and I know you’ll be shocked — shocked! — to hear that there’s a robust advertising campaign gearing up against it:

The American Beverage Association, a national trade group, has been running radio ads since March calling it a “grocery tax on the kind of drinks we buy for our family.”

I’ve heard the radio commercials: a woman’s voice (I’m pretty sure she’s supposed to sound “black”) complaining about how much the new tax will add to her grocery bill. To which I respond, Cut me a break! No one needs soda, or other sweetened drinks. It’s an expensive luxury that’s not even good for you, as I tell my patients with diabetes, many of whom are obese, over and over and over.

We’ve been telling parents for years that children should only drink water and milk. Even juice has been a no-no for quite some time now. But that doesn’t seem to stop anyone from getting their children addicted (yes, I’m using that word on purpose) to sugary drinks.

What’s really happening here?

Sugar in large quantities is bad for you. No, it doesn’t make kids hyper, but it does cause rapid fluctuations in blood sugar, insulin spikes, and weight gain, which in turn contributes to obesity, heart disease, and in susceptible individuals, diabetes. It can also cause cravings, leading to more sugar consumption, and so on around and around in a vicious cycle. Sugary beverages are one of the major sources of excess sugar in the American diet, so anything that results in less consumption of them stands a pretty good chance of being good for health.

Interestingly, though, Philly isn’t touting this as a nanny state scheme to get people to drink less sugar. That’s more of a desirable side effect. They’re earmarking the tax revenues to pay for universal Pre-Kindergarten, which is another intervention shown to improve school achievement, especially in children from impoverished backgrounds. Who could argue against helping out the kiddies?

Here’s my take: Sugar is just as bad for you as tobacco. No one seems to have any trouble with steep tobacco taxes, which are just as regressive as the sugar tax; the higher your educational/socioeconomic class, the less likely you are to smoke OR be obese. So if you want to keep damaging your health by swigging down gallons of sugar water, the least you can do is give back to your community. You’ll be “taking” from them plenty as your diabetes gets worse and you start having heart attacks and strokes. Then again, all you have to do is make do with water. More money in your pocket and better health as well. The ultimate win-win.

All we have to do is stand up to Big Sugar like we eventually did to Big Tobacco. They’re killing us just as surely.

Reconciling medication lists — keeping them up to date with a patient’s correct meds — is an important task that I try to do at each visit. Sometimes a patient has stopped taking a pill for some reason: it was too expensive, or another doctor told them to. They may be taking new meds from different doctors. Sometimes, thanks to the way my EMR handles electronic refills, I have duplicate entries on the list.

True story:

Reconciling the med list for a diabetic lady the other day, I noticed that I had two entries for metformin. The first was correct and had her current dose (two pills twice a day, increased from the previous visit.) The second must have been a pharmacy-generated duplicate.

“Oops,” I said as I set about correcting my records. “It’s in here twice.”

“Is that because you told me to double up on it?” she asked.

After LMFAO, I asked her if I could blog the story. Not only did she agree, but she begged me to use her name. I declined. She asked why. I thought about it and realized I don’t use real names on this blog for anyone. Not for my kids or other members of my family, much less patients. The closest I’ll come is real initials. SO; this one’s for you, GP.

Being a doctor is hard. There’s a lot you have to know, whatever specialty you go into, and that includes rote information about how the body is put together, how it works, how it goes wrong, and how to fix it. We also must always keep in mind that these are people we’re dealing with, not just bodies, so we need to learn how to take care of sick people.

As doctors, our job is to figure out what is wrong with our patients (diagnosis) and what to do about it (treatment.) We don’t necessarily do this all by ourselves. We have colleagues who help us by performing consultations, studies, and procedures. But the bottom line about being a doctor is we are the ones who make the diagnosis and figure out the treatment, even if then carried out by others.

We can also turn to many other people who can help us take care of our patients: nurses, physical therapists, social workers, home health aides, and so forth. They can help provide us with information, sometimes crucial, that help us make the diagnosis or refine the treatment. But diagnosis and treatment is the definition of medicine. It is our job as doctors.

Medical school is where we begin learning how to be a doctor. It’s a process that continues through postgraduate residency training, and throughout decades of practice. It is laughable to think that medical school is the only place we’ll ever learn what we need to know. It’s four years that seem forever at the time, but in retrospect seem scarily short. Same thing for residency. Looking back, Imposter Syndrome seems entirely justified.

Of course it’s vitally important that those four years are used wisely. Which is why things like this really piss me off:

Many medical school students don’t know the difference between Medicare, which is for seniors, and Medicaid, which is for the poor.

It doesn’t hold them back in medical school. But after they become doctors, not knowing the basics of the health care system can prevent them from understanding why their patients can’t do or get the things needed to be healthy….

The AMA’s Dr. Susan Skochelak said “what [doctors] haven’t been good at is often what patients care the most about.” That includes things like finding their way through the health care system, understanding what their health care providers are telling them, and overcoming financial and other barriers that might prevent them from taking medications and otherwise following their doctor’s orders.

In addition to everything else we have to know, med schools are adding “Health System Fluency” in order to fix this grievous defect in medical education. Students will now be:

[S]ent to a local family medical practice, and given the role of health care “navigator” for three patients.

Her role involved becoming familiar with the patients’ ailments, talking to them on the phone and visiting them at home. In the case of one who claimed to be taking prescribed medications, but whose blood work suggested otherwise, a home visit by [the student] revealed the patient’s neurological condition prevented the patient from opening childproof bottles, resulting in missed doses. Contacting the pharmacist provided a remedy.

Another patient who had a high sodium level told of regularly dining on spaghetti with red sauce, which didn’t seem like a problem. But [the student] in her navigator role discovered the patient was eating canned spaghetti that was very high in sodium.

Leaders of the effort say doctors need such glimpses into the real lives of patients in order to fully grasp their illnesses and fully serve them.

Hey, I get it that home visits provide tons of information. Even though we may not have done them in medical school (mainly because we were still too busy learning all the basic stuff we didn’t know yet) of course we were taught that the hospital environment was terribly different for our patients. I did house calls in residency, where they taught me how to function in an environment other than the exam room or hospital ward.

Look again at what Dr. Skochelak lists as things doctors haven’t been good at that patients care about most:

Finding their way through the health care system

Understanding what their healthcare providers are telling them

Overcoming financial and other barriers that might prevent them from taking medications and otherwise following their doctor’s orders

Everyone talks about the “health care system” as if it’s a thing. What the hell is the “health care system” anyway? One of the most important things to help people “find their way” would be hospital signage. Where do they park? Where do they check in? Where are they supposed to go? I can and do give people very detailed directions and instructions, but a lot of this “system” stuff isn’t medicine and doesn’t require 7+ years of post-college training to provide.

Understanding what we’re telling them? All through medical school, even as we learned the specialized terminology of our profession, our jargon, we were also told not to use it when talking to patients. Some of us are better at it than others. I often listen to other doctors talking to my patients and cringe. But just because many people don’t use clear enough language when speaking with patients doesn’t mean we weren’t taught it. Keep teaching it, by all means, but don’t kid yourself that this is something unique to 21st century medicine.

And what about these barriers? Already in medical school we are taught to use simple regimens (once daily medication dosing whenever possible), generic medications, easy-open pill bottles. We know this stuff. Again, we may not always do it as well as we could; some more than others. But there’s nothing innovative about it, despite the fact that medical schools are finding new ways to siphon away precious curriculum hours.

Here’s what I want to know, though: how is doing the work of a visiting nurse or social worker going to help medical students with any of those three things, or anything else, for that matter? You can list objectives, but what good is it to design a program that doesn’t address any of them? It may achieve different objectives, but are they worthwhile ones? Seems like rather a bait-and-switch to me.

Here’s their bottom line:

Without a solid understanding of the health care system, doctors can’t fully function as “change agents,” said Dr. Jed Gonzalo, the associate dean of health systems education at Penn State Hershey College of Medicine.

I’m a doctor, dammit, not a “change agent.” Whatever the hell that is. Medical students need to learn to be doctors, and not let themselves be sucked into the “system.”

In the end, the best way — the ONLY way — to help the patient is to be the best damn doctor you can.

Dear Dr. Dino:Would you consider writing a blog entry on medical trials? Clearly medicine wouldn’t make much progress without them, but to put it in patient vernacular, they seem very scary…[Details about a specific medical condition and a chance to participate in a clinical trial that]…[I]nvolves a cutting-edge technology and drug which might at some future date be shown to cause serious, unanticipated health problems. I am at a loss trying to balance the benefits with the hazards……[W]ould you be willing to write a column that details an organized way of thinking about medical trials, and some of the questions that patients should ask?

Obviously clinical trials are important. Few people like the idea of being “guinea pigs” or “experimented on.” Fewer still are altruistic enough to participate with an endeavor explicitly for the benefit of others (for “science”) when there is none that will accrue to them (at least when clearly so stated. The vast majority of late stage cancer treatments fall into this category, and too often patients and families are allowed to believe it could be a “miracle” for them when it really isn’t. But I digress…)

Participation in clinical trials requires a much more detailed Informed Consent form than most routine medical procedures. These consist of pages upon pages of detailed descriptions of the proposed interventions, side effects, risks and hazards. Frankly, they work very hard to downplay the benefits, which I think is fair. Thus, a full reading of the consent form will usually provide most of the necessary information. The main thing you need a doctor for is to make sure you understand all the terminology and exactly what the form is saying.

After that, the decision really is up to you.

I understand that being faced with a long list of risks and benefits can be daunting. The old advice to write down all the pluses in one column and all the minuses in another and then see which is longer isn’t usually all that helpful in real life. I find whenever I do that exercise, I end up trying to justify the decision I really want to make.

Which means that balancing benefits and hazards comes down to very personal values; how much are you willing to risk (potentially) for how much (potential) gain? It always comes down to your gut.

But it has to be yours! Mistakes and misgivings come from trying to substitute someone else’s feelings/reasons/values for one’s own, which usually happens in high stakes decisions and people you care about a great deal. ie Older person willing to forego cancer treatment but acquiescing to kids/grandkids “You can’t die! Do it for us!” and ending up miserable.

I don’t think there is any way to “organize” those thoughts. After you’ve read the consent form and everything else you can get your hands on about the condition and the study, go with your gut, and know that it’s okay to do it that way. Ultimately, it’s a decision you do not have to justify; not even to yourself.

The title is in quotes because it’s also one of the alt-texts for the cartoon.

The other is, “I await your hatemail, pertussis enthusiasts.”

I love this guy. I recently supported the Kickstarter for his latest book Religion: Ruining Everything Since 4004 BC, and got great use out of the Mini Bible (“Abridged Beyond the Point of Usefulness”) on my recent trip to Israel.

Apologies to Mark Twain, but reports of the death of private practice are somewhat exaggerated. There are still plenty of us around and most of us are making out quite well. Not all, though. I’m quite sure the howls murmurs of discontent have reached many ears by now. So much so that many doctors unhappy with the status quo have taken action. One such action is to “go Concierge.”

“Concierge” practice, also known as Retainer medicine, is basically an arrangement where the patient pays a fee up front (generally quoted as an annual figure, often payable in monthly installments) for the doctor’s professional services.The idea is that for their usually rather hefty annual payment, the patients receive “enhanced” services, most often as longer, more leisurely office visits, and greater access to the physician, typically his cell phone number.

Here’s the thing: I’m already doing all that. Standard appointments are thirty minutes; longer if you need them, same day if necessary. As for my cell phone, all you need to do is ask. Actually, if you want me to text you with test results, you’ll have my cell number forever after. No one has ever abused it, just like my residency director told me thirty years ago (though he was talking about the home phone number; same idea.) Leisurely appointments whenever you want them and total access all the time.

Ah, but what am I getting paid for all this, you ask? As long as I’ve been in practice, I’ve taken almost all insurances. How do they pay? Put it this way: I’m not getting rich, but I’m not starving. Still, I’m providing Concierge level care at insurance prices. Why do I keep doing it?

After all this time I’ve amassed an incredibly diverse patient panel (even though I don’t know how big it is) encompassing a wide span of socioeconomic class. Working class folk, professionals, white and blue collar workers alike are equally welcome. I can’t afford to give away a lot of free care, but once you’re an established patient, I’ll work with you on payment issues for as long as you need. I like it this way. Just as Family Medicine doesn’t limit me to one organ system, gender, age, or set of diseases, taking all insurances provides me with a further variety of patients; people from all different income levels and walks of life.

That means one big reason not to go Concierge is so as not to betray the 99%, or whatever fraction of my patients couldn’t afford the annual fee. Besides, the actual transition would be nigh impossible, since I’m not sure what more I could do in the way of “customer service” than I already am.

There’s another more subtle issue, though, that I’ve seen more outside the office setting; mainly from friends who have signed up with Concierge doctors. The amounts of money involved tend to create an entitlement mentality, shifting the physician into more of a “servant” role, running the risk of compromised medical care. My concern is hearing a patient say something like, “Hell, for $2000 dollars a year, the least you can do is give me some goddamned amoxicillin.” Frankly, dealing with stuff like this scares the crap out of me.

I’ve actually looked into Concierge, finding out exactly what’s involved. I spoke with a reputable company, including many doctors who were pleased with them and were incredibly happy with their new practices. I thought about it long and hard. But in the end, the two things above (deserting my patients, and dealing with newly enhanced entitlement issues) confirmed that this is not the right model for me.

There’s a variant of this known as Direct Primary Care in which the fees are much less, and the contracting is generally month-to-month. While it’s an awesome new model that I may embrace sometime in the future, it’s still not right for me now. Why? To be continued…

Now and then I get requests for guest posts on my blog. To date, I have never allowed them. However this time, I am prepared to make an exception for my Dearest Darling Spouse, who asked if he could add to the Back-Dated Travelogue on our Israel trip:

I think Dr. Dino’s travelogue posts provided a nice overview of our trip, some of the marvelous sights we saw and things we experienced. I’d like to thank her for the opportunity to add some of my observations.

Several people both before and after our trip asked us if we had concerns for our personal safety. Beforehand, we responded that we felt confident the tour operator would do whatever was required to assure our safety. Upon our return, we can confirm that we did indeed feel completely safe at all times throughout our stay, which included walking around on our own and taking public transportation. In fact, the cold, blustery, rainy weather had a greater impact on our itinerary (via the washed-out road to Masada) than anything related to security. Bottom line: we were never in any danger.

The most compelling parts of the trip for me were the visits to Yad Vashem, and the military cemetery at Mt. Herzl. The impact of walking in the darkness of the Children’s Memorial is indescribable. The sight of Mike Levin’s grave, and my sister’s reaction to finding the grave of the child of friends of hers, had a very deep impact on me that will never be forgotten.

The real highlights for me, though, were the things that were unplanned and unexpected, like discovering that our guide at the Western Wall tunnels and I had been at the University of Delaware together in the 1970s, and sharing our study session at the Jordan river with two bored IDF soldiers.

I too hope to return someday, if that is G-d’s will. Though in the meantime I agree with Dr. D that there is nothing better than Shabbat in Jerusalem.

The flight back was much calmer than the one over. We even got to sleep some, though of course not nearly enough. Having left New Jersey in over two feet of snow, we were less than thrilled to return during another snowstorm. At least this one was slated for more northerly climes, and it stopped the moment we crossed the Delaware river. Still, it was a gray, messy, slushy, miserable drive.

We were both seriously jet-lagged for several days. We even ducked out of our traditional Super Bowl party at halftime to go home and pass out. The nice part about conking out between 7:30 and 8:00 pm was that I awoke on my own, refreshed, around 4:00 am, which let me get to the office bright and early enough to clear up all the accumulated busywork there.

A friend at the party asked, “What was the one biggest highlight of the trip?” I couldn’t answer her. I could come up with the highlight of each day, but so much of it was so very special that there was no way a single moment could truly sum it all up.

I know these posts have been terribly superficial; mainly an excuse to share a few of my 200+ pictures. Even the journal I kept couldn’t keep up with it. Luckily I have a notebook full of readings and texts, only some of which were used in formal study sessions, to go back over again, when I get the chance.

All in all, it was the kind of experience that pleads to be experienced in real time, in the moment, as events unfold, without trying so overly hard to keep a record, whether photographed, handwritten, or blogged. I’ve got my memories — which I’m happy to share with anyone who’s interested — but they’re still mine to treasure. And I shall.

The last day of the tour, and it was back to Mount Herzl, this time for to see the tomb of Herzl himself, the guy who started the ball rolling toward what is now the State of Israel. We also toured the military cemetery there, which included the graves of many of the Prime Ministers.

Herzl’s tomb was a square black marble slab sitting in a circular plaza, itself surrounded by enough wide open space to accommodate the annual Israeli Independence Day festivities held there. Herzl never actually lived in Israel, as it wasn’t founded until after his death. So at his tomb the irreverent thought came to me that here, he was a square peg in a round hole:

The military cemetery was very different from Arlington. Instead of wide open fields of green covered with acres of white crosses, this was terraced into a hill and thick with trees. The graves, identical for all ranks, look like beds: cream colored brick biers about half a meter high with a blanket of rosemary, and a headstone that looks like a pillow. Five star generals rest between privates, corporals, and the current Prime Minister’s brother. In death, all are equal.

Some of the newer graves were a little more personalized with things like flowers and flags. Turns out the military authorities understood the need to accommodate mourners’ needs.

We headed for the memorial for Ethiopian Jews who died on the way to Israel. Much of the group took a longer, more circuitous route in order to avoid a rather steep flight of stairs. But our guide led me and several other more hardy souls up the more direct route. At the last tier of graves, we stopped for a moment. To our right were three soldiers who had died the same day in the 2006 war with Lebanon. I gasped.

The one on the left was plain. The one on the right was unusual in that it had a picture of the soldier, which was what the guide wanted to show us. A young Ethiopian kid, his machine gun slung over his shoulder. So young. But the one in the middle…

I’d had a vague recollection of a kid from Philly who had made Aliyah [moved to Israel] and died while serving in the Army, but I never would have dreamed of asking to try and find his grave. But here it was. Michael Levin, from Bucks County, PA. At the head were two Israeli flags. Covering the stone were patches and medals and dogtags. Off to the left was a pile of baseball caps, mostly Phillies. There was a bar rigged up that held lanyards and kerchiefs and more flags. The bed was piled high with stones, bracelets, knick-knacks, cards; library cards, college IDs, drivers licenses, all kinds of things. It’s the custom on visiting a Jewish grave to leave a small stone or pebble atop the marker, but this was staggering.

My Dearest Darling Spouse nudged me and pointed something out. Near the bottom, under a Temple University guest pass and an ID bracelet, sat a yellow and red Wawa gift card. The same as the one we’d left for the Jock (almost exactly four years younger than Michael) to use while he was house sitting for us. That’s when I lost it. Laughing, crying, I couldn’t tell the difference, but neither could I stop the tears.

DDS was silent. He was thinking about his previous visit to Israel when he was 17, in 1968. At the time, he told me, he’d considered staying. He did the math. He would have been 22 in 1973, the year of the Yom Kippur war, the same age as Michael when he was killed.

That could have been him.

Without a word, DDS slipped the lanyard with his ID for the tour off his neck, and added it to the dozens of others swaying in the gentle breeze of Mount Herzl.

As we pulled into the Yad Vashem complex, we began in the Grove of Righteous gentiles. Walking over to a random group of benches (that [our guide] swore was indeed random) what do I see but a plaque bearing the names Jan and Miep Gies, from Holland. Anne Frank’s Miep! Tears began to well up.

It feels blasphemous to say it, but all…the readings and discussion felt like a distraction. Every other thing [our guide] said sent me off onto my own thought tangents. Even if I’d tried to share them, it wouldn’t have worked into his conversational flow. So I held them, like shells collected on a beach for their odd colors or interesting shapes.

The grove: all those trees; so many who helped. But the only names there were those who were known. How many more? How many people helped — or tried to help, failed, and had to live with that — without anyone ever knowing about it? A huge part of the Shoah tragedy is the idea of people not just dying, but of being forgotten. They’re trying so very hard to compile those names and those stories, the six million. But what of the forgotten Righteous, the unknown among the Gentiles, who also helped but have no tree, no plaque, no little numbered tag to cross-reference their story in the Archive? To them, as we stood to go, I offered a silent collective “Thank you.”

…Then the museum. So many words. Pictures and artifacts and stories. So very many words. There must have been more than six million words, but it still wan’t enough. Never enough. How could there be? How can mere words ever manage to convey the totality of it? It started seeming presumptuous to try. But we are human, and words are the way we share our stories, along with songs, and pictures, and objects, which then in turn need even more words of explanation. All in vain. Trying to explain the inexplicable.

Not enough words. Never enough words.

The Hall of Remembrance specifically calls for silence. That didn’t stop our group from saying Kaddish, though even if the group hadn’t done it, I had every intention. They were just words, but they felt right.

The Children’s Memorial. No words. Just five candles, and enough mirrors to create an infinite expanse of specks of light: all the descendants who never existed, of a million and a half murdered children. Walking through it in the dark was terribly disorienting, as I’m sure it was meant to be.

Engraved in the concrete arch over the exit, words from Ezekiel:

“I will put my breath into you and you shall live again, and I will set you upon your own soil.”

At the exit from the museum stood a podium with a book. Blank pages. No lines. And a blue ball point pen. I picked it up and wrote without thinking:

Marble Dinosaur Eggs:

Beverage Alerts:

To obtain reimbursement for keyboards, monitors and other computer equipment ruined by spewing liquids,
email place of purchase, original purchase price and sales clerk's mother's maiden name to:
sorryaboutthat@toughshit.wtf