Navigating Loneliness in the Era of Virtual Care

BY: NORM WETTERAU, MD - FMHF PRESIDENT

The January 24, 2019 issue of the New England Journal of Medicine had an opinion article titled, Navigating Loneliness in the Era of Virtual Care. This esteemed journal has had several articles on physician burnout and this article addresses an aspect of that theme. The Article below is based on this article, plus additional ideas from the newsletter’s editor in paragraph 2 and 4, Norman Wetterau.


Doctors used to make hospital rounds and discuss cases on the floor or in the doctor’s lounge. Doctors belonged to medical societies. They ate lunch and at times dinner together. Today they communicate with the front desk via the EMR, so they may not see any fellow doctors or staff during their day in the office. They see patients with their face in the EMR. There is much written about burnout, and this opinion article addresses what may be part of it. In addition to what this article says, there is the subject of social cohesiveness in the younger generation. They are not joiners of medical organizations, other groups or churches. My grandson, who rarely gets together with his friends after school argues that they are more connected due to social media. There may be some truth to this, but not for all teens, and certainly not for doctors who spend 60 hours a week on the electronic medical record and no longer see medical or other friends.

Once burnout begins, some people become more isolated. The workload is so great that there is no time to talk to someone at lunch or to share an evening together. A feeling of hopelessness comes on. This same process happens in other areas of one’s life. When things go bad, hide out. The article proposes some solutions, including face to face time with other health professionals. Some of this time is in non-medical activates and large medical groups can help felicitate this. Another way is through discussion about certain themes of medicine and of life. What he describes sounds a little like our retreats. As members of the Free Methodist Health Fellowship, let us see our own churches, and even our fellowship as a solution to loneliness. God made us to be connected. Being involved in a church is part of this and being connected to a group like the Free Methodist Healthcare Fellowship cannot hurt.

Let’s invite other: MDs, NPs, PAs, RNs, and others. Our theme for September’s Conference is: Serving God Throughout our Professional Lives, will bring us together to explore this, whether one is just starting out or is in retirement. The speaker, Dr. Bill Morehouse, also brought doctors and medical students together through the University of Rochester Christian Fellowship. One good way to prevent or address burnout is to share time and one’s life with others, including those Christians in our profession. A weekend of physical, social, and spiritual refreshment is a good way to find joy and prevent burnout. Share this article and invite a friend to come along too.

Roberts Wesleyan College School of Nursing Updates

With 3 nursing programs (traditional entry level BS in nursing, RN-BS in nursing, and graduate degrees in nursing education and nursing leadership and administration) the SON is a busy place! Some of the events we are anticipating in the near future include:

  • Nursing Camp – From July 29 – August 2nd 24 high school students will come to campus to explore nursing roles, work with faculty and current students, and enjoy our extensive clinical laboratory facilities

  • Transcultural Nursing course taking place on location in Costa Rica this May. Fourteen students and 2 faculty will work with Christ for the City holding a week-long nursing clinic where in past years they have seen up to 900 patients.

  • Inter-professional Simulation Day where nursing, social work and criminal justice students participate in an emergency department simulation experience with patient actors who bring a myriad of physical and psychosocial concerns.

  • As with the end of every semester we look forward to hearing the presentation of our honor’s students’ project and our graduate student theses. This year, for example, 2 graduate student projects will present on “Implementation of Neurological Best Practice Program in the Emergency Department” and “Reduction of Incidence and Duration of Ileus and Associated Symptoms in Postoperative Patients”.

If you are interested in Roberts nursing programs,
please visit www.roberts.edu/nursing or call 585-594-6686.

Dr. Bill Morehouse - 2019 Keynote Speaker

By: Dr. Bill Morehouse, MD

I grew up throughout the Northeast after my father’s return from WWII, moving multiple times over the years to follow his career in engineering. With each move we became active in a local mainline Protestant church, including Presbyterian, Methodist, and Episcopal congregations where I became involved in youth work. By the time my undergraduate medical education was complete, I had matriculated at 12 different schools and expanded my religious perspective into a misguided global interfaith belief in the goodness of mankind, coupled with the New Age sense accompanying my emerging liberal “hippie” lifestyle that all religions were basically groping around the same set of truths.

I chose to attend the College of Medicine at the University of Kentucky with its focus on primary care because I wanted to be a personal physician (“a real doctor”) who cared for everyone in the family. I went on to residency in the new Family Practice Program in Rochester, NY because its emphasis on caring for underserved rural and urban populations was in keeping a persistent sense I have had that doctors and communities should focus their attention on the places in society that need the most help, similar to the way we focus more of our attention on the sick parts of a person while protecting and supporting those parts that are healthier.

Following the nationally known prison riot at the Attica Correctional Facility in 1971 I was instrumental in evaluating and recommending major changes to the failed health system there and offered my services to implement them. When my proposal was turned down, I took a job at an OEO poverty clinic in Rochester where my lifestyle and intense commitment to do a God-sized task led me into the personal crisis that culminated in my dramatic conversion to Christ in April 1974, a conversion that reconciled my sin, stress, hopes, fears, and entire church upbringing.

After a year of discipleship, followed by brief stints in emergency and occupational medicine, I met and married my wonderful wife of 43 years. Susan and I felt called together to open a whole person Christian clinic in the heart of the inner city neighborhood where we were living. Susan became a homemaker, community builder, mother of our four children, harpist, and grandmother of our seven grandchildren. What God started in 1978 has grown from a solo practice with one staff member to a multi-provider Federally Qualified Health Center serving two poorly resourced Rochester neighborhoods with numerous providers and support staff.

Over the years I’ve delivered over 1500 babies, cared for thousands of inpatients of all ages, and probably had nearly 100,000 documented “face-to-face encounters” with patients in the office. Training medical students and residents has always been part of it, with many going on into missions at home and abroad to establish similar works in other places. We’re active in the Christian Community Health Fellowship and have overseen the development of student and practicing provider support groups in Rochester that are active at the University Medical Center and broader community, reaching the lives of hundreds over the years.

God is good, and the life He gives us is not only embedded in this fallen world but will go on into eternity beyond it. Susan and I are looking forward to being with all of you in September!

Review: The Contemporary American Drug Overdose Epidemic

By: Norman Wetterau, MD - FMHF President

Why does the United states have a much higher drug overdose rate than other countries? Why do we have this epidemic?

As an addiction specialist and former board member of the American Society of Addiction Medicine, I have observed the whole development of this epidemic and have some strong opinions. In February an open access article was released: The Contemporary American Drug Overdose Epidemic in International Perspective by Jessica Y. Ho.

This is a detailed article with many graphs and mathematical analysis as it examines drug overdoses In other countries, changes in life expediency and various drug policies. You may find it worth reading, but here is a summary of some of its findings and additional information which is common knowledge to those in the addiction field. The information on the AAFP is not widely known but is truthful and likely common in other organizations as well. The information on the joint commission and on the AAFP is not in Dr. Ho’s article. The opioid epidemic is not all the fault of the drug companies or the patients. It is complex, but something that must be addressed or it will not go away.


Review:

I became concerned about opioids shortly after the introduction of Oxycodone, but never imagined that things would get to where they are now: seventy thousand plus deaths a year (includes all drugs, but opioids are involved in the majority). Some of my patients have had 2 or 3 of their friends die from this and others have siblings and children. What has surprised me is that in spite of Narcan and buprenorphine, the death rate continues to climb. Due partly to this epidemic, the life expectancy of the average American has decreased by over a year.

A recent article by Jessica Y Ho looks at the opioid epidemic from an international perspective. First the article documents the incidence of overdoses in various countries. The US is highest with Scandinavian countries and Canada behind. The US overdose mortality rate is 3.5 times that of other countries with a range of 1.6 to 28. The differences are illustrated in various colored diagrams. The article documents how the overdose death rate has been a major factor in the falling life expediency in the US, and one reason why Americans do not live as long as people in other developed countries.

So why is this? The previous parts of the article have extensive mathematical documentations. The second part, which to me is more interesting, is more descriptive.

A major cause was the introduction and promotion of Oxycodone and other strong opioids. In much of the world stronger opioid use is more restricted and Oxycodone is not used nearly as often. In the United States the drug companies heavily marketed these drugs to physicians and to the public. The United States allows direct consumer advertising of prescription drugs, one of only 3 countries in the world.

The article shows the relationship between how physicians are paid, opioid prescriptions and overdoses. Health systems where physicians are mainly paid salary or by capitation have the lowest opioid prescription and overdose rates. In the United States physicians are paid mainly by how many patients they see and are given incentives for patient satisfaction. So, physicians faced increased financial pressure, caseloads and time restraints, plus their employment and pay was often tied to patient evaluations. So, if a patient comes in on oxycodone 20 mg bid and the pain has increased, one can double the dose, and send the patient away in 5 min. They will likely be happy. If instead one spends a half hour discussing the pain and making suggestions but actually reducing the opioids since it was not helping the pain, the doctor might be fired.

Additional reasons which were not a major focus of that article, but well known, was that the joint commission and various state governments made pain the 5 th vial sign. Doctors who did not prescribe strong opioids for pain were penalized and, in some cases, lost their license. States required doctors to take courses on pain relief and these courses taught that we should not be afraid to prescribe opioids for pain. The courses taught that addiction to opioids when used for pain relief was rare. Indeed, from my perspective, this is the first major deadly health epidemic caused by drug companies and doctors, with the help of the joint commission.

The causes do not end here. Through advertising, Americans were taught that they should not have to experience any long-term pain or discomfort, in contrast to many other countries. This does not just apply to opioids. Now marijuana is being promoted for all types of discomfort and some doctors are freely endorsing this. Benzodiazepine usages in the US has been rising in spite of the fact that it is addicting, contributes to overdoses, and that tolerance builds up so that the dose has to be increased.

Another cause is what insurance paid for. Various studies show that long-term opioid use does not statically reduce chronic pain, but comprehensive pain treatment, including PT, counseling and even group sessions does work. insurance usually does not pay for that. The insurance would usually pay for an opioid prescription but PT, and other treatments required prior approval. Counseling is not paid for and drugs other than opioids also may require prior approval. MRI’s and surgery are paid for. So, the one thing that works the best is not paid for.

The final difference was the availability and easy access to treatment for addiction. In France buprenorphine was available and used for addiction treatment long before it was approved in the United States. Even now most American doctors will not prescribe it. Until recently drug treatment has been more available in many other countries. It is estimated that only 10% of Americans with an addiction problem are receiving treatment for this. The figure is higher for those with opioid use disorder, but still much lower than many other countries. In the United States many treatment programs refused to use medications like buprenorphine or methadone, but this is finally changing.

Can we imagine an epidemic of any other disease in which doctors would refuse to become involved? Stigma is an issue. Young people with overdoses are sent away from emergency rooms with no drug treatment except for an injection of Narcan. As expected, they may repeat the overdose until they finally die. Is there any other disease that has been treated as such? This is an epidemic caused by American Medicine and then American Medicine refuses to treat it. The national AAFP even refused to appoint a member to the buprenorphine advisory group and refused to increase their CMEs on addiction in the early 2000’s in spite of a resolution from New York that passed their national congress asking them to do this. The president of the AAFP meet with members of ASAM, including myself, and said that there were too many other issues to deal with (this information and the strong language in this paragraph are not in the article which is being reviewed).

Fortunately, things are changing. The epidemic has grown and grown. It may take years to totally subside. The AAFP is now very supportive of appropriate opioid prescribing, and treatment, including buprenorphine. Family and Emergency medicine are on the forefront of opioid addiction treatment. In a congress that can hardly agree on anything, they almost unanimously approved two bills to dramality increase drug treatment and provided financial support for this. Churches of often very supportive of those who struggle with addiction. On the whole things are beginning to change, but some of the causes, including the payment system of American doctors, drug advertising and lack of universal health insurance still exist. Most experts feel that this epidemic will kill hundreds of thousands more people, including many young people, before is subsides. Finally, if we cannot address some of the underlying causes, we will have another major epidemic with benzodiazepines or medical marijuana. The later does not kill, but it certainly does not produce an improved life. Rather than discussing which addictive drug is not as bad as others, the conversation should be around preventing and treating all addiction, including alcohol, legal and illegal drugs, marijuana and gambling, which may be the next big addiction.

The Free Methodist Church had a prohibition against the manufacture and advertising of alcohol by its members. Are we behind the times or ahead of the times?

2019 Conference Announcement!

Free Methodist Healthcare Fellowship
Fall Conference

September 20-22, 2019 at the Essenhaus Inn & Conference Center (Middlebury, IN)

Theme: Serving God Throughout our Professional Lives
Speaker: Dr. Bill Morehouse

Dr. Morehouse has spoken often locally and at the Christian Community Health Fellowship National Meetings. Through his talks and discussion, we will explore Christian calling to students, residents, practicing health professionals and the issue of retirement.

Invite a student, resident, young doctor, dentist, nurse, or someone older or considering retirement.

Register by August 20th to get the best rate.

For questions about the conference, student scholarships, or childcare, please email Norm Wetterau (normwetterau@aol.com)

Ebola, NEJM, and the Book of Revelation

By: Norman Wetterau, MD - FMHF President

The fourth horseman of the Apocalypse rides in Congo. This is recognized in the New England Journal of Medicine but do our churches know this?

“And there before me was a pale horse. Its rider was named Death…they were given power over a fourth of the earth to kill by sword, famine, and plague”.
- Revelation 6:7-8 

According to the New England Journal of Medicine, August 22, 2018, Ebola or something similar will sweep our globe unless we can improve the medical infrastructure in Central Africa, and specifically in Congo. The civil war in Congo killed by sword and famine and unless we can assist this country medically, plague may sweep the earth.

Is support of our medical missions in Central Africa optional? Currently, our hospitals in Burundi, Rwanda, and Congo are not budget items for Free Methodist Missions but do get support from groups like CAHO. Most churches put support of their own church programs and buildings above medical and development missions. In Congo, we have a 100-bed hospital and 20 clinics, which are the main health care for 200,000 people. The hospital runs on $100,000 USD a year, of which 25% comes from US donations. Health infrastructure and care are poor. There are national doctors and nurses. We have nursing schools in Burundi, Rwanda, and Congo and a medical school in Burundi, but there is often no money to support the trained staff. Many recent graduates of Hope Africa Medical School are unemployed. The medical infrastructure and staffing are not enough for even basic medical care: treatment of malaria, TB, and c-sections, but this is far away and often of little concern. Many churches have never had a medical speaker from Africa or given an offering. This is too far away to be on our radar. There are needs right here. We are concerned about Ebola, but it is in Congo, not here.

Recently there was another outbreak of Ebola in Eastern Congo near some of our churches, but farther north than our hospital. This outbreak has been made worse by the lingering civil war in Congo. Some aid workers were attacked by rebels. The situation could become much worse in the coming months. The August 22 issue of the New England Journal of Medicine had an article that every American needs to read:

“Outbreaks in a Rapidly Changing Central Africa - Lessons from Ebola”
Vincent J. Munster, PH.D. et al.
New England Journal of Medicine. August 22, 2018.

It talked about the current epidemic and the situations that cause such epidemics to arise and spread. Although in the past we have brought these mini-epidemics under control, the article says that the conditions are ripe for the development of new infections and new spread. At some point, it will become uncontrollable, and suddenly reach the populations of Europe and the US, where it will spread death to thousands or hundreds of thousands of people. If we ignore the situation there, we will have to deal with it here. The article had a possible solution, a solution on which we need to get our churches on board:

“In light of the increase in frequency of Ebola outbreaks in DRC and their relatively rapid detection, it seems that it would be well worth the relatively small cost of investing in diagnostic capacity and training to avert the cost of containing any large outbreak. We believe that a similar return on investment could be expected from financial and educational support for improving and expanding the clinical care infrastructure.”

Yes, this is something for WHO and the UN (which some Christians do not support), but also something we can help with. God had given us the opportunity to establish some of the first hospitals, many which still exist and are the mainstays of medical care for large populations. If we continue to just look at our own needs and not that of our neighbors, we may experience what is foretold in the NEJM and also in Revelation 6: death and pestilence.

Update: After writing this article, on November 28 the New England Journal of Medicine published a second article: Ramping Up the Response to Ebola by Jennifer B. Nuzzo PhD, and Thomas V. Inglesby, MD. It is not long and I would encourage you to read it. This article was referenced on the BBC news recently. This is Congo, where our hospitals are and where the Nobel Prize winner is. We have a hospital, over 20 clinics, and over 100,000 members, so we are a major player in that region. Also look up more about Dr. Denis Mukwege. Finally pray for the elections in Congo which will be held Dec 23.

Nundu Deaconess Hospital on the Front Lines Offering Hope

By: Norm Wetterau, MD - FMHF President

Nobel Laureate, Dr. DenisMukwege. Photo: ANP Martijn Beekman.

Nundu Deaconess Hospital has been in a region of civil unrest for more than twenty years. Nundu is located in South Kivu, which is an eastern region of the Democratic Republic of the Congo. Over 5 million lives have been lost, hospitals and schools have been destroyed, and untold numbers of citizens have been terrorized. Women have been especially vulnerable as they have become victims of rape by gangs of soldiers, resulting in gynecologic injuries and the spread of HIV-AIDS. Our hospital at Nundu has survived by God’s protective hands and the prayers of the Free Methodist Church of the Congo. Thank you for being among those who have prayed for God’s protection and provision.

Yes, God has not been silent in the face of terror. Our hospital in Nundu was ransacked but not destroyed. Many of our outlying clinics continued to function at a basic level. People would carry medicines on their backs up the hills to these clinics. The nursing school at Nundu retreated to a safe place but continued to function.

Dr. Esther Labunga Kenge, the wife of the Free Methodist Bishop of Congo, spent time in South Africa as a refugee during this time of terror and has written and taught about this sexual violence and HIV. She has taught that women who were terrorized and traumatized are not being punished by God and are the special focus of God’s love. She is spreading this word and through International Child Care Ministries is developing projects so that widows and their children can grow food, care for animals, and support themselves. The goal is for the mothers to work, receive love and healing through the church and for their children to attend school. Your support of these programs through ICCM is very much appreciated. Though the situation for many has seemed hopeless, God has not been silent in the face of terror.

During this same period of war, a sister hospital known as the Lemera Swedish Pentecostal Hospital was totally destroyed. Rather than withdraw from the Congo, the Swedish Pentecostal Church established a medical center and medical school in the provincial capital of Bukavu. Dr. Denis Mukwege, a Christian Congolese surgeon and member of the medical school faculty, developed a graduate training program in gynecologic surgery. His special interest has been perfecting surgical procedures to repair the damage resulting from violent rape. He has dedicated his life to offering hope to victims of sexual violence. After his complicated surgeries, women have been able to maintain pregnancies and live a normal life. Their curse was healed by God through Dr. Mukwege.

This year the world became aware of what has happened in the Democratic Republic of the Congo. How did this happen? In 2018, Dr. Mukwege and Nadia Murad, a woman who was enslaved by ISIS and escaped, were chosen to receive the Nobel Peace Prize. Nadia did not receive this prize because she was raped nor did Dr. Mukwege receive recognition simply for his surgical skill. They received this honor because they have spoken on behalf of women both in the middle-east and in the Congo who have become the victims of violence. Dr. Mukwege has spoken at the UN even as he has been threatened for making the story of war and terror known throughout the world. It is wonderful for a Christian to receive such a prize. It is not just recognition for him, but for the church and God’s Kingdom.

What about the Free Methodist Church in the US? The Free Methodist Church in the Congo is strong and growing. They evangelize, maintain schools, operate clinics and hospitals, and worship with enthusiasm. Even in the face of civil war, they did not give up. Indeed, in some areas, the church actually grew. How is the North American Free Methodist Church to respond to such overwhelming human tragedy? In our affluence and in our relative domestic stability, poverty and the terror of war make us feel uncomfortable. It is easy to not want to hear. There is too much for us to handle. Frankly, over the years I have offered to speak in churches about this situation and very few want to hear about it. This is a common reaction for people presented with overwhelming hopeless situations. Is it because the realities of war are so far away and seem so hopeless, or is it because we feel that our meager donations cannot do much? Now the world knows about the realities of the Congo through the Nobel Peace Prize offered to Dr. Mukwege.

Nundu Deaconess Hospital is on the front lines of offering hope. Our challenge is to be informed and tell the story of the Church in the Congo. Pray for those who have been the victims of violence. Pray for the North American Church as it faces the realities of a world with overwhelming human need even as it enters into countries which have been closed to the Gospel. Pray that there will be a response with the resources God has blessed us with in addressing the humanitarian needs of the Congo.

FMHF 2018 Conference Recap

By: Norm Wetterau, MD - FMHF President

Beautiful Seattle

The campground was beautiful and even though the 45 people there were less than we often have, there were many new faces and people to get to know. We will return to Indiana next year, but with good memories of the Northwest and we hope a few new people from the west coast will follow us to Indiana.

The speakers, Eric and Rachel McLaughlin, are both physicians at Kibuye Hope Hospital in Burundi. Their talks were more spiritual than medical. In their medical work in Burundi, things often do not go well. God makes promises, but sometimes God appears to be breaking those promises. We reach out to those who are hurting but our efforts sometimes appear futile. These were some of the themes the pair, one a family physician and one an obstetrician, shared with us.

On Friday night we looked at Abraham. Promises were made to him, yet year after year they were not fulfilled. God promised that his offspring would be as the sands of the sea, but he still had no children. Yet he had faith. Although when he died these things had not all happened, they have happened now. God was faithful. God will answer, but not always when and how we plan. Revelation 21:5 is a key verse here, “He will make all things new”. In their hospital, many will not be healed, but let’s admit that even in our most advanced hospitals, all will eventually die, but God will make all things new.

On Saturday, we looked at 4 areas: insufficiency, losing hope, never enough, and darkness. Each issue was illustrated by at least one case that they had cared for. Insufficiency: Rachael cared for a woman who was infertile. She had lost 4 pregnancies and on her fifth she ended up with a ruptured uterus, In spite of Rachel’s best efforts. She was unable to save the uterus but did save the mother. Infertility, which is a big issue in Burundi, will remain. Her efforts were insufficient. Normally, delivering babies is a happy time, and sometimes it is for Rachael, but she does not do normal deliveries nor even normal c-sections. In the US, she felt that her skills were good, but in Africa they often appeared insufficient for the cases in which she is called to intervene. In 2 Corinthians, Paul says that God’s power is made perfect through his weakness and Rachael shared how she has experienced this. As she walks with those in need, she does not need to lose heart.

Losing Hope: Eric shared a case of triplets. After over 100-days one had finally gained enough weight to be discharged. This very premature baby had gone through many trials, but after 3 months, Eric felt success. It was all worth it. 2 days later, that baby suddenly died. Can a Christian physician have despair? Is lament in the scripture the same as despair? Eric pointed out that lament and despair are two very different things. Despair is the denial of God. Lament presumes that there is a God. Job never quit praying. In spite of his suffering and feeling of extreme sadness, he still believed in God, even a God who would not give him any answers. Many of the Psalms are laments, but one needs to work through various verses and stages until at the end the psalmist can see God. Lament is part of a Christian’s life, but despair should not be.

Never enough: We work hard, we do so much, but it is never enough. There are so many patients and so many needs. We are exhausted, but maybe we could have done more. We watched a short video from Schindler’s List where Schindler kept saying: “I could have done more”. Hundreds of Jews were in the room telling him that he had done so much, but he kept repeating: “I could have done more, I could have done more”. Eric referred to a sermon given by Tim Keller (Hope for the Poor - October 4, 2009) where he agreed with Schindler, that he could have done more. The main message is that our drive to feel that we have done “enough” is often motivated by a desire to earn God’s approval. Effectively, we want God to say that we have done enough. But the gospel (and the beginning of 1 John 3) remind us that God’s love and his adoption of us as sons and daughters is never dependent on us having done enough. It is an utterly free gift of grace.  So, in the face of feeling like we have “never done enough”, we need to return to the unmerited nature of God’s love for us. The motivation for what we do is God’s love. As people we can never do enough, but God can. We need to turn our life and actions over to God.

Darkness: At times things seem very dark. The situation may be very dark and hopeless for our patients, and at times for us. Jesus is the light of the world and that light can shine in any darkness, but we also are the light. In spite of difficult situations, we are involved in and patients who appear to be in darkness, but the light is Jesus and we reflect that light as it shines through us.

So many points were brought up in the talks that one could write a book, which is indeed what Eric has done. It is in the final stages of editing and should be available within the next year. We felt privileged to hear Rachael and Eric share their stories and insight as to how God is present in the most difficult and seemly hopeless situations. We should never lose heart.

On Saturday evening we had another treat. Eric writes music and is an excellent guitar player and pianist. He sang songs he had composed around the theme such as “Man of Dust”. The words were much deeper than many contemporary Christian songs and deeply reinforced his talks. Many of these songs are on his website, so for those who could not attend, there will be the book and his songs, but even more important, Christ and his Word. Let us not lose heart!