How to Find Nice People

Deep Creek Trail, Great Smoky Mountains National Park

There is so much rudeness and meanness in the world that I sometimes wonder, “Where have all of the nice people gone?” I do not know where all of them have gone, but based on 6 days of first hand observation I have reached the conclusion that a great many of them are in Tennessee. I have experienced so much kindness, goodness and politeness this week on vacation that I may go into withdrawals when I get home to California.

We have been in the Smoky Mountains this week (which, unbeknownst to most of my California friends, is a huge national park and tourist area) watching the leaves turn orange, red and yellow, listening to Southern Gospel Music at Dollywood, and eating unhealthy amounts of fried food. Wherever we found ourselves, it seemed every waiter or waitress, cashier or attendant took an interest in where we were from and in making us feel welcome. The people reminded me of the dog from the movie “Up”, it was if they all felt that they had just met me and they loved me.

Today we went for dinner at a place called “Elvira’s” a café about a mile from the cabin where we have been staying. We received the typical warm and friendly greeting but this time with a twist. It was given in a distinct Russian accent! The owner of the place, a woman in her 30’s, had emigrated from Siberia a little over 15 years ago. In typical Tennessee fashion, she took the time to share her story with us as we finished our dinner.

She was a linguistics major in Russia specializing in British English. She traveled to America to work on her language skills (She said that at the time her conversational English primarily consisted of, “Pardon me, but can you repeat that?”) She knew very little about our country and her knowledge of US geography was limited to New York, Los Angeles and Texas. She did know that she wanted to see American rollercoasters and therefore eventually ended up in Pigeon Forge, Tennessee at Dollywood. She fell in love with the Smoky Mountains and never wanted to leave.

She moved here, became fluent in the language (She can pull off a perfect southern accent), and eventually became a citizen. Seven years ago she opened her own restaurant. She told us her family marveled that all she had to pay for the government permit was the $20 business license fee at city hall. Her Uncle Sasha couldn’t believe it and kept asking her who else she had to pay off! She spoke with joy at her good fortune in being able to live in America and be an American. Freedom is a gift she clearly appreciates and values.

This appreciation of America was something we saw displayed several times this week. One of the gospel groups we heard sang a version of “I’m Proud to be an American” during their show. The entire audience rose to their feet and sang along. We went to a family dinner show another evening that closed with a medley of “America the Beautiful” and “God Bless America”.  The entire audience, similarly unprompted, also stood and joined in, and applauded loudly. They love their country.

Things in Tennessee were much simpler, slower, and more genuine than they are in California. The area is nowhere near as affluent as Orange County, but the folks here seemed happy, content and grateful. It was a good week. Hopefully I will be able to bring some of the nice home with me.

Surprised by Cancer

The patient’s symptoms defied explanation. He wasn’t sleeping, felt as if breathing was a chore, and had persistent pain in his abdomen that wrapped around into his back. He had been suffering for weeks and was at the end of both his physical and emotional ropes. Multiple physicians had already been consulted, dozens of lab tests had been ordered, and a stomach specialist had even put a camera down his throat to check out his stomach and esophagus. No answer could be found.

I was not hopeful. His symptoms were unusual individually, together they were beyond confusing. As intense as the symptoms were, they did not fit any diagnosis with which I was familiar. After hearing his story and performing a brief exam I sat quietly and thought, completely dumbfounded. Other doctors, similarly perplexed, had told him that he was having anxiety. While this was a possible explanation (and an easy one at that), it didn’t make sense to me. I had seen hundreds of anxious patients over the years, many with physical symptoms, but none whose complaints matched his.

I went over his labs again, looking to see if anything had been missed. His potassium had been off, and I remembered that abnormalities of cortisol production were often associated with changes in potassium levels. It was a diagnosis I had seen only once, and that was over 20 years ago, but I went ahead and ordered the test.

That night I sat at my computer and searched for other possible causes. I read about rare conditions I had never seen before and vaguely remembered from medical school. Nothing fit. I decided that if the cortisol was normal I would blindly look everywhere I could. I knew I would probably not find an answer, but I was determined to be thorough in my search.

The cortisol test was normal, so I decided to order imaging tests. Deciding which tests to order was also a challenge. His symptoms were nonspecific so I was not sure where to start, what body part to image first. Frustrated and uncertain, I decided to order CT scan images from his neck to his waist. I doubted I would find anything but I could at least tell the patient I had tried.

He went in for the scans the next day. The phone call from the radiologist came the day after. “I am not sure why you decided to include the abdomen in your order, but it is good you did,” he said, “he has a 5 centimeter mass on his right kidney.”

I felt the color drain for my face. “Oh crap,” the words came out of my mouth involuntarily. 5 centimeter kidney masses are always cancer. I did not know whether it was dumb luck or divine intervention, but I realized that my decision to take pictures of everything may have just saved his life. Importantly, the scans showed no signs of spread, suggesting we may have caught the cancer in time. I could not explain how or if the cancer was related to his symptoms, but I had found it!

I spent the next few days reflecting on the near miss, on how easy it would have been to not order the tests, to refer him elsewhere or blame anxiety. I realized that I had found the cancer not because I knew what I was looking for or because I understood his presenting symptoms. I found the cancer because a patient was worried that something was wrong and I believed him. 

My reflections included memories of times when I did not believe worried patients as I should have, of concerns I may have dismissed and diagnoses I may have missed. I promised myself to be better in the future. I cannot always know, but I can always listen and I can always care. 

- Bart

A Powerful Movie with an Important Lesson

I knew the story well. I read the book when it was first released and contributed to the crowd funding campaign that helped launch the movie. I knew the details, knew the outcome, and knew what to expect in almost every scene. Nevertheless, my knowledge was insufficient to constrain my tears. At several points in the movie my eyes overflowed. Anger, disgust and sadness rose within me at the horror depicted and my emotions took over. The movie is Gosnell: The Trial of America’s Biggest Serial Killer.

The movie is powerful, and it may be the most important movie you have never heard about.

Gosnell was a gynecologist in Philadelphia who ran a private abortion clinic. He specialized in abortions other doctors wouldn’t do. Many of them shouldn’t have been done for legal reasons. Pennsylvania law, similar to the majority of states, prohibits abortions after 24 weeks of pregnancy, the age at which many babies can survive outside the womb. Gosnell ignored the law and routinely provided late term abortions, including on babies at 30 weeks of gestation or more.

Term limitations for pregnancy terminations were not the only laws he held in contempt. He did not adhere to the most basic health and safety regulations. He reused instruments without cleaning them, allowed cats to wander through, and defecate, in the office, and had assistants with no medical education or training give IV sedation to patients when he was not in the building. He also made thousands of dollars illegally prescribing opioids.

While it was the selling of narcotic prescriptions to addicts and dealers that first led authorities to his clinic, it was his failure to appropriately medicate and monitor patients, combined with providing very late term abortions, that ultimately led to his undoing.

During the course of the narcotics probe investigators searched his facility. In addition to deplorable filth, non-functional equipment and unattended patients they found dozens of aborted fetuses in bags, milk cartons and jars. Several of them were clearly far beyond the 24 week limit. Clinic employees, aware of their own possible criminal liability, told the police about other horrors. They related tales of severe injuries to patients, including the recent death of a mother who had undergone a botched late term procedure. Perhaps most horrifying, they told of late-term patients being given drugs to induce abortion who ended up spontaneously and unintentionally delivering live babies. These viable babies could have survived with appropriate medical care. Dr. Gosnell‘ s common means of handling such cases was brutal. He would dispassionately take a pair of scissors and cut the spinal cord at the base of the skull, murdering the child. (He was charged for 7 such deaths in the movie. The grand jury report suggested he had similarly ended the lives of hundreds of babies in this fashion over the years.)

When I read the book and while I watched the movie I found myself wondering, “How could something like this happen?”

For Gosnell, it was clear that he was overcome with greed, deceit and hubris. Greed, because in illegal abortions he discovered a lucrative cash business. He did not need to deal with insurance billing, and as he dealt with poor and desperate patients he had little fear of being reported to the authorities. Deceit, as he told himself that their was nobility and honor in providing women with a service no one else would provide. Hubris, for he thought himself so noble that laws and regulations did not apply to him, and that the deaths that occurred on his watch and at his hands were not his fault. They were expected and appropriate.

Though astonishing, I find Gosnell’s individual evil something I can process and partially comprehend. I know there are evil people in the world, and I know there are bad doctors as well. There are over 950,000 physicians in the United States, and one would expect that there must be at least a few terrible individuals among their number. There is no such thing as perfect screening or perfect oversight, and some bad people are bound to slide through the medical admissions, education and training process.

While I can rationalize the existence of an evil individual, I cannot come to grips with the systemic evil that allowed Gosnell to do what he did. Grand jury and trial testimony revealed an astonishing truth. The Pennsylvania health department had declined to perform any quality inspections on the clinic for 17 years. While hospitals, surgical centers and even nail salons were regularly required to undergo mandatory inspections, process reviews, and quality checks, the governor had ordered that abortion clinics not be assessed at all. Multiple reports were submitted about Gosnell, including reports of patients infected with STD’s due to contaminated equipment, life-threatening injuries resulting in hysterectomies and intestinal damage, and at least two patient deaths. All were intentionally ignored.

The reasons behind the decision to not inspect were chillingly simple. The pro-choice governor feared that inspections might reveal that some abortion clinics were unsafe or dangerous, and that such reports could provide ammunition to pro-life advocates who might seize on such reports to push for limits on abortion. Simply put, those commissioned with protecting patients were more interested in protecting an agenda. The cause was more important than the people it was supposed to serve. A woman’s right to an abortion was more important than a woman’s safety.

This biased agenda was not limited to state agents and agencies. One would think that a trial involving 8 murder counts and over 200 other criminal charges against  a physician with a 30-year history in the community would have been front page news in Philadelphia. The trial was universally ignored. The empty courtroom seats revealed just how politically sensitive the abortion issue was.

It is still politically sensitive. Although the film is in wide release in over 670 theaters and likely to debut in the top 10 films at the box office, most newspapers have ignored it. The website MetaCritic lists only a single review (Another movie released into 248 theaters this week, “The Hate You Give”, has 34 reviews.) I have read some of the few reviews and articles about the movie that are available, and they say Gosnell is an “anti-abortion movie” intended for “conservative Christians.” While it is true that the Gosnell story may be used to bolster the arguments of those who are against abortion, these authors and critics appear to have a bias that prevents them from seeing the larger point of the movie. It is more about evil and its coverup than it is about abortion. Regardless of the issue, there is always a danger of putting an issue ahead of the people who are supposed to be served. When things become more important than people, terrible things happen.

(This loss of focus can be found on the pro-life side as well. The Catholic Church, perhaps the world’s loudest voice on behalf of unborn life, is currently embroiled in a massive abuse scandal. A grand jury in  the same state of Pennsylvania recently released its findings on the systematic coverup of sexual abuse by over 300 priests over several decades. Church leaders apparently decided protecting the church and her reputation was more important than protecting the children she claimed to serve.)

It is easy to sit in judgment of Kermit Gosnell and the state officials who turned a blind eye to his crimes, to bemoan the failings of the Catholic Church and its priests, and to tell ourselves we would never do such a thing. We need to be careful, to continually examine ourselves for any signs of such self-deceit. The story of Gosnell, in fact the story of all human history, reminds us that human beings have a profound capacity for self-justification and a remarkable ability to overlook evil when it serves our agenda.

We must be ever vigilant.

- Bart

I strongly encourage seeing the movie. It is extremely well done and manages to communicate the horrors of Gosnell without gore or offense.  

Why Can’t We All Just Get Along?

I have read a lot these last few weeks about the division and hatred that now characterize political debate in the United States. There appears to be no room left for simple disagreement. Sides have been chosen, battle lines have been drawn and enemies clearly identified. Winning is no longer enough, for many it seems that destruction of others is the goal. The questions arise, “Is there any hope for us? How can I make a difference?”

I stumbled across the answer a few weeks ago in my men’s Bible study group. We had just finished a several month’s long review of the Sermon on the Mount, Jesus’ remarkable discourse on the nature of a godly life. To the Jewish people living under Roman rule, people looking to overthrow their oppressors and restore their freedom, Jesus taught sacrificial love for their enemies. He told people to bless those who persecuted them, to pray for those who would do them harm.

His words were challenging then and they are challenging now. Even more, they seem nice and sweet on the page but impractical in reality. There are some people who seem out of reach, some people with whom no peace seems possible. There are cultures too different, beliefs too contradictory, for common ground to be found.

While this is a natural assumption the gospel writer made it clear that Jesus did not intend his teaching to be merely theoretical. He demonstrated this immediately following his discourse. In two successive interactions with outcast and despised individuals he showed how it is we can go about breaking down barriers with those who are different from us.

The first encounter was with a leper. Lepers were social outcasts, banned from societal contact and interactions. Their disease was viewed as more than a contagious illness, it was a sign of condemnation and separation from God. When the man approached Jesus in search of healing Jesus did not scorn him or reject him (the standard responses of the day). He saw him as a man in need of physical and spiritual healing. Against all societal conventions and norms, Jesus reached out and touched the man, healing him.

The second encounter was with a Roman soldier, a representative of the hated empire. The centurion came to Jesus on behalf of a paralyzed servant. Jesus’ response to news of the Roman servant’s plight had to stun all those who heard it, “I will come.” He was willing to enter the home of someone considered by others to be the enemy, to go where no one else would go.

In each of these cases I believe Jesus was motivated by perception. Where others saw ethnicity and illness he saw men in need. He did not see a leper or a Roman he saw men created by God, in God’s image. He did not see them as outcasts or enemies but as children of God. It was not that the men were not different from Jesus, it was that the differences were not as important to Jesus as was their humanity.

A powerful example for all of us. Peace can only be found when people choose to focus on our common humanity, common desires to be loved, understood and known, and on the value that comes from being people created in the image of God. When we focus on anything else we lose sight of our shared condition and division is inevitable.

• Bart