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<title>askDrJim</title><link>http://www.askdrjim.com/foler/index.html</link><description>Medical Questions and answers</description><dc:language>en</dc:language><dc:creator>doc@askdrjim.com</dc:creator><dc:rights>Copyright 2007 James Schindler</dc:rights><dc:date>2010-05-28T21:05:16-04:00</dc:date><admin:generatorAgent rdf:resource="http://www.realmacsoftware.com/" />
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<lastBuildDate>Mon, 26 May 2008 23:02:08 -0400</lastBuildDate><item><title>iPad therefore I am</title><dc:creator>doc@askdrjim.com</dc:creator><dc:subject>askdrjim blog</dc:subject><dc:date>2010-05-28T21:05:16-04:00</dc:date><link>http://www.askdrjim.com/foler/page3/index.html#unique-entry-id-89</link><guid isPermaLink="true">http://www.askdrjim.com/foler/page3/index.html#unique-entry-id-89</guid><content:encoded><![CDATA[Yes, I am an early adopter of technology.    Not to the degree I would like to be.     I pour over tech sites to look for the latest gadgets.    Recently I purchased an iPad.    I must explain I never was entirely a PC guy.     I always toyed with other models (Commodore Amiga's in the past and Mac's in the present).    I was nearly in the Amazon store purchasing a Kindle when the rumors started flying about some type of Apple product.    So I waited.     Late winter came and the announcement of the iPad was streaming online while I watched Steve Jobs put it through the paces and the announcment.    Then April came but I waited to see one in the Apple Store in Knoxville.    Finally, I got a 3G version about a month ago.     All I can say is I think tablets will change the way we seen computers.    They always were intended to be more that tethered keyboards (remember Star Trek anyone?).     This thing is amazing with one very large caution.....there is very little medical content of worth.....  YET.      I see the possibilities here of holding in my hand most of my books I reference weekly, my CME courses, my applications for educating patients and my conduit to the electronic medical record in my office.    It is a way to communicate with patient's and specialists, a way to market and research, a way to think about problems and a way to interact with an ever changing world of medical information.     I am excited.]]></content:encoded></item><item><title>When all is crumbling around</title><dc:creator>doc@askdrjim.com</dc:creator><dc:subject>askdrjim blog</dc:subject><dc:date>2010-05-28T20:56:24-04:00</dc:date><link>http://www.askdrjim.com/foler/page3/index.html#unique-entry-id-88</link><guid isPermaLink="true">http://www.askdrjim.com/foler/page3/index.html#unique-entry-id-88</guid><content:encoded><![CDATA[It is hard not to see all the chaos out in the world and wonder if there is any sense to it all.    The gulf oil disaster may harm the coastal marshes for generations.    The North Korean chest thumping threatens to break into a major conflict.     The ongoing violence in the name of religion or country seems never to slow.    It is difficult to see a quiet end.    And that's the point.     I believe the world is spinning closer and closer to the type of violent climax we all fear.    I have friends who say "I've read the ending of the book and know how it turns out" and I would have to nod to that thought.    But what if you were a character in the book.    Would you know how it was going?       It is a sad thing to see so much evil and hate in the world.    Then I think of the movie that has my last name and the scene the director shot following a single little girl walking through the chaos.    She was the only one that was shot in color with black and white all around.     The idea the a remnant of good of purity of righteousness exists in spite of the chaos around is a metaphor of the hope people of faith hold to so tightly.      God is there in the pain.    Evil can only be understood if good exists as the marker unchanging.    Hold tight to hope.]]></content:encoded></item><item><title>Flu&#x2c; Flu and Flu</title><dc:creator>doc@askdrjim.com</dc:creator><dc:subject>askdrjim blog</dc:subject><dc:date>2009-10-24T19:26:18-04:00</dc:date><link>http://www.askdrjim.com/foler/page3/files/oct-2009#unique-entry-id-87</link><guid isPermaLink="true">http://www.askdrjim.com/foler/page3/files/oct-2009#unique-entry-id-87</guid><content:encoded><![CDATA[Well,the H1N1 is upon us in East TN.    I thought I would put down some information that might give my take on the ever changing CDC recommendations.    First, this is a "novel" H1N1 Influenza A virus.     It's genetic makeup resembles viruses from the 1950's and after that they presumably jumped in the hog population living there for 50 years before re-emerging in this past year.     Generally flu viruses change over time and occassionally they will have a major genetic shift.    Whenever that happens any potential immunity developed from previous years is non-existant and larger numbers of people are prone to getting infected.      When a very different strain emerges this is especially true.    This virus and variations of it have not been seen by folks less than 50 years old and therefore more young people will be getting ill. 


We have known that influenza is especially spread by school children and efforts to immunize them in this country have been increased in the past several years.      Generally seasonal influenza is riskier for people who are infirmed, elderly or immun-compromised with healthy kids not being particularly at risk for severe disease and death.    The pandemic H1N1 seems to be affecting children group more seriously.     Children under 3 years (especially unter 18 months), pregnant women (who's immune system is downregulated to prevent damage to the "parasite" in the womb) and the usual high risk groups are the most likely to get severe disease and even death.


Remember that death from influenza generally is a result of overwhelming pneumonias that developed during or shortly after people contract the flu.     Aggressive use of antibiotics may help but people need to understand that the fever and cough of flu are not the fever and deeper cough of pneumonia.  ...  See or call your doctor for help.


Early on we thought we would be using a lot of Tamiflu as we faced this deadly strain.    However, with experience the CDC has urged more prudent use of the drug.    As most people in low risk catagories are not getting very ill they have suggested using the drug for those who are hospitalized, caregivers of high risk persons or housemates of high risk persons.     The drug will decrease the illness by about 1/2 day and contagiousness by about 1 day.  

...It is produced just like seasonal flu.    If you are over 50 without high risk designation it is not recommeneded although will be used if someone insists.     If you are in a high risk group it is recommended with some younger children needing a booster dose after the initial dose.     In east TN where seasonal flu comes in late December through March I have suggested to my patients to try to get the H1N1 first and then get their seasonal flu shot.     There is some theoretical benefit to getting the shots in that order and not the other way around.     The nasal spray is live virus and you cannot take 2 nasal sprays at the same time.    I would space nasal sprays by 1 month for maximum effect.     The shots can theoretically be given without spacing but as I said above I would urge people to consider spacing the shots if they can.   ]]></content:encoded></item><item><title>Faith and courage</title><dc:creator>doc@askdrjim.com</dc:creator><dc:subject>askdrjim blog</dc:subject><dc:date>2009-04-09T23:27:03-04:00</dc:date><link>http://www.askdrjim.com/foler/page3/files/apr-2009#unique-entry-id-86</link><guid isPermaLink="true">http://www.askdrjim.com/foler/page3/files/apr-2009#unique-entry-id-86</guid><content:encoded><![CDATA[I have not had the time or creative energy to do much writing of any sort lately.    Winter does that for a doctor.    There is lots of illness and work to be done but the days are short and by the time the day is over you have darkness.     It's natural to start to feel down or deflated.    My ability to be self-centered is boundless but at times God pulls me back to reality by showing me a glimpse of what he intends for us to experience as we walk in relationship with Him.   


Last fall one of my brother's daughters was found to have a rare cancer in her abdomen.    After a time of rapid evaluation and second opinions half way across the country, she was started on chemotherapy prior to what was possibly going to be a horrific surgery to try to save her life.    The chemo and complications of it meant that her senior year in high school was to be very different that what she had thought it would be.    A great athlete, she would have her basketball season cut short and her soccer season ended before one game.  


Through it all she had a peace and faith that God was in charge and would use this event, awful as it seemed, to bring about great things.     An outsider might say this was just innocence of youth or delusions of an old religion.    That outsider would be wrong.     Through her fight and her testimony she has touched literally thousands of people in her state and the love poured back on her and her family has been nothing short of astounding.   


The day came last week for surgery and we all knew that this story was no longer one of cancer but of courage and great faith.    When the surgeon opened her abdomen no new sites were found and those that had been there had been killed by the chemo.    Now just a week after surgery she is eating some, walking and has been told she is cancer-free.    Now this is all good stuff and worthy of great praise to God for His kindness and healing but my view was seeing a young woman, her family and her faith community coming together with love and support.     As a result all who came into contact with them were blessed.     To me that was the purpose and that was the miracle.   


As a doctor I see the ravages of cancer but I also have seen how disease, especially cancer, can transform patients, families and communities.    I have been blessed to witness such a transformation through my niece.      Thank you Katie.    Praise to our Great Father.  ]]></content:encoded></item><item><title>No&#x2c; Not Everyone</title><dc:creator>doc@askdrjim.com</dc:creator><dc:subject>askdrjim blog</dc:subject><dc:date>2008-11-28T20:18:13-05:00</dc:date><link>http://www.askdrjim.com/foler/page3/files/nov-2008#unique-entry-id-85</link><guid isPermaLink="true">http://www.askdrjim.com/foler/page3/files/nov-2008#unique-entry-id-85</guid><content:encoded><![CDATA[Our church had a recent revival and I am still processing what was changed in me.      Revival assumes something was previously alive and then has been re-energized.     This primarily then, is a term for Christians as opposed to a crusade for evangelism.    


The first night's speaker gave me two kernels for thought and hopefully songs that I will attempt to flesh out here.    First was the idea that we have the DNA, the finger prints so to speak, of our Father IF we indeed are Christians.     He used the text where Christ says that not all who call Him "Lord" when standing at the brink of heaven or hell will be welcomed by Him into paradise.    This is a disturbing passage.     Those who rely on their own works (the texts says casting out demons, prophecy, healing and the like) are not the criteria upon which God's decision will rest.    Rather it will be the act of Christ's death only that will be used to credit righteousness for us.


Those who are His will be unmistakable to Him.     We have the DNA of the Holy Spirit residing within us.     Our way of talking, acting, living all should be identifiable as from His family.    Just as earthly children come to act like and resemble others in their families, we too should have a family resemblance.    It is too true that I often must appear to the world as not from the family by the choices I make and the way I act. 


The second thought was "No, not everyone".     Meaning that not all who think they are Christians will actually be saved.    This is the scary part as one starts to question "what about me?"     The passage paints a picture of humans pleading their case somewhat indignantly when told "I do not know you".     How then are we to be comforted?     By the Comforter who dwells within us.     The Holy Spirit will confirm to those in whom He resides that their salvation is sure and real.     He was sent to teach, to comfort and to make manifest in us the new DNA we possess when we are saved.


That's a lot to chew on for one sermon!]]></content:encoded></item><item><title>Grace</title><dc:creator>doc@askdrjim.com</dc:creator><dc:subject>askdrjim blog</dc:subject><dc:date>2008-09-14T22:02:00-04:00</dc:date><link>http://www.askdrjim.com/foler/page3/files/sep-2008#unique-entry-id-84</link><guid isPermaLink="true">http://www.askdrjim.com/foler/page3/files/sep-2008#unique-entry-id-84</guid><content:encoded><![CDATA[Today in Sunday School we were discussing the concept of grace.    Unmerited favor is the way I have always thought of grace.      In the Christian world view this would mean that nothing within me should have caused the God of the universe to carry out a plan to remove the blood-guilt that my sin demands.     God&rsquo;s act of grace starts and ends in the will and action of God alone.    I am the unworthy recipient.  


Ah, but I must both see my need, confess my inability to save myself and then accept the grace that is given me by the act of Christ dying in my place.    There&rsquo;s the rub.  


 Accepting grace and then understanding that it was all sufficient and freeing is not easy.      Grace frees us from the slavery to sin under which we lived and places us in a righteous (here I would say blameless or sinless) position free to live fully the way God intended.    The problem is the way we think about it as humans.


I tend to look back or regret my sin....to wallow in my guilt.     This is almost like a slave once freed who has no idea how to live free.     I have patients who have a complaint and after an exhaustive work-up are told, &ldquo;good news, there is nothing dangerously wrong with your body&rdquo;, who seem unhappy with the news!   Moreover many go from doctor to doctor trying to find something wrong rather than embracing their health and living.     Too often I see myself in that pattern.     Bound up by guilt of past sin or of future sin afraid to seize the joy that grace has given to me.


In the Screwtape Letters, C.S.   Lewis outlines how Satan desires to keep humans focused on the past (regrets) or the future (fear) rather than living fully free in the present.    He says that the present is the closest thing to the &ldquo;eternal now&rdquo; of heaven and if humans fully embraced the present as God intends our eternal nature would recognize its joy  and Satan would lose his grip on our lives.     Embracing grace would seem to be the first step.    If you are a Christian saved by the death and resurrection of Christ then you indeed have received a clean bill of health.  ]]></content:encoded></item><item><title>Vitamin D</title><dc:creator>doc@askdrjim.com</dc:creator><dc:subject>askdrjim blog</dc:subject><dc:date>2008-09-14T21:51:23-04:00</dc:date><link>http://www.askdrjim.com/foler/page3/files/sep-2008#unique-entry-id-83</link><guid isPermaLink="true">http://www.askdrjim.com/foler/page3/files/sep-2008#unique-entry-id-83</guid><content:encoded><![CDATA[I know that I have written about Vitamin D before but I have got to do so again, albeit briefly.     When the research on Vitamin D deficiency&rsquo;s link with depression was published a couple of years ago I became curious about what I had read.    Then consistent research linked low levels of vitamin D with not only depression but increased cancer risk and, certainly, poor bone deposition.     I started to test patients, especially those who were elderly or at risk of osteoporosis fractures or the ones that were depressed.    Gradually I began to test more patients in my practice.    The results have been astounding.     Like most silent epidemics, vitamin D deficiency is easy to find when you are first testing in a population.    The prevalence is high and the yield of testing is also high.    I was not prepared for 8 of 10 tests to return under the levels thought to be needed for good bone health.     That&rsquo;s correct...80%.     Both men and women are testing low and largely middle aged to elderly.    Those who get little sunlight and little supplemented dairy products are the largest group.   


With supplementation I have seen levels rise to acceptable and those patients will be able to use OTC supplementation thereafter....we hope.    The question will be &ldquo;Is there a clinically relevant benefit to raising these levels?    Given the associations with cancer and depression and osteoporosis one would hope so.    Time will tell.      More later.  ]]></content:encoded></item><item><title>Olympics</title><dc:creator>doc@askdrjim.com</dc:creator><dc:subject>askdrjim blog</dc:subject><dc:date>2008-08-17T23:55:23-04:00</dc:date><link>http://www.askdrjim.com/foler/page3/files/aug-2008#unique-entry-id-82</link><guid isPermaLink="true">http://www.askdrjim.com/foler/page3/files/aug-2008#unique-entry-id-82</guid><content:encoded><![CDATA[Of course I have been watching the Olympics this past week....who could not.    The drama of sport at high levels is reality TV cubed.     I enjoy the races of all types.    It seems a great way to test your competitor.    I&rsquo;ll race you to the tree.     Just the type of race we all had when we were little.     I like but get frustrated with the judged competitions as it seems there is way too much subjectivity.     I do like the stories and pictures of sportsman/womanship.     The Games seem to always bring some type of special stories out.     But I still don&rsquo;t get Greko-Roman Wrestling.      I will be back from the summer hiatus soon and hope to have some changes to put on the site.   ]]></content:encoded></item><item><title>Kids and Statins</title><dc:creator>doc@askdrjim.com</dc:creator><dc:subject>askdrjim blog</dc:subject><dc:date>2008-07-07T21:31:09-04:00</dc:date><link>http://www.askdrjim.com/foler/page3/files/jul-2008#unique-entry-id-81</link><guid isPermaLink="true">http://www.askdrjim.com/foler/page3/files/jul-2008#unique-entry-id-81</guid><content:encoded><![CDATA[OK, so those of you who know me already know where this is going.    Today the American Academy of Pediatrics released and expert panel statement recommending more aggressive screening of cholesterol in kids AND selective use of statin drugs in kids as young as 8 years old AND a move away from whole milk in children after the age of 12 months especially if they are overweight.     The first is in an effort to identify those with risk of heart disease who may benefit from intervention.     The second is based on some small studies that did not show harm if children used the meds for a short term (long term followup does not exist yet).    The last is a major deviation from long held belief that for younger kids a certain amount of fat in the diet is crucial for brain development.


My take is mixed:   Obesity in children is rampant in America.  ...  We eat too many calories, too many calories as rapidly absorbed sugars and too little good protein and fiber.   ...  We have used sweet sports drinks to satiate our kids growing sweet teeth and as a society we &ldquo;do exercise&rdquo; rather that &ldquo;live active&rdquo;.    Our schools and social institutions feed our kids poorly and cheaply and exercise them rarely.     Our kids sleep too little (which in the < 8 year old crowd has been linked with obesity.


...We reach for pills because we don&rsquo;t want/cannot spend time with patients trying to educate and change lifestyles.    We have not been out front in advocating for healthy local school food and against corporate takeover of the lunchroom.     We have reached for pills to correct ignorance or sloth from parents who seem not to understand that they are killing their kids and we have gone away from common sense approaches.


Medicine has not lead the way in nutrution even for the youngest amoung us (unless they have an illness).    Did you know that nearly 1/3 of our baby boys in some surveys are drinking SOY forumla.     At the same time we promote soy as a phytoestrogen to help with the sympotms of menopause.   ...  Although obesity < 2 years of age has not been as strongly linked to adult obesity as in kids 3-8 we now seem poised to recommend against fats that nearly all science says may be cruicial for brain development in a toddler.  

...If you think that the pharmaceutical industry is not licking its lips anticipating a new group of &ldquo;patients&rdquo; who will take meds FOR LIFE you are kidding yourselves.     Doctors will not want to be &ldquo;behind the times&rdquo; and will start screening (not a bad thing) and given meds.    My experience over the years especially when I was teaching was that given a choice between educating and prescribing a medication, the Rx always won.   ...  So do not be decieved, these recommendations will largely increase testing costs, prescriptions to younger kids and side effects from those meds.


...Obese parents who eat poorly and do not exercise may wish their children were fit and active but, in my experience, the children quickly adopt the parent&rsquo;s livestyle.  ...  Sugars must become public enemy number one with high fructose corn syrup becoming our number one bad guy.    We need to have health care integrate nutrition and exercise eduation for children.     We need to insist on good independent sources of research on nutrition rather than relying of data compiled by manufactuers of medications.     We need to see that consuming is not healthy when it comes to medications and that the hard road of personal discipline and long term view is far better for society than the short term gratification of our taste buds.    We need to put patients back on the hot seat as active in their own health.  ]]></content:encoded></item><item><title>BFF</title><dc:creator>doc@askdrjim.com</dc:creator><dc:subject>askdrjim blog</dc:subject><dc:date>2008-06-30T22:04:52-04:00</dc:date><link>http://www.askdrjim.com/foler/page3/files/jun-2008#unique-entry-id-80</link><guid isPermaLink="true">http://www.askdrjim.com/foler/page3/files/jun-2008#unique-entry-id-80</guid><content:encoded><![CDATA[The other great thing about cyberspace is the fact that folks can find you drifing out there.     Recently I had a dear friend from years ago contact me because they found my website.     This was amazing in and of itself as we have had < 5000 visits in the past year!     Anyway I was found and then contacted.     I am so greatful that they took the effort to connect.    The other thing I have learned is that certain things are eternal.    I am sure that the eternal part of each of us recognizes the eternal part in our close friends.     How else can it be that after decades you can pick up almost without a pause?     It seems that certain types of human interaction just trancend (or may suspend) time.     Thanks for reachiing out when you did.       I have not had much to blog about with a busy summer schedule and I try to avoid politics other than bashing the pharmaceutical/medical/industrial complex.    There have been some studies out recently that I am digesting and trying to put into words to get out here.    I am also going to look at a podcast (because those of you who know me know I can talk and talk and talk).   Catch the poem in the verses page look at some friendship lines.  ]]></content:encoded></item><item><title>Forum on Hold</title><dc:creator>doc@askdrjim.com</dc:creator><dc:subject>askdrjim blog</dc:subject><dc:date>2008-06-30T22:02:27-04:00</dc:date><link>http://www.askdrjim.com/foler/page3/files/jun-2008#unique-entry-id-79</link><guid isPermaLink="true">http://www.askdrjim.com/foler/page3/files/jun-2008#unique-entry-id-79</guid><content:encoded><![CDATA[OK so maybe it was not such a good idea.    I certainly don&rsquo;t LIVE to sit at the computer typing and trying to intice &ldquo;friends&rdquo; to cyberchat.    The forum will go into hybernation for now.     I still would like have ideas on how to develop a more interactive site.     I really would like to &ldquo;ask the doc&rdquo; for both patients and others visiting the site but the forum was not working and I don&rsquo;t want to look at the site with in on any more.     The king is dead.    Long live the king.]]></content:encoded></item><item><title>Flippin Out</title><dc:creator>doc@askdrjim.com</dc:creator><dc:subject>askdrjim blog</dc:subject><dc:date>2008-06-30T21:54:24-04:00</dc:date><link>http://www.askdrjim.com/foler/page3/files/jun-2008#unique-entry-id-78</link><guid isPermaLink="true">http://www.askdrjim.com/foler/page3/files/jun-2008#unique-entry-id-78</guid><content:encoded><![CDATA[If you check out the last page on the site you will find a video of a trip I recently took with some friends and family.     The amazing thing is the camera on which the video was shot.     The Flip Mino is a new small video camera that is about the size of my very small cell phon.    It looks a lot like a blak iPod with a lens on one side.    The back has a large red button around which are four directional toggles and above which are 2 selection buttons.     The form is much like and MP3 player and is very intuitive.    There is a built in microphone and electronic zoom and a 1.5 inch LED screen in the back to watch what is being shot and to review the video clips.     Much like a digital camera, you can trash the clip if you don&rsquo;t like them.    It can record up to 1 hour of video/audio.     Now here it the kicker, it has a built in USB male port that pops out at the push of a button alowing you to link and download to a Mac or PC without much fuss.     If you want to use Quicktime or other players it is pretty straight forward.     And you can dump into movie software.     Thus the first effort you see posted.    This will be great for web video work.      I&rsquo;m just learning the ropes and will let the kids take it on a trip to North Dakota in July to shoot more footage.     I love the fact that you can be creative with minimal investment. ]]></content:encoded></item><item><title>What are you doing here?</title><dc:creator>doc@askdrjim.com</dc:creator><dc:subject>askdrjim blog</dc:subject><dc:date>2008-06-21T23:07:16-04:00</dc:date><link>http://www.askdrjim.com/foler/page3/files/jun-2008#unique-entry-id-77</link><guid isPermaLink="true">http://www.askdrjim.com/foler/page3/files/jun-2008#unique-entry-id-77</guid><content:encoded><![CDATA[Last week we were looking at the Old Testament story about Elijah and the phophets of Baal.    In the story Elijah is led to prove once and for all that his God is living and supreme and that Baal is an idol.     He challenges 450 of the prophets of Baal to build an altar and have their god produce fire from heaven to come down onto their altar.   ...  He then produces a simple altar, soaks the wood and the sacrifice with more water than was needed to make his point and then prays simply that God would show who is &ldquo;the Lord&rdquo;.  ...  Elijah has the false prophets seized by people who had come to watch the contest and then he has them all killed.     He prays to God to end the long drought that had ravaged the land and a torrent occurs.  

...He has been filled by God&rsquo;s Spirit  and with that filling has done miraculous things and observed God&rsquo;s power and constant attention to His people.     Our discussion looked at the way he was locked in to being brave and faithful in the story.


What struck me was the next chapter (1 Kings 19) where Jezebel has been told of the outcome of the duel and the death of the prophets (whom she supported).   ...  And fresh from his mountaintop experience and aware of God&rsquo;s power, the prophet........  He eventually wanders into the mountains and ends up in a cave apparently depressed and hiding.


...God does not ridicule him, demand he have more faith or punish him.   ...  The man complains that all others have been unfaithful and he has tried to do God&rsquo;s bidding and now he is in danger of his life.      God again, does not punish or correct, He tells Elijah to go out of the cave and stand on the mountain so Elijah can be there when God passes by.    Elijah does so and observes a great wind that shakes the mountain and shatters rock (and the text says &ldquo;&rdquo;But the Lord was not in the wind&rdquo;.   )   Next came an earthquake and then a fire with the same response.     Finally, there is a quiet voice of God which says... 

...Elijah repeats his statements of before and again, God does not chide him.   ...  Then God reminds the prophet there are still 7,000 men fiathful to Him during this time of turmoil. 


...Right now I am in a place where I am complaining, feeling sorry for myself and being generally depressed.   

...God is always in the places where we are, waiting, full of action and hope.    He has plans for us that He desires to tell us.   ...  He does not rebuke us for these but he wants us to move outside of the place where we are so that we can see Him.     He can hear our complaints but desires to put us firmly into His plan.    He also comforts us with the knowledge that we are never as alone as our emotions would tell us we are.     Lastly, He certainly can show us His presence in big and powerful ways but He does not need to do so because the power He places inside us is sufficient as long as we look to Him and obey. 


I hope that I can learn this lesson and move out from the cave to hear what He has for me to do. ]]></content:encoded></item><item><title>Abba</title><dc:creator>doc@askdrjim.com</dc:creator><dc:subject>askdrjim blog</dc:subject><dc:date>2008-06-08T23:48:57-04:00</dc:date><link>http://www.askdrjim.com/foler/page3/files/jun-2008#unique-entry-id-76</link><guid isPermaLink="true">http://www.askdrjim.com/foler/page3/files/jun-2008#unique-entry-id-76</guid><content:encoded><![CDATA[Today at Sunday School we were discussing the issue of fear.    The question at hand was &ldquo;where is God when I fear?&rdquo;   and the myriad questions that sprout from that point.    It is a very relevant question.     Daily in my practice I see people whose lives are dominated by fears and anxiety.     Some have phobias, some reactions to past traumatic events, some seem to be unable to leave daily worries alone and many are ashamed of their fear.


My take on this may be a bit different.     I believe God has given us all our emotions.     I cannot tell you where fear would fit in before the fall of man but certainly the adrenaline rush and &ldquo;fight or flight&rdquo; reaction it can produce is not in and of itself an evil thing.    God does not tell us to be ashamed of our fear.    He asks us to understand we have reason to boldly face the things that make us anxious through his power.


The passage that caught my attention says that we have not been given a spirit of timidity but of power.    We are not slaves but adopted sons and daughters and can call &ldquo;Abba&rdquo; or &ldquo;daddy&rdquo;.    I bet I had read or heard that passage dozens of times but it struck me today that an orphan wandering in the world faced with a fearful situation will likely cry and dispair.     A son or daugher yells &ldquo;DADDY!&rdquo;   fully expecting the rescue, the comfort and the support of the father.    The Spirit we are given is His Holly Spirit within us.    This certainly is not a spirit of timidity and we can cry out for Abba to come and be with us in our time of deepest anxiety.  ]]></content:encoded></item><item><title>Are You Confused Yet?</title><dc:creator>doc@askdrjim.com</dc:creator><dc:subject>askdrjim blog</dc:subject><dc:date>2008-06-01T23:50:49-04:00</dc:date><link>http://www.askdrjim.com/foler/page3/files/jun-2008#unique-entry-id-75</link><guid isPermaLink="true">http://www.askdrjim.com/foler/page3/files/jun-2008#unique-entry-id-75</guid><content:encoded><![CDATA[This past week the British Medical Journal (BMJ) published three very interesting articles related to Type 2 diabetes.    This is the most common type of diabetes seen in the world and is the one linked with central obesity and diet.    You see, over the past decade there has been a wealth of new medications including new types of insulin that have come on the market enhancing our ability to bring sugars closer to normal in most patients.    Many folks are now on several drugs and may be on drugs and insulin.     They also are monitoring their sugars multiple times per day to be more aware of their control. 


Much of the reasoning behind the desire to tightly control Type 2 diabetics was extrapolated from research on the other type of diabetes, Type 1 diabetes.    In this form the body&rsquo;s insulin production is impaired, often after a viral or autoimmune or other insult to the pancreas.    The result is generally patients who absolutely need insulin to live.     What was discovered years ago was that the rate of development of renal failure, blindness and other complications was slowed dramatically by tightly controlling sugars.    Since these people needed insulin, you started to see testing with each meal and in between meals to help them decide how much insulin to use.    Because of the pain with testing, new meters emerged that required less blood and caused less pain.   


It was thought that diabetes was diabetes and if tight control was good for one type then it must be good for another.  ...  Certainly, it is a patient&rsquo;s best interest to not have remarkably high sugars or wild fluctuations.    It is also good for them not to have hypoglycemia and pass out.   ...  If so it would require a lot of testing and more medications.


Enter coroprate America who was only too happy to settle the question.....if it gets paid for it should be done.    We now have organizations that aggressively market to patients who have diabetes offering to supply their testing materials delivered to their door with no hassle.     As a doc I get the &ldquo;request&rdquo; from these companies to test.    They are only too happy to send out more supplies regularly (even if the old ones are not used up) and to provide reqular upgrades, batteries, reagents and even blood tests normally done at a doctor&rsquo;s office.     All of this is for the patient&rsquo;s convenience AND to help with their control.      And of course now patients are testing so much that they become afraid or ashamed of the results and request more medications to control them &ldquo;to normal&rdquo;.


...Three articles:  the first was looking at whether it was cost effective to detect diabetics or prediabetics so interventions including diet, exercise, education and medication could be initiated:  This one was simple....it was cost effective to find the prediabetics and diabetics so we could intervene mostly with non-drug methods.     The second and third articles looked at the cost effectiveness and other outcomes of having patients monitor aggressively their sugars at home rather than seeing a doctor episodically and having adjustments to medications made at that time.    (You seen in Great Britain they have BUDGETS for their health care and they want to know if they are spending the money wisely or not).   


What they found was that aggressive monitoring by the patient was NOT cost effective, DID NOT result in better control but DID result in a LOWER QUALITY OF LIFE ASSESSMENT SCORE and HIGHER scores for depression!


Their editors questioned the value of aggressive home testing for the majority of Type 2 Diabetic patients and rightfully so.    Makes you wonder why we are pushing so hard.]]></content:encoded></item><item><title>Gas Prices and Other Thoughts</title><dc:creator>doc@askdrjim.com</dc:creator><dc:subject>askdrjim blog</dc:subject><dc:date>2008-05-26T22:42:41-04:00</dc:date><link>http://www.askdrjim.com/foler/page3/files/may-2008#unique-entry-id-74</link><guid isPermaLink="true">http://www.askdrjim.com/foler/page3/files/may-2008#unique-entry-id-74</guid><content:encoded><![CDATA[Gas is approaching $4 per gallon here and filling my truck is over $70 a pop now.      One becomes a conservationist in a hurry when the wallet is hurt that badly each time you fill up.    I certainly don't recall the gas rationing of the 70's very vividly but I wonder how far away from that we may now be.     As a consuming nation we have always "lived large".     America more than any other definition is one of excess to the rest of the world.    Excess violence, excess consuming, excess waste, excess pop culture.      Maybe this looming economic change for us will force some type of maturity on those types of patterns.    Then again, maybe not.    I know that Satan certainly uses our consumerism to aid our tendency toward greed and idolatry.    Not that we need much encouragement.  


 I find that the more I have, the more I want and the more I want the less I seem to have.    That is far from the contented life that Christ advocated.    We were not to even worry about things of material nature both because God will supply what we need when it is needed and because looking to the future with worry or convoluted plans robs God of our attention now.    By diverting our attention to something that does not exist (the temporal future) to something that does (our eternal security through Christ's grace) Satan achieves a goal of weakening our perception of eternity.    We are "amphibious" as C.S.   Leis wrote....both temporal and eternal beings.     The more we concentrated on one part of our nature, the less we will concentrate on the other.    God desires that we look to the Eternal and Satan desires we think only on the temporal.     If we could see from God's view we would be able to be as Paul was "content" in all circumstances.


The other thoughts I have had recently are about milestones.     Certainly, with school ending we see our children and friends marking, often publicly, a transition in their lives.    Other milestones pass uncelebrated but not unknown.    These may be special days in the lives of those whom we care about or those who have left us for eternity.     Memorial Day is a time to not only remember those who have died in the line of duty to our country but also those who have served or are serving honorably.    My thanks for those of you who have done so and my prayers for those whose milestones happen this month.]]></content:encoded></item><item><title>Me and Pat</title><dc:creator>doc@askdrjim.com</dc:creator><dc:subject>askdrjim blog</dc:subject><dc:date>2008-05-18T17:09:01-04:00</dc:date><link>http://www.askdrjim.com/foler/page3/files/may-2008#unique-entry-id-73</link><guid isPermaLink="true">http://www.askdrjim.com/foler/page3/files/may-2008#unique-entry-id-73</guid><content:encoded><![CDATA[Just a short blurb on another event this week.    I was asked to speak to a women's luncheon about weight loss and exercise.     I was prepared for a group of a bout 50 or so.    When I got to the event there were around 400.     That's 400 women and 4 men (the pastor of the church, one husband, a guy who may have wandered in and myself).     That is kind of the definition of intimidating!


Luckily, one of my first slides said that "Talking to a group of women about diet and weight loss is like trying to tell Pat Summitt how to coach!!"    


The talk went well and I think I am learning as I go about this whole diet issue.     One interesting fact from my preparation:  the LUMEN of the intestine appears to monitor its contents and sends signals to the brain and other body parts depending on what is found.     Let me say that again....our gut tests not only what is being absorbed into its bloodstream during digestion but MONITORS WHAT IS PASSING THROUGH as it attempts to tell our brain how much and what to eat.


We are fearfully and wonderfully made. ]]></content:encoded></item><item><title>Water and Blood</title><dc:creator>doc@askdrjim.com</dc:creator><dc:subject>askdrjim blog</dc:subject><dc:date>2008-05-18T16:52:04-04:00</dc:date><link>http://www.askdrjim.com/foler/page3/files/may-2008#unique-entry-id-72</link><guid isPermaLink="true">http://www.askdrjim.com/foler/page3/files/may-2008#unique-entry-id-72</guid><content:encoded><![CDATA[My middle son was baptized today.     There were several others at the church that went through the ceremony.    I was very happy and proud of his decision to publicly show what was a spiritual commitment that he had made.    I has me thinking about the sign of baptism.    I do not believe that there is anything in the ordinance that makes or breaks someone's eternal security.    That being said I know that Christ was baptized in order to "do all right things". 


...We are nurtured in the womb in a bath from which we emerge to face the world as a new creature.    Everything is changed and yet we are prepared for it physically.    Much will be hard.     There will be times of sickness, pain and loneliness, yet the journey begins as we come out of the water.    Christ told Niccodemus that he would need to be "born again" in order to inherit eternal life in paradise.    By using water the ancients re-inacted the physical birth.    By using some words (Christ's suggestion to baptize "in the name of the Father and of the Son and of the Holy Spirit." the ceremony is raised to a different and more meaningful level.  


We are submerged and dead, lost and unformed.     We emerge with this new life in Christ sinless, alive and growing toward His likeness.     The old is passed and the new has started.     We also identify with Christ's own baptism and life and say to the world "I am a follower of the Christ."    These are deep spiritual truths that all lie behind the act of baptism.    We do this in front of witnesses (even if only the pastor) in order to make that proclamation public and real.


Here is east TN baptism can be a real social event.    Some churches wait for months and do mass baptisms.    Others baptize new believers immediately.     Many still will "go to the river".    I attended one such baptism about a year ago that brought the simplicity and beauty of the act fully into view.    With nature all around and the flowing water of the river as a background, it was hard not to imagine Christ standing there, smiling and nodding.


I am glad that God has chosen to ask us to do public things to align ourselves with His cause.     It is far too easy to do what the crowd wants these days and my son's decision to run counter to that makes me proud. ]]></content:encoded></item><item><title>Stories and Connections:  Ramblings</title><dc:creator>doc@askdrjim.com</dc:creator><dc:subject>askdrjim blog</dc:subject><dc:date>2008-05-04T23:47:34-04:00</dc:date><link>http://www.askdrjim.com/foler/page3/files/may-2008#unique-entry-id-71</link><guid isPermaLink="true">http://www.askdrjim.com/foler/page3/files/may-2008#unique-entry-id-71</guid><content:encoded><![CDATA[I guess one of the things that entices me about medicine in general and primary care specifically is the diversity of stories and the way they are told.     I try to use the "pattern recognition" that seems to aid all of us in primary care because common things are common.   


In this day and age we have medicalized everything that used to be the realm of others:  nutrition, exercise, aging, spiritual pain, emotional upheaval as well as routine birthing.     The small step from childhood immunization for polio and smallpox has become an lucrative industry of well child visits.    These paternalistic encounters presupposed that parents cannot think about safety and diet and development themselves....it is far too complex.    Sure, I have detected developmental delays, abuse and neglect and the occasional congenital condition but these largely were self-evident or brought to me by a parent.     And, yes, I have seen my share of unfit parents who were clueless about feeding a 2 month old solid food or other basic issues.    


Yet I feel this reflects familial and social failings that would best be addressed elsewhere.     When I was in Houston we had an early model of RN's doing well-child visits largely because the MD's were too busy in an overloaded public healthcare system to perform the evaluations well.     The nurses did the screening as well as most of the doctors would have done BUT we found that the questions they were asked and the confidences shared were quite different.    They began to function as the wise aunt or grand-dame of the family who knows child-rearing from years of experience and observation.     The nurses also had a more culturally appropriate point of view as they often lived or grew up in the communities our clinics served (not the case with our doctors).


Back to my point.    I feel that primary care is about stories, listening to those stories and then responding both with expertise and inquisitiveness while being a caring human.    What I find daily is that the stories are fascinating...even the ones that are "made up" for the doctor to hear.    These are the convoluted histories that hide abuse or addiction or loneliness.    The stories make the day fun.   


The connections make the day stressful.     The child who is not quite right but you are not sure why and the parent (a friend ) puts their trust in you when you have no clue what is wrong....just some vague hunch.     The treatment that does not seem to work that keeps you awake at night wondering if you missed something in the story or the lab.     The patient who is sent to a specialist who, also a human, misses the story's point and dismisses symptoms I feel are urgent.    These are the things that terrify me.


It is the same with other jobs, I am sure.    Other people worry about the construction of a home for a friend or working on a car that doesn't quite seem to be right.     They too feel the pressure that is more than just a craftsman's care.     It is the connection with another whom you are serving with your chosen profession.    I am glad of the feelings because I have seen and taught folks who did not have them....and I would not send patients to them. ]]></content:encoded></item><item><title>Forum</title><dc:creator>doc@askdrjim.com</dc:creator><dc:subject>askdrjim blog</dc:subject><dc:date>2008-05-04T23:44:05-04:00</dc:date><link>http://www.askdrjim.com/foler/page3/files/may-2008#unique-entry-id-70</link><guid isPermaLink="true">http://www.askdrjim.com/foler/page3/files/may-2008#unique-entry-id-70</guid><content:encoded><![CDATA[If you look at the menu you now see a "Forum" area.    This is a fledgling bulletin board of sorts.     Forum are places where folks can leave thoughts in more connected ways and develop community with other visitors.     I will moderate this area and pull off postings or people that prove offensive.     I have started a few discussion areas and can post more.    I would like to leave this up for a while and see how people respond to it.    The general category is for  questions and advice on what should be on the forum.    The other areas are self-explanatory.    I would like you to be creative and give some input.     If it works we will keep it up otherwise it will die.  ]]></content:encoded></item><item><title>Help With This Site</title><dc:creator>doc@askdrjim.com</dc:creator><dc:subject>askdrjim blog</dc:subject><dc:date>2008-04-27T23:18:01-04:00</dc:date><link>http://www.askdrjim.com/foler/page3/files/apr-2008#unique-entry-id-69</link><guid isPermaLink="true">http://www.askdrjim.com/foler/page3/files/apr-2008#unique-entry-id-69</guid><content:encoded><![CDATA[Now that I have a new iMac and can find time to work on this website more I am thinking about how to change it for the better.     I would like to have a separate blog for medical issues and one for other things.    I would like to look into some podcasts.    I would like to compile RSS's from other sites that have breaking medical news for folks.    Given an interest in diet and exercise I would like to push out some tips or foods to make or buy.     I would like to think of automated emails to people who would like to have a regular update of some type.     I would be interested in doing some chat times "ask the doc" like times.


Help me filter out the things that would not be good and those that might be interesting.      Thanks. ]]></content:encoded></item><item><title>KISS Principle</title><dc:creator>doc@askdrjim.com</dc:creator><dc:subject>askdrjim blog</dc:subject><dc:date>2008-04-27T23:02:32-04:00</dc:date><link>http://www.askdrjim.com/foler/page3/files/apr-2008#unique-entry-id-68</link><guid isPermaLink="true">http://www.askdrjim.com/foler/page3/files/apr-2008#unique-entry-id-68</guid><content:encoded><![CDATA[Yesterday I went to the Franklin Graham Festival in Knoxville.    It was youth day and that meant lots of energy and 2 bands before the message.   ...  I would say the music but, yes I am officially old, I heard mostly chaos.     I think that the fusion type of hip hop that is common right now is interesting.     Synthesized voices, samples for beats and background and then several folks giving lyrics in rhythms that accentuate the background.    Generally one singer singing a few repetitive phrases that are catchy or function as a counter-tune.    All of this is done with a general frenzy and energy that includes jumping, hand pumping and slamming bodies.     The "lead" singer generally acts like a DJ asking the crowd to respond and the energy increases.     Sometimes the words are good....mostly the singing is not.     Finally it all seemed very choreographed and thematic.    Both bands could have come out of the same blender....but the kids liked it and that was important.


Now to the real heart of this blog.     When it was time for Franklin Graham to come up and speak, he did so with very little of the polish and emotion that you see from TV preachers.    The message was plain and simple and very brief.     He didn't talk down to folks and didn't use a lot of theological language.    He got the basics of the gospel and the call to repentance and then he was done.     I had been praying during the sermon that God would move in a mighty way but as Franklin spoke, I began to waver.    I thought this might be the first time no one came forward with a decision to come to Christ.


Now I know that the crusade places counselors all over the hall and they also come down at the time of the invitation.    This helps those "on the fence" gain the courage to step out as they see others coming.    I don't know how many folks were there as counselors.    All I know is that hundreds of people, both adults and children, came forward to the floor.     I was humbled and marveled at the strength of the Spirit that could call people with such force when what I had seen did not seem compelling from a human standpoint.   


This brought home to me the fact that God does not call us to save others.    He does not require that we be polished or have all the answers.    He does not need us to be perfection.    He only asks that we go and witness to what we have seen and heard and to make disciples.   ]]></content:encoded></item><item><title>Turn off the Lights and Watch Them Glow&#x21;</title><dc:creator>doc@askdrjim.com</dc:creator><dc:subject>askdrjim blog</dc:subject><dc:date>2008-04-22T22:18:42-04:00</dc:date><link>http://www.askdrjim.com/foler/page3/files/apr-2008#unique-entry-id-67</link><guid isPermaLink="true">http://www.askdrjim.com/foler/page3/files/apr-2008#unique-entry-id-67</guid><content:encoded><![CDATA[Twice a year I do a New England Journal of Medicine education program that forces me to dig deeper in the journal to look at research and reviews that often help me in my practice.     The next few blogs will be seasoned with some of the gleanings.      Did you know that over 4 million CT scans are performed each year on children?    That in and of itself might not be bothersome but increasingly these CT's are repeatedly done on the same child as a condition is followed or symptoms persist.    Think of the child who complains of headaches.     Of course it could mean they need glasses, become hypoglycemic from their high sugar diet or have migraines brought on by lack of sleep or preservatives in their food but IT ALSO COULD BE A TUMOR or some other rare but dangerous condition.     Picture the desperate parent going from doctor to doctor and ER to ER without relief AND without communication between doctors.    Eventually several CT scans of the head may be performed.     A review in the November 29th journal commented that, compared to abdominal x-ray, a CT of the abdomen had more that 50 TIMES the organ dose of radiation that is absorbed.     There is reasonable evidence by looking at nuclear survivors and cancer development that having had several CT scans increases the risk for organ cancer development in adults and "The evidence is...very convincing for children."     This should be a cause for concern and restraint on the part of both doctors and patients.    One straw poll of radiologists cited in the article suggested that perhaps 1/3 of all pediatric CT scans could be avoided without significant clinical harm.


We all know the data about childhood obesity in America.     I have outlined before the link in my mind with high carb diet (especially corn based sugars), lack of exercise and action oriented video games.     These kids can and do lose weight if those things are changed.    End of story....right?     Well, not exactly.    A Study by Baker, Olsen and Sorensen in the December 6, 2007 Journal reviewed body mass index (kind of a weight by height ratio) in childhood and the risk of coronary heart disease in adulthood.    What they found was  increased risk stronger in boys than in girls.     We need to get our toddlers off sugar and exercising.    Doing so may help prevent not only coronary disease later but hypertension, diabetes, some types of cancer and degenerative arthritis.      We are spoiling our kids literally to death with our poor habits and parenting and our society will pay.  ]]></content:encoded></item><item><title>Hidden in My Tent</title><dc:creator>doc@askdrjim.com</dc:creator><dc:subject>askdrjim blog</dc:subject><dc:date>2008-04-13T23:00:30-04:00</dc:date><link>http://www.askdrjim.com/foler/page3/files/apr-2008#unique-entry-id-65</link><guid isPermaLink="true">http://www.askdrjim.com/foler/page3/files/apr-2008#unique-entry-id-65</guid><content:encoded><![CDATA[Today at church Brian, my pastor, drew a startling connection between a familiar Old Testament story and a New Testament truth.   ...  The open ones are the ones we have become so familiar with that we excuse ourselves before the Spirit can prick our conscience.  ...  At first it is painful but with time the triangle cuts a circle and I feel the pain no longer".     These are those open sins:  the angry look on the freeway, the impatience with the clerk while in line at the grocery store, the prideful words when comparing ourselves with our neighbors.   


...These too can become numb to us as they are so common to us that we excuse ourselves before reflecting upon them.    These are the ones not anyone but you and God see: the lustful look at a stranger,  the anger we will not release,  the delay in loving others until they love us.   


Hidden sins are the ones we do know are harmful but we collect them and store them away.    Maybe we are afraid to ask for God's forgiveness, maybe we know he will ask for repentance and restitution that we do not want to give, maybe we want to sin again and want to ignore the Spirit's warning.   


...Jericho has fallen but Isreal has not been able to succeed in another battle.     God reveals that this is because of a specific sin and the accused is revealed by God to Joshua.     When confronted the man admits to taking spoils from Jericho in direct disobedience to God's stated desire.     He tells the men that he has hidden the gold and other spoils in the dirt in his tent.   

...He reminded us that OUR BODIES ARE THE TENTS that now contain the Holy Spirit!   ...  We seen to be unable to find joy or God's blessing in our lives but we have hidden sins in our tents and seem unaware that He knows and HE CARES.   ...  Surely I have open sin that all the world can see.   ...  I can ask God and the others who see the sin to forgive and support me.     It's the ones buried deep in the dirt of my tent.  ...  The man in the story said he "coveted" the gold and silver and cloth he took.    He loved the created more than the creator and when he coveted he took and completed the sin.   


...I mean that I don't want to let them go.    I find something base in myself that likes the sin and won't let go.   ...  I think they are the same for to gossip generally means you put yourself up in a better light than those about whom you are speaking.     So pride seems to be the root of much of my "hidden" sin.


...We know that God has forgiven our sin.   ...  God has ongoing knowledge of our sin and HAS forgiven us.    We must work with the Spirit to see, dig up and throw out the sin for it creates a barrier to our effectiveness that will not go away by other means but God's love is a constant not some type of popularity poll.     Sanctification is painful and messy but we need to have a clean tent with which to house our Lord. ]]></content:encoded></item><item><title>Oops&#x2c; We Did It Again&#x21;</title><dc:creator>doc@askdrjim.com</dc:creator><dc:subject>askdrjim blog</dc:subject><dc:date>2008-04-09T22:15:22-04:00</dc:date><link>http://www.askdrjim.com/foler/page3/files/apr-2008#unique-entry-id-63</link><guid isPermaLink="true">http://www.askdrjim.com/foler/page3/files/apr-2008#unique-entry-id-63</guid><content:encoded><![CDATA[I know I'm a week late on the Vytorin, Zetia mess but I had no way to get to the site.      For those of you following the box score,  Zetia and Vytorin (Zetia mixed with generic Zocor) recently were "outed" in a study reviewed at a national cardiology conference in Chicago and then published in the New England Journal of Medicine last week.     The study looked at over 700 people who carry a gene for VERY HIGH cholesterol levels.    The company-sponsored research set out to prove that the 2 drugs were better than Zocor (a "statin drug") used by itself.     The results looked good for the company:   ALL THE INTENDED LAB VALUES MOVED IN THE RIGHT DIRECTION.     The cholesterol and sub-fractions of "bad" cholesterol all went down, the good cholesterol rose and the measure of inflammation (CRP) thought to contribute to heart disease/attack went down.


In other words it looked like the study had done what the companies wanted:  proved that we all need to take the new drug not the old drug (that a few years ago they convinced us we all needed).     One little problem, the cholesterol plaques they monitored in the patients DID NOT GET SMALLER.     And to make matters worse, there appeared to be no mortality benefit.     Too bad.     Guess we'll just stick to the older, cheaper drugs.   


BUT WAIT.     It appears that the company knew the results for a couple of years now.     By the way during those 2 years they marketed the Zetia/Vytorin like crazy and they became MULTIBILLION winners for the company and its stockholders.     So releasing the study now isn't quite so hard for them to swallow.      In the end patients AND doctors have to shake our heads and wonder "what it the truth anymore?"   when it comes to research.


More concerning (enough to prompt some comments in the editorial) is the thought:   "if everything we wanted to have happen went right then could our entire theory of the progression of heart disease be flawed somehow?"     The closest we saw was a suggestion that there must have been another mechanism at work that gummed up the outcome.    But I ask again:  Could we have this wrong?     We see folks with low cholesterol have heart attacks and we see smoking, cholesterol consuming Frenchmen living long and happy....what if we are wrong?     More importantly...what if we are being told what best sells stock?      Be careful out there. ]]></content:encoded></item><item><title>Get Going Again</title><dc:creator>doc@askdrjim.com</dc:creator><dc:subject>askdrjim blog</dc:subject><dc:date>2008-04-09T22:09:16-04:00</dc:date><link>http://www.askdrjim.com/foler/page3/files/apr-2008#unique-entry-id-62</link><guid isPermaLink="true">http://www.askdrjim.com/foler/page3/files/apr-2008#unique-entry-id-62</guid><content:encoded><![CDATA[Well, I have an new iMac for use and so I should be able to update this site more readily.     I am thinking about having a portion of the blog be questions from patients or site visitors who want some type of medical information.    This would give me food for thought.     I am also looking at trying to do an email list to send out updates and possibly a podcast.     Ambitious, I know, but it will keep me busy and away from the TV.     The new iMac is a joy as usual.    So easy to get going and so easy to back up.     The new keyboard is a small metal one and I really like the feel of the keys.    I don't have as many sticking keys as the other iMac.


I also have a iTouch iPod that really excels.     It can do wireless internet through my or other open networks it encounters and allows web browsing and Email!     I am looking at software that would allow me to update the Blog from email remotely which would allow me to do it sitting in McDonald's etc.     Next medical. ]]></content:encoded></item><item><title>Sleep Apnea</title><dc:creator>doc@askdrjim.com</dc:creator><dc:subject>askdrjim blog</dc:subject><dc:date>2008-03-16T13:37:47-04:00</dc:date><link>http://www.askdrjim.com/foler/page3/files/mar-2008#unique-entry-id-61</link><guid isPermaLink="true">http://www.askdrjim.com/foler/page3/files/mar-2008#unique-entry-id-61</guid><content:encoded><![CDATA[I'm doing another medical type entry today.     I was listening to a radio program and the diagnosis sleep apnea was being discussed.     Not to belittle the suffering folks have with other conditions which are bursting out all over (restless legs and the like) but sleep apnea does deserve attention.     There was a time when it was funny or quaint to talk about the snoring of a spouse or friend.    We would tease and talk but no one paid much attention.  


Emerging research has linked obstructive sleep apnea (stopping breathing in the night due to obstruction of the airway, generally by a relaxed tongue) to high  blood pressure, congestive heart failure, glucose intolerance, stroke and sudden death.     These are serious effects.     Generally I see a man or woman who has AM headaches, obesity, sugar issues and elevated blood pressure where many meds have been tried but no assessment for sleep apnea has occurred.     The overall workup is noninvasive and relatively inexpensive compared to the outcomes that may occur if left untreated.    The treatments are not perfect but newer treatments are emerging.     The main issue is our lack of detection.


If you or a loved one snores loudly, stops breathing while snoring or has other disruptive sleep I would strongly suggested talking with your doctor to have it evaluated before a stroke or heart attack occurs and it is too late.  ]]></content:encoded></item><item><title>Take your medicine.  Drink the water.</title><dc:creator>doc@askdrjim.com</dc:creator><dc:subject>askdrjim blog</dc:subject><dc:date>2008-03-15T15:09:11-04:00</dc:date><link>http://www.askdrjim.com/foler/page3/files/mar-2008#unique-entry-id-60</link><guid isPermaLink="true">http://www.askdrjim.com/foler/page3/files/mar-2008#unique-entry-id-60</guid><content:encoded><![CDATA[Don't know if you followed the story recently about major cities testing municipal water supplies and, surprise, traces of medication were found.     Several years ago I read a book about the complex interactions in nature especially things we feel are more static (like plants and water).     The author went through several reports about the high level of pharmaceutical products being found in our ground water.


Now you may think that a little penicillin in the water is no big deal.    But would you think the same about hormones, antidepressants, narcotics?     I know it sounds a bit bizarre but the major thing found at that time was estrogen!.     Remember that our food supply (animals) are being fed large amounts of hormones, hormone laced foods and antibiotics.     People also consume increasing amounts of drugs and .... well they end up somewhere if that are not degraded by our bodies.     In the old days penicillin was expensive and the urine of patients who received it was collected and the penicillin was removed and reused.  


The concern here is not just drug interactions or allergies that may develop.    I am worried about low levels of so many centrally acting drugs (drugs that work in the brain).     Could our epidemic of depression, ADHD and the like be made worse by our water supply?    It is indeed frightening.      And those of you who use bottled water are not off the hook.     As I understand it there are no requirements to remove or test for drugs in the process of bottling water so we just do not know.     It all comes back to an old rant of mine....be careful in the use of medications.]]></content:encoded></item><item><title>What a week&#x21;</title><dc:creator>doc@askdrjim.com</dc:creator><dc:subject>askdrjim blog</dc:subject><dc:date>2008-03-01T22:10:31-05:00</dc:date><link>http://www.askdrjim.com/foler/page3/files/mar-2008#unique-entry-id-59</link><guid isPermaLink="true">http://www.askdrjim.com/foler/page3/files/mar-2008#unique-entry-id-59</guid><content:encoded><![CDATA[Thanks for those of you that have called or written comments about this blog.    I am hoping to get a new PC for home that will allow me to be more creative with this site.    I really would like to develop a place for social networking about health and creativity.      Stay tuned.


This week was, in a word, disorienting.     With the new management came a flurry of activities.     By Monday afternoon curtains were ordered, lab reorganized and workflow adjusted.    Our new nurse and clinic "boss" both had to be trained on the electronic record, and phones, and Dr.   Schindler quirks...this was no small feat.     I must say they dealt with it all very well.     I became a bit irritable at times.     It is funny how we talk about wanting change in our lives but really desire constancy.     The change was unnerving to me during the week but we'll get through.   


By midweek we had a bit much estrogen in the building, which is already quite small, and the cleaning and straightening caused me to be chagrined realizing how stuck in a rut I could be.     I can promise you that the basic feel of the clinic (being small and personal) will not change but the decor and trimmings will reflect Lakeway's commitment to the White Pine community.    I have been impressed with their speed and professional approach.    I only hope I can keep up. 


Please keep me informed as to problem you encounter, things you would like to see changed or added AND good things you want kept or see happening.     We would not be here if not for the community of patients that we are building.    Use this site to email me your comments and keep in touch.  


Stay tuned!]]></content:encoded></item><item><title>Transitions</title><dc:creator>doc@askdrjim.com</dc:creator><dc:subject>askdrjim blog</dc:subject><dc:date>2008-02-24T14:36:24-05:00</dc:date><link>http://www.askdrjim.com/foler/page3/files/feb-2008#unique-entry-id-58</link><guid isPermaLink="true">http://www.askdrjim.com/foler/page3/files/feb-2008#unique-entry-id-58</guid><content:encoded><![CDATA[  NOTE:  THIS IS WRITTEN SUNDAY 2/24...the blog date seems to be stuck.  


My practice (as well as my life) has been going through some times of testing.    Without going into a lot of detail I will say that there have been some extreme financial pressures since early Fall of 2007.    After delaying for as long as possible I began to pray about whether I needed to close the practice to avoid more financial debt or look at other options.     My options were limited in White Pine.     There are always jobs for doctors so I knew I could move the practice elsewhere, join another group (which would make me move) or choose to be employed somewhere (also entailing a move).    I had set a 3/1/08 deadline for a decision.


In the first week of February a friend informed me of another option: talking with a local hospital that was considering expanding their clinic network into White Pine.     After some preliminary inquiries I found that, indeed, this might happen and that they may be interested in negotiating with me.    By February 12th I had a preliminary contract in hand and after much prayer I decided to sign at noon on February 15th.     By the 20th the practice's assets had been reviewed and the ball was rolling.   


Long story short, on 2/25/08 the clinic (which largely will look the same for now) will be operated by a subsidiary of Lakeway Regional Hospital in Morristown.     I will by employed by them and they will provide all the supplies and staff the clinic.     Whew!    This moved very fast but seemed to provide for the top goals I had:  1) to stabilize finances personally for my family and their future and 2) to keep the practice in White Pine.    A month ago this was not on the radar and I pray that I have heard and heeded God's providence.


The changes will not be without pain.    I will lose some control of operations and billing and collecting.    The hospital is committed to helping my existing patients remain.    They also take all the major insurance that I do (including TriCare and Medicare and all the TennCare).      The staff will be hired and managed by the company.    This means we will have more staff but the staff will change.    This likely will cause the most pain as our team in the past has been so important to what I do.    Believe me when I say I hope this change will keep our care improving daily.


Thank you for all the thoughts and prayers from those of you that know the stress I have been enduring the past year.    Your prayers and encouragement have helped me get through this time.    I hope and pray that by remaining in White Pine, although under different practice management, I will return to you and the community the commitment you have shown me.]]></content:encoded></item><item><title>Truth</title><dc:creator>doc@askdrjim.com</dc:creator><dc:subject>askdrjim blog</dc:subject><dc:date>2008-02-17T08:06:29-05:00</dc:date><link>http://www.askdrjim.com/foler/page3/files/feb-2008#unique-entry-id-57</link><guid isPermaLink="true">http://www.askdrjim.com/foler/page3/files/feb-2008#unique-entry-id-57</guid><content:encoded><![CDATA[Our men's group is studying a book on the need to hold to absolute truth in this world.     As we have moved into a world that has developed some understanding that science and logic is not going to answer all the questions of life (the Post-Modern world of thought), truth, especially absolute truth, has become a casualty.     We have moved more and more to the use of relative truth.    We feel this makes us tolerant and  encompasses the ambiguity and chaos that we see around us.    "Well, that's my opinion" is a commonly heard phrase that really means "I believe what I just said right now regardless of the facts and I may change my mind in the future.    This is America and I can have and express that opinion."


Indeed, the relative freedom we think we have in modern democracies allows all types of ideas to, in theory, be expressed boldly.    Ideally those ideas would be discussed, tested and discarded if they have no basis in some type of truth.    In reality our desire for tolerance often means the ideas stay out in the public consciousness as "relative truth" that is not tested or questioned.    Outside of hard science we feel uncomfortable with someone stating that there is an ABSOLUTE truth that can be known and understood.     A person holding to that view is seen as "rigid" or "narrow-minded" and, in our politically correct environment, "fundamentalist".


In Christianity this denial of absolute truth is harmful.     By allowing "fuzziness" to replace clarity we open the Church up to false doctrine.     By championing tolerance over truth (tough though it may be) we weaken our witness.     In the garden the original way Satan attacked human relationship to God was "God did not really say..." and that doubt allowed the sin to seem less obvious as it dangled there in front of them.


Christ said "I am the way and the TRUTH..."   this means that if we as Christians believe Christ was the Divine incarnated as a man that His Words ARE truth.    When He says we must love others as ourselves or that the hour of His return is not to be know by any but the Father or that God so loved the world that He was sent so that anyone who believes would have eternal life these are truth.     To make His life and words fuzzy is to dangerously flirt with changing (not enhancing) the truth.


Certainly we run the risk of being rigid like the Pharisees of old but their rigidity was exposed by the fundamental lack of truth in the way they lived their lives.    Christ opposed their form of religious practice and offered the Truth-based alternative for us to follow.     "You have heard it said.....but I say..." was a way of showing us that the absolute truth on which this universe is based comes from God....  IS GOD.     Ultimately God is the truth and as Christians we must look to Christ and his example and his words as the expression of that truth.


If we believe this then our we may be called rigid or intolerant.    However,  no one would say that showing people the door marked "EXIT" in a burning building is rigid or intolerant.     Not just any door will do and insisting that there is a door and that it is clearly marked is not a sign of narrow-mindedness!]]></content:encoded></item><item><title>Why Only Some?</title><dc:creator>doc@askdrjim.com</dc:creator><dc:subject>askdrjim blog</dc:subject><dc:date>2008-01-19T14:17:23-05:00</dc:date><link>http://www.askdrjim.com/foler/page3/files/jan-2008#unique-entry-id-56</link><guid isPermaLink="true">http://www.askdrjim.com/foler/page3/files/jan-2008#unique-entry-id-56</guid><content:encoded><![CDATA[I'm sorry about the delay in the blogging.    People are complaining and I just don't have access to my software enough each week to do updates.    The good in the delay has been stories from friends and patients.    Some are stories of joy and miraculous events, others of tragedy upon tragedy that seem too much to bear.  


 I had one new patient who with their new insurance was finally able to see a doctor.     They had an alarming physical finding and x-ray confirmed what appeared to be a life-threatening problem.     Many were praying and a few days later when seen by the specialist the finding had almost completely disappeared!    One explanation is that the first reading was wrong.    The problem with that is every other piece of data from the exam that was abnormal was confirmed on the followup.    One explanation is the wrong name was attached to the file....again with such a specific test and alarming answer at the same hospital on the same day on the same side of a body of the same age and sex....well you could do the math.     I'm left wondering about the power of prayer for this person and what really happened.   ...  What are they supposed to do with the years of healthy life that will result from this change in events?   

...Another family had a sudden unexpected death of a loved one, a child sick with a major illness and a cancer in another member all happen in the span of a few days.  ...  The outcomes, however, were not all good.  ...  Were they not just as worthy?  

...I remember in college first being questioned by non-believing friends about the "capricious" nature of God.    His apparent kindness to some and indifference to others.    They would say they just could not believe in a God that would send any to hell or allow any illness or calamity in the world.   ...  There in history in black and white were the apparent acts of an almighty God that appeared to pick favorites.   


It was only when I fully understood my sin and the utter evil it represented in the face of a Holy God that I could say "All (I) have sinned and fallen short of the glory of God".    ...  It was in understanding that fact that the grace of the cross became clear.    Far from capricious, God reaches to all with a lifeline of grace.    That grace is for our ETERNAL security and in no way promises security or happy times always in the staging area we call life.     Not all reach out for that lifeline to eternity but for each one who does the grace is indeed amazing.     It helps put the events here on earth in a different perspective.    Sure, some may have happy and even miraculous outcomes....praise God.    But the real miracle will occur when we stand before the throne of judgement and claim our eternal reward based solely on the the grace provided by our Savior's sacrificial death for us. ]]></content:encoded></item><item><title>Milestones</title><dc:creator>doc@askdrjim.com</dc:creator><dc:subject>askdrjim blog</dc:subject><dc:date>2008-01-06T13:14:51-05:00</dc:date><link>http://www.askdrjim.com/foler/page3/files/jan-2008#unique-entry-id-55</link><guid isPermaLink="true">http://www.askdrjim.com/foler/page3/files/jan-2008#unique-entry-id-55</guid><content:encoded><![CDATA[Sorry about the delay in postings.    I am still sharing a iMac and I love the software.     I have not been able to work on it for a couple of weeks now.     I hope to have one of my own soon so I can blog "when the spirit hits me".     Obviously we are into a new year and all the reflection that usually accompanies that milestone.     Humans have a real need to reflect on the past in order the place themselves within history and in order to see how far they have come.     We honor new years, anniversaries, birthdays, days of historical or religious significance.    In each we attempt to reflect on the past event, remembering the who, what, where and when.    We weep or laugh or merely reflect.     We might picture the loved one or event in our minds or we may play the video of the event.


But we cannot turn back the past.    We cannot know or even plan accurately the future.    In the old testament writings, the Jewish people and their prophets would reflect on the history they shared with their God and His mighty works.    They would renumber His attributes and that remembering would draw them back to a relationship that existed in the present moment.     I believe we are called to remember in order to realign in the present.


In this new year I am hoping to remain in White Pine learning about serving others with my gifts in my practice.    I desire to be convicted about my shortcomings as friend, father, doctor and to understand how I might change ingrained patterns that are harmful into those that reflect Christ in me.     I pledge to be more in the Word and on my knees.     I hope to be more generous with my time, money and friendship.     I intend to grow stronger in my own self so that I can be an example to my family.


I can do none of this without God's guidance and strength.    I know that He desires that I be more like Christ and that I be closer to Him so these goal of mine should mesh with His goals for me.     I pray that at the end of 2008 I will be able to look back and say that I was found faithful in these things.    I hope your New Year's thoughts will be achieved in 2008.]]></content:encoded></item><item><title>Songs of Worship</title><dc:creator>doc@askdrjim.com</dc:creator><dc:subject>askdrjim blog</dc:subject><dc:date>2007-12-23T12:07:10-05:00</dc:date><link>http://www.askdrjim.com/foler/page3/files/dec-2007#unique-entry-id-54</link><guid isPermaLink="true">http://www.askdrjim.com/foler/page3/files/dec-2007#unique-entry-id-54</guid><content:encoded><![CDATA[Today we had our choir program for the church.    It has been good to see the growth in the choir.    We have some very nice voices and the folks both singing and directing have Christ in their lives so it is a joy to sing with them.     Worshiping through song is one of the greatest gifts we have from our Creator.    I know that  other creatures in nature sing but humans have unlimited creative capacity to put tones and words and instruments together.  


 I am struck by how simple a song can be and yet no one has ever had exactly the same song....that is amazing.     God is the source of this.    Just look outside at the variety of plants, animals, insect life and humans.     He loves to create unique things.     Each has its place in the ecosystem and certainly for humans each has a design best suited to serve and praise Him.


This Christmas season just enjoy the diversity of music that we have been given.    Find one that means something special and make it your meditation.     Rejoice in the creative God that is the originator of music and song.     It is fitting that Christ's birth was heralded by angels SINGING His praise.      To Him be the glory and honor of the season. ]]></content:encoded></item><item><title>Is Christmas Special?</title><dc:creator>doc@askdrjim.com</dc:creator><dc:subject>askdrjim blog</dc:subject><dc:date>2007-12-22T19:36:54-05:00</dc:date><link>http://www.askdrjim.com/foler/page3/files/dec-2007#unique-entry-id-53</link><guid isPermaLink="true">http://www.askdrjim.com/foler/page3/files/dec-2007#unique-entry-id-53</guid><content:encoded><![CDATA[Christmas in America (starting now in mid-November) is the over-the-top celebration of.....consumerism.     All around us advertising and messages tell us of the things our loved ones need to feel our love.  ...  The more expensive the better and don't worry about the payments as we can delay them for months.    In our area robberies are up around this time with folks coveting or desiring money to buy something to fulfill themselves or others.   ...  Everything we do sees to scream "LOOK", "BUY" "WATCH" "WORSHIP WITH US".


...The only drama was played out in the hills near the town where a bunch of boys and men were waiting for ewes to lamb in the early morning (as they tend to do), sharing watches for predators who also awaited lambing season in the hills.     To those uneducated, poor, common folks a sudden presence of first one and then myriad of angelic beings announced the birth of the Messiah long awaited. 


  I don't know what the visitation was like.  ...  Did they all hear the same words in the same way or as at Pentecost were there multiple ways the song was heard?


I don't know but we have no record of others seeing or hearing the announcement.  ...  The link with David is obvious the town being Bethlehem and all.    And the great psalm of David about shepherds (I bet they all knew that  one!).   ...  We have no record they were notified, just tired working people at their job site.  

...One thought that I have is that as remarkable as the incarnation of God as a fully human/fully divine being was, God visiting earth and simple people was nothing new.    The entire history of the old testament is dotted with God reaching down to man tangibly and directly.    To think He would appear even as a flesh and blood person may not have been a major step beyond what He had done for centuries.


No, what was remarkable was the reason for his incarnation...to live fully human and fully sinless in order to repair the rift between the sinful souls of men and the sinless Creator.    Ignoring sin could not work...they payment was demanded (the soul that sins shall surely die).     Forgiving was not possible or He would be inconsistent with His law.    No, payment was demanded with no "work around"  UNLESS a sinless man died for all and that sacrifice proved acceptable.   ...  Christmas never brings up the result only the initial event leading to the sacrifice.


Other than Luke (who does it beautifully) there is little hype about the birth of Jesus in the gospels....  Paul and others discuss it only as the needed initial step.   ...  Without the empty tomb and the stamp of approval that Easter represents we would not know the sacrifice was acceptable and complete.  ...  The time was set to try to aid pagan cultures in their transition to state religion of Rome.  ...  Easter changed the world forever and without it Christmas would not even be in our culture as it is today.


So I think on Tuesday I will thank God for the gift that became acceptable sacrifice....the one that Easter proclaims. ]]></content:encoded></item><item><title>Joining to Others</title><dc:creator>doc@askdrjim.com</dc:creator><dc:subject>askdrjim blog</dc:subject><dc:date>2007-12-16T14:39:24-05:00</dc:date><link>http://www.askdrjim.com/foler/page3/files/dec-2007#unique-entry-id-52</link><guid isPermaLink="true">http://www.askdrjim.com/foler/page3/files/dec-2007#unique-entry-id-52</guid><content:encoded><![CDATA[Christmas is a time to reflect on gifts that God has given.    The greatest was the gift of life to us through the life and death of the God/man Jesus Christ.     This unexplainable act of grace and mercy was rooted in love and desire to have relationship.    I cannot understand why He humbled himself to come as a man, as a child, as a commoner.     I can believe and be grateful that His act was the only way that my soul could hope to live eternally in the presence of the Creator.    If I can embody that belief then daily all other issues of life become easier.    If the God of the universe loved me enough to come humbly and die for me then how can I doubt His love an protection and guidance every day I live here on earth?  


The desire to have relationship, to love and be loved, to know and be known is a fundamental need etched into our human nature.   ...  He desires that our relationships here on earth teach us about what His love and His relationship with us is at its most basic level.  ...  In heaven He will have version 9.0 and we will be able to fully feel His love and presence.    While here, however the closest we can get is in our church family and to a degree in our earthly family.     It is in these relationships that we will experience the love, disappointment, support, rejection, sadness and joy that help us understand more fully our relationship to  Him.   


...I feel that the men's group has helped me in miraculous ways to begin healing from a long season of hurt and sin.  ...  I met with Brian earlier in the month and then "walked the aisle" today.     I walked it alone knowing that I come broken with my family broken.    I came knowing that only in committed relationship with other believers can I hope to heal an begin to serve and find my mission for this time in my life.     The sadness of coming alone was overwhelmed by the joy of the welcome the church family gave.  

...Often deep inside where we keep our secret and true self I have a feeling that I am not worth the notice of others I meet.    My face daily of the "doctor" makes me act with confidence but that is hiding insecurity about my worth to others.   ...  Brian had spoken about times when we may give or receive God's touch through the touch of other humans.    Today was such a day for me and I am grateful to the church for that gift. 


Now the hard work of trying to use my gifts and time to give back to Christ.     It is exciting to have a new family who will be helping me find the path that is ready for me.    God has been so good through this desert time in affirming me and moving me closer to Him while causing me to search for my role.    In the end that is really the great gift we have been given.    By freeing our soul from the slavery of sin and the inevitable eternal damnation that awaited us, God has allowed us to use our life and gifts to serve and praise Him without regard to the world and its standards.    We are free not only in the next life but in this one to serve Him with an unfettered heart.
]]></content:encoded></item><item><title>Sports</title><dc:creator>doc@askdrjim.com</dc:creator><dc:subject>askdrjim blog</dc:subject><dc:date>2007-12-09T13:04:47-05:00</dc:date><link>http://www.askdrjim.com/foler/page3/files/dec-2007#unique-entry-id-51</link><guid isPermaLink="true">http://www.askdrjim.com/foler/page3/files/dec-2007#unique-entry-id-51</guid><content:encoded><![CDATA[Over the past week I have attended about 5 basketball games.     I am now a spectator.    I used to not pay much attention to the folks in the stands because the game was everything.    The joy of the competition is something many of you can understand.    Sure, winning was great but often just the joy of feeling your body move and act in ways you wanted was...well, a joy. 


 I have 2 sons now playing ball and I do get some nerves for them as I want them to enjoy and savor the time.    The pride I feel has been real when I watch them.    Several things recently made me proud.     One son showed great sportsmanship recently and great capacity to help the others on the team feel good and achieve.    This is a gift and is not often seen during competition.    I am glad that he has learned that not all the lessons of the game are the points you score or the accolades you receive.      It makes me proud to know that he has internalized some ideals of sport that I hold very dear.   


The other son is younger and right now is learning in practice and watching from the bench more than on the court.    What I have seen from him is the joy of being a good teammate.     He actually seems more glad when a friend of his excels than when he does himself.     He has praised kids less talented than him and is a loud cheerleader from the bench.    I am proud that he understands that everyone on the team is important.


In healthcare we so often focus on the flash and the achievement and the stars.     The surgeon who saves a life is praised but the scrub-nurse that caught the fact that he left a sponge in the patient just as they were ready to close the wound gets hardly a notice.    Sports can really help you as you think of healthcare.     Teams are needed and all the skills are essential to the health of the patient.     The team leader IS the patient and they must feel that they are part of the process of healing or they will not achieve the goals they desire in their personal health.   


Church is like this too.    Today my pastor was talking about evangelism and about the skills we all bring to the table.    All the members are important, all have gifts to bring to the team.    No one is the center of the church save Jesus.       I am glad that in my and now in my boys' lives that sports teaches us so much about how our lives should be lived. ]]></content:encoded></item><item><title>What&#x2c; How and Who</title><dc:creator>doc@askdrjim.com</dc:creator><dc:subject>askdrjim blog</dc:subject><dc:date>2007-12-08T16:50:08-05:00</dc:date><link>http://www.askdrjim.com/foler/page3/files/dec-2007#unique-entry-id-50</link><guid isPermaLink="true">http://www.askdrjim.com/foler/page3/files/dec-2007#unique-entry-id-50</guid><content:encoded><![CDATA[I am sinful and disobedient and stand in need of grace and mercy.  ...  In my personal life I am willful and selfish when I think I am being open and honest.     I sin and sin and find no good in me on a regular basis.   

...To learn the what of the Bible and to then trust that knowledge will deliver me.   ...  I will just read and learn and the answer would be there.    I can better myself and then I will do good and receive peace in my soul.     The problem is that knowledge may not change my heart.    Knowledge does not have the power in itself to change my character and to make me new in a moral sense.     Ultimately knowledge would also depend on what I read and where I seek my answers and that may lead me astray or imbed non-truth.


Another approach is to try to feel my way and worship my way to grace.    If I could just find the right song or worship experience or body of believers then I would feel close to God and ultimately would feel delivered.     I could look to dynamic leaders who structure the worship experience to focus on my needs and how I feel.    I could raise my hands or say "amen" or cry at the alter again and again.     The problem with this is shown by David's attempt to bring the ark back to Jerusalem.    He did so with what he felt was the right method but he was wrong.    In the end people died and he was forced into a period of introspection until he did God's will and worshiped as God desired.     Worship focused on the how actually worships the creature not the creator.  

...The final way to try to deal with my sin nature and need for grace is to look at the object of my worship, my knowledge and my faith.   ...  I must have faith in God and my faith does not make Him who He is.     My lack of knowledge does not change His will or character in the least.     My worship follies do not change His eternal might and power.    Certainly knowing God involves learning of Him but the demons know these things.    The essence of what I think He wants is me and a relationship with me.  ...  Only in relationship with Him can I come to do the first and find the second.     He is the object of the worship.    Knowing Him and His will should drive my study.     Since He is the source of my power and of my redemption, it is "Who" that I must focus upon each day. ]]></content:encoded></item><item><title>Joy and Hope</title><dc:creator>doc@askdrjim.com</dc:creator><dc:subject>askdrjim blog</dc:subject><dc:date>2007-12-01T17:54:06-05:00</dc:date><link>http://www.askdrjim.com/foler/page3/files/dec-2007#unique-entry-id-49</link><guid isPermaLink="true">http://www.askdrjim.com/foler/page3/files/dec-2007#unique-entry-id-49</guid><content:encoded><![CDATA[This is a long weekend.     I have been challenged to feel God's leadership and to focus on His loving control of my life.     There is nothing brought into my life without His consent: no tests, no temptations, nothing.    He considers, and scripture says, allows these things AND makes ways for me to both escape the temptation or conquer the test.     My head knows this but my heart, my emotions have quite another take on the subject.     Part of me wants to rebel and tell Him to leave me alone to my own choices.    Part of me wants to complain about the fact that his omniscience causes me to be more like a puppet than a person.  


 Both those parts reflect old patterns and areas of my life that are not yet sanctified.     The fact remains that He knows my limits, my skills and my fears.     He also loves me enough to allow me to be tested and tempted.    When it happens He knows I can overcome and that He is right there with me.    The psalmist says that He is "near to the brokenhearted" and I have had to rely on that one quite a bit lately.


I have such strong emotions at times that I don't know that I can understand or control them.    I have had to come to grips with the fact that He has made me this way.    That He has emotions somehow and that as the Christ on earth He felt and now fully understands the ones that I have.    I still cannot fathom why, after calling and saving me, He allows pain and sorrow in my life.    I can feel so small and so lonely here on earth yet He knows and intends for me to come through these emotional upheavals with stronger hope in His salvation.  


This then is the joy to which we are called.     To have a deep and abiding understanding of the God who is our Lord and the sure Hope of our eternal security.     The passions of this world and the sorrow, pain and loneliness that sometimes come into our lives should not shake joy.    This weekend I need to focus on this thought and to cling to Him.     He is near to my broken heart. ]]></content:encoded></item><item><title>Homesickness</title><dc:creator>doc@askdrjim.com</dc:creator><dc:subject>askdrjim blog</dc:subject><dc:date>2007-11-30T22:34:05-05:00</dc:date><link>http://www.askdrjim.com/foler/page3/files/nov-2007#unique-entry-id-48</link><guid isPermaLink="true">http://www.askdrjim.com/foler/page3/files/nov-2007#unique-entry-id-48</guid><content:encoded><![CDATA[Wednesday night wrapped up the Beth Moore tape study on the Patriarchs.    She is a very good leader and her fresh insights inspire me.  ...  The idea was that as humans God has placed within our beings a longing for heaven and an innate knowledge of eternity.      We KNOW that there is more.    Goodbye is then such a temporary and artificial thing rooted in us living in time now.    In eternity time will have no meaning and goodbye will have no meaning.    She then tied the concept of the wandering of Abraham, Isaac, Jacob and finally Joseph to this thought.     Throughout scripture we are pointed to the God of these men and as we reflect on their lives we realize they were aliens on earth and their home was in heaven.     Again and again she brought out scripture that reinforced this concept.  ...  God does not intend for this world to be final.     Since the fall ALL CREATION (including me and you) groan for the fulfillment of the promised  perfection of the new heaven and the new earth to come.     She challenged us to embrace the discomfort of our earth as an affirmation that God has promised us more.


In my walks around White Pine in the morning I always see geese flying about the same time and same place on my trek.     I have come to look for them and as I walk I thank God for them.    I have seen them as a reminder of my North Dakota home which I miss daily.    I thank Him for the little slice of home He sends my way to remind me of that place.     Well, after the last Beth Moore talk I mentioned above, I decided that the next morning I would also see those geese as a reminder or my final home in heaven.     Sure enough morning came and as I walked I heard the familiar honking (you always hear them before you see them if you are a hunter).     As they flew by I thanked God that He has promised me a place in the perfect home that my soul KNOWS is there.


...There were quite a few more geese  flying Thursday morning than usual.    As I was praying a friend (who knows of my meeting with the geese each morning) sent me a text message that read: "I bet God sent all those geese as a gift 4 u 2day."     I was speechless before God.     It was a moment of praise without words.     Not only did I agree with the message but I was humbled that He exceeded my request to see some geese each morning.     His abundant grace to us is open for all to see.    He does not hide many of life's blessings from us or other Christians.     We just need to be alert....you might hear it before you see it. ]]></content:encoded></item><item><title>Overwhelmed</title><dc:creator>doc@askdrjim.com</dc:creator><dc:subject>askdrjim blog</dc:subject><dc:date>2007-11-25T13:54:47-05:00</dc:date><link>http://www.askdrjim.com/foler/page3/files/nov-2007#unique-entry-id-47</link><guid isPermaLink="true">http://www.askdrjim.com/foler/page3/files/nov-2007#unique-entry-id-47</guid><content:encoded><![CDATA[Today in Sunday School our lesson was again on money and giving.    This can be a very difficult area for me and, I assume, for many Christians in America.     We are wealthy beyond belief to 90% of the world even if we are lower middle-class.    We are consumers and buyers and covetous and we live in a culture that encourages all those traits.  


Christ called us to be sacrificial givers yet we barely give and even then too often with reluctance.     In the end our things often control us.    It might not be money, it might be clothes or cars or our physical appearance that demand time and resources that should be spent serving Him.    We can give money from our excess but rarely give of time or other things sacrificially.    In the end my lack of generosity stems from a lack of faith and a desire to get rather than give.


In the lesson we looked at a passage in Malachi 3:  "Test Me in this," says he Lord Almighty, "and see if I will not throw open the flood gates of heaven and pour out so much blessing that you will not have room enough for it."    This was in response to the people not giving God an adequate share of their material goods.


Now I am not a proponent of the theology that uses God like an ATM.    " Pray  or give or serve or request and God is only to happy to give more material wealth to you."     Notice that the above passage says God will pour out blessing not particularly wealth.     We may get to see the results of our giving and be blessed.     One group member said that in giving we may receive more  the mind of Christ and in that way will be able to see our world in a different light and be blessed.     That is a fresh way to see how He desires to make us more like Him and may have the essence of the blessing captured in a way I never imagined.


The part I focus on is the excess He is planning.     It's not "double your money".     He plans to overwhelm us with His gracious blessing.    The picture I have is from childhood when Captain Kangaroo would ask about a ping pong ball and then he would be completely covered with a shower of hundreds falling from above.    The picture is clear.     God as the owner of all in the universe PLANS to shower us with blessing.    We need only to exercise the faith to believe His promise by giving of our lives and our material goods in a sacrificial way.     He wants us to learn about the impermanence of the world in the face of His eternal being and love.


I am being challenged to disregard more and more the world's ideas of success as they are tied to things that will burn up in the fire of God's presence.     I need to acknowledge His place by yielding all to Him without regret or fear, knowing that His blessing will overwhelm my expectations.]]></content:encoded></item><item><title>David again</title><dc:creator>doc@askdrjim.com</dc:creator><dc:subject>askdrjim blog</dc:subject><dc:date>2007-11-24T20:42:57-05:00</dc:date><link>http://www.askdrjim.com/foler/page3/files/nov-2007#unique-entry-id-46</link><guid isPermaLink="true">http://www.askdrjim.com/foler/page3/files/nov-2007#unique-entry-id-46</guid><content:encoded><![CDATA[The book I am currently reading is about the life of David.     Again and again I am reminded that he was "a man after God's own heart" and that he was was called a friend of God.     His story and his psalms are nuggets of gold as I try to understand what made him those things.    


I am struck by two things as I read his writings:  first, he is transparent with God.    He pleads, he argues, he complains, he rejoices, he praises and he worships.     He seems to have complete honesty in telling God what he is feeling.     Too often my prayers are formulas or types that I think are "holy" when in fact I am closing my mind off to God by being less than open with Him.      That does not foster intimacy and God craves intimacy with us.     My best friends are those with whom I can be more honest about thoughts and feelings....some bad and some good.    Without that honesty and I am just playacting at true intimacy.


 Second, he has a proper perspective of his position relative to God's.     He always understands God is in charge.    He knows that God has all power and that God's will is going to occur.    He never orders God but he lets God know his mind before bowing to God's will.      I can learn a lot from this.    Too often I beg God and then pout when I don't get what I want the way I want it.     David's approach is better.    He lets God know and then meditates on His word  and bows to the perfect result.     No wonder God lifted him up to us as an example of what a man after God's heart is like.     We are to be both intimate and bowing creature before our lover-God.   


David also used emotions and words and music in his relationship with God.    I believe God gave us language, music and other art to express more fully our human emotions in our praise to Him.     Jesus got to experience human emotions while here on earth and we never see him apologizing for feeling or expressing love, anger, loneliness, joy and the like.    He showed us that emotions can bring us closer to God in worship (the woman washing His feet with her tears) and in prayer (Jesus sweating drops of blood).    David was a man's man and a great warrior and yet he was very emotional, weeping often, dancing with abandon and laughing with joy.


David is just such a great example of how God desires that I live:  fully aware of my emotions, strong in my confidence of His power in my life, secure in my relationship to Him and knowledgeable of my dependence on His grace every moment of every day.    I hope to be more and more "David-like" in my life.
]]></content:encoded></item><item><title>Giving Thanks</title><dc:creator>doc@askdrjim.com</dc:creator><dc:subject>askdrjim blog</dc:subject><dc:date>2007-11-24T20:19:08-05:00</dc:date><link>http://www.askdrjim.com/foler/page3/files/nov-2007#unique-entry-id-45</link><guid isPermaLink="true">http://www.askdrjim.com/foler/page3/files/nov-2007#unique-entry-id-45</guid><content:encoded><![CDATA[Of course I will write a bit about the holiday that just passed.     The nation needed a time of healing and unification when Thanksgiving was birthed and it has always been linked with the traditional end of harvest festivals that generally occurred this time of year.     Although it is a family holiday (more so now than even Christmas given the fixed nature of the day giving a long weekend) I have not spent it with my North Dakota family for over 2 decades now.   


...Because of coursework I got home late Wednesday night and early the next morning went with a second cousin for a "short deer hunting" trip that was to end in time for the meal.      We got up early and went to a spotting hill at dawn.     Snow had started to fall as we noticed a buck and doe about 1/2 mile away walking slowing in  a pasture.     After the deer went over a hill we got out and began to walk to the last site we had viewed them. 


We found the trail in the snow and it was starting to snow quite heavily.     We were walking in about 1 foot of snow and the trail was easy to follow.    After quite some time we came over a rise and saw a large brush pile ahead.     About the time I said this might be where they had bedded down, both jumped up and we shot both cleanly.     We gutted and cooled the carcasses with snow and then realized we were 3/4 mile from the car.    This was too long to drag the deer so we walked back to the vehicle only to find it completely snowbound.


About 1/2 mile away was a farmer's home and we trudged there and found that everyone had gone into town for the holiday!  ...  Finally a farmer we knew drove by an we got our car pulled out of the snow so we could drive the 10 miles or so back to town.     We were a bit late but ate the meal with relish and then had to figure out how to get back into the middle of nowhere in the snow to get the deer.      Another farmer used a 4X4 truck to drive us almost right to the spot and we got the meat home before dark.      All in all it was a memorable time and one that my friend, his family and my family mention about every Thanksgiving since.


That gets me thinking about what we have to be thankful for this season.  ...  Recently, however, I heard a speaker who said that the only two things you really will carry to eternity will be your own soul and your relationship to God.  ...  Family, though important, is not what I will have as my responsibility as I enter eternity.    Since my place in eternity is linked to my relationship to God, my salvation is my most precious and permanent thing that I have.  


I do not understand free will in the presence of an all-knowng God who is apart from time.    I do not understand the love it took to send a part of the God-head to be my sacrifice.  ...  I don't even understand why I was important enough for all this to take place.    What I do know is that His plan is real, His grace is true and His forgiveness is total.


...I pray daily to I tell others of this grace and see them accept it for themselves.   ]]></content:encoded></item><item><title>Knowledge&#x2c; Power&#x2c; Suffering</title><dc:creator>doc@askdrjim.com</dc:creator><dc:subject>askdrjim blog</dc:subject><dc:date>2007-11-18T13:59:27-05:00</dc:date><link>http://www.askdrjim.com/foler/page3/files/nov-2007#unique-entry-id-44</link><guid isPermaLink="true">http://www.askdrjim.com/foler/page3/files/nov-2007#unique-entry-id-44</guid><content:encoded><![CDATA[Today at church my pastor was talking about the the many little things daily we should be thankful to God for in our lives.     Certainly this is the case and if we, like David, would put pen to paper the list would be long and it would drive us to praise Him continuously.    Our very life not to mention things like music, color, touch and smell.     God has thought of us and gives our senses a symphony every day that is beyond man's making.   


The part of the sermon that got me really thinking was his use of one of my favorite verses.     Philippians 3:10 says "I want to know Christ and the power of his resurrection and the fellowship of sharing in His sufferings, becoming like Him in His death, and somehow, to attain to the resurrection from the dead."    Paul's powerful expression of Christian desire should be every Christian's template for life.     We all want to know and be known by our maker.     What a privilege that He actually wants us, calls us to such knowledge.    This is rooted as in any relationship in wanting to deeply understand and communicate with another person so that the relationship can deepen to our mutual fulfillment.     We should seek God as we do a lover.    Wanting to know everything about them, their history, their dreams, the things they like and dislike and what we can do to please and love them.   


Understanding the power that is at our disposal as Christians is difficult because it is a spiritual not earthly power.    I cannot lift a car because I am a Christian.    But I can tell satan to get behind me in the name and power of Christ and he must do so.     The power that raised Christ from the dead is one that no human will ever posses on their own and it is the source of power into which our lives are "plugged".    We must live boldly and fearlessly with that knowledge securely in mind. 


The next one is the difficult one.    How many of us really desire to share the "fellowship" of suffering with another?    Two things here.    First the suffering we endure for being Christian is HIS suffering not ours.    We are merely the vessel on which that suffering may be placed.    This does give comfort.     Jesus not only knows that suffering but He also OWNS it and is there with us (the fellowship part) when we are suffering for our faith.    Stephen's death by stoning is a beautiful example of how Christ was with someone during such suffering.     Many Christians in this world suffer daily for their faith and our Lord is right there with them.


If we could daily aspire to know more, to understand and use the power at our disposal and calmly suffer WITH Him, our lives, like those of Paul could change the world!]]></content:encoded></item><item><title>Thinking about Job and Joseph</title><dc:creator>doc@askdrjim.com</dc:creator><dc:subject>askdrjim blog</dc:subject><dc:date>2007-11-17T22:31:58-05:00</dc:date><link>http://www.askdrjim.com/foler/page3/files/nov-2007#unique-entry-id-43</link><guid isPermaLink="true">http://www.askdrjim.com/foler/page3/files/nov-2007#unique-entry-id-43</guid><content:encoded><![CDATA[The women at our church are going through a Beth Moore study on Genesis on Wednesday nights and a few of us men sneak in to watch the videos.    Having read some of her books the videos are a revelation because I can see her teaching style and the way she pulls your emotions.    


The last lesson was looking at the scene where Joseph, now a ruler of all Egypt second only to the pharaoh tells his brothers who he is and why he is alive.      Now the natural thing would have been revenge, blame or retribution but Joseph says that God had intended the circumstances to be for the good of his family.    In other words God was in charge and knew the situation and used it for His glory.     She then talked about Job.     Now Job is interesting because in the initial "dialog" between God and satan it is God that first brings up Job and his righteous living.     God pushed Job to the top of satan's hit list and then allowed circumstances to develop as satan tried to break Job down.    God was still in charge though certainly not behind the evil done to Job.


The point of both stories is this:  God is the supreme ruler of the universe and is in charge.    He will not allow trials in our lives to break us.    Rather He sees in us the result those trials will have with the ultimate aim that His purpose is achieved and His praise is proclaimed.     Now, sometimes it may be hard to see why a trial that is so hard on us or our family can have any good.  ...  Moore described her childhood of abuse and later relationship disasters typical for women who were abused as children.    Her eventual deliverance came through her faith.     That evil background has now been used for overwhelming good to the praise of God every time she picks up a pen or stands in front of a microphone.


...Trials MUST come and are given to us in proportion with our ability to learn and bring praise to God.      God didn't say "consider my servant Fred" because Fred was not ready to be so harshly tested.   Rather he pointed to Job knowing full well what he could expect from that servant.    And, in the end, after remaining true (complaining but true!), Job was also blessed.     I have been praying that I see my trials and even those events that appear downright evil as conduits to a more sanctified life that would bring praise and service to God.    I have a friend who seems to get more than a standard share of trials.    I used to question God about the unfairness of it.     Now I marvel how He has continuously said "Consider my servant..." and then watched as their spirit is tested and emerges stronger AND more able to serve and to praise.


Joseph had the right perspective through all His trials he KNEW God was on the throne and that he needed just to keep that in mind trusting that the blessing would eventually come.    His family was saved and God was praised.     What more could we ask of our trials?]]></content:encoded></item><item><title>Testing One&#x2c; Two&#x2c; Three</title><dc:creator>doc@askdrjim.com</dc:creator><dc:subject>askdrjim blog</dc:subject><dc:date>2007-11-16T21:51:42-05:00</dc:date><link>http://www.askdrjim.com/foler/page3/files/nov-2007#unique-entry-id-42</link><guid isPermaLink="true">http://www.askdrjim.com/foler/page3/files/nov-2007#unique-entry-id-42</guid><content:encoded><![CDATA[I am getting a bit tired of only being able to blog once or twice a week but then maybe I have too little to say!


 A few entries ago I wrote about being more and more open to tests that God brings every day in an attempt to develop fruits of the Spirit in me.     I have been so excited about what I am learning that I have told everyone who will listen about being more open to see the test then to fully pass.    It is a decided joy to work with fellow Christians when I am learning so much because sharing these lessons and praying for each other as the day progresses becomes a more and more natural thing. 


This week after having a discussion about this very thing ,  we cared for  a family that has been very tested by tragedy.    We knew little more.     After they left tears were shed for the father who was trying so hard to keep it together.    We wondered if that had been "one of our tests" for the day.     Before much time passed the father returned as if God was saying "next page on this test."    He saw the tears and instead of hiding them or excusing them Holly told him that she had been thinking (and weeping) about him since he had left.     I was in the next room and was struck by the frank honesty and compassion.    He responded as well and after opening the conversation to spiritual issues he let out a history of hurt from the Church during his time of pain....  How many people are wounded by the very Church that Christ intends to heal them.


Because of the openness to the test and responding so honestly the man was healing before our eyes.    I fully expect that he will seek out another Church and God will be at work.     What a moment to observe and all because of being open to the Spirit's leading.


Today I saw a young person who was quite interested in the inventory of feelings and behaviors we get on teens to screen for mental health issues.    I missed their interest at first but they (and the Spirit) persisted and I sat them down apart from their family and a heard about sadness and rejection.     I then asked "what brings you joy?"    Hardly a question that I would ask a teen.    After some thought "I love to sing" was the answer and their face shone with, well, joy!    I then learned that they had a gift but had left church where they sang and did not do choir in school.     We talked about music and singing and I encouraged them to try another church and use, not hide their gift.      I am praying that Sunday will find both these families back in Church.


We have such a privilege in our work to be able to ask intimate, personal questions boldly.....and I have found a hunger by people to be asked and to discuss spiritual things.     In doing so I have found how much God is at work in what I do each day.    I am convinced our role is to see these moments and respond with love and compassion and see what He works out.  ]]></content:encoded></item><item><title>Variety in Medicine and Life</title><dc:creator>doc@askdrjim.com</dc:creator><dc:subject>askdrjim blog</dc:subject><dc:date>2007-11-10T17:05:21-05:00</dc:date><link>http://www.askdrjim.com/foler/page3/files/nov-2007#unique-entry-id-41</link><guid isPermaLink="true">http://www.askdrjim.com/foler/page3/files/nov-2007#unique-entry-id-41</guid><content:encoded><![CDATA[We have had a cool snap finally ending the heat we lived under all summer.    Variety is such a refreshing thing.      I know it might be nice to live in southern California and have similar weather daily for months but I think it would get boring.      In family medicine each person walking through the door is a new problem, new family of origin and new communication challenge.     It is why I love primary care and don't think I could be a specialist.     Oh, it would be nice to corner the market on a more narrow area of medicine.    It would be fun at times to be expert at a body of knowledge.    Certainly within a a narrow specialty one could have variety from patient to patient (they are after all unique individuals).     I just think I would go crazy seeing similar problems day in and day out.   


My youngest patient in the office thus far has been 3 days old and my oldest is 99.     I see women, men, boys, girls, married or not, straight and gay, white, black, Asian, native American and Latin.    Each day presents challenges to me and every day I must read about things to know how to proceed.     I am stretched by interpersonal and family dynamics and I need to call on other specialists, counselors, physical and occupational rehab specialists, lawyers, law enforcement, nursing and social work professionals to do my job.     The variety is what keeps me going.   


Life also has such variety....think of the number of plants, animals, stars, humans that God gives us.    We have summer, fall, winter and then spring.   ...  He's certainly no specialist.    He gifts us all differently and then set up tests to mature those gifts.     He gave us song and words and mankind has yet to exhaust those sources of inspiration (hip hop lyrics excepted at times!).       I am glad our God is a God of diversity and creativity. 


 It is when I ponder this that I can begin to understand why my life takes such turns and has such richness of variety even though that very variety challenges me when I want to remain comfortably unchallenged.      My recent life changes have certainly blown my comfort and that of my family out of the water.    In the end this has been very good spiritually although hard interpersonally.     God is molding and shaping me through the tremendous change that has happened and the variety of challenges I have been facing have caused me to be much more open to looking at my character and my way of loving family and friends.    It has allowed me to be open to my darkness and then to hold those areas up to Him for cleansing and renewal.


I keep thinking that winter's cold and darkness are followed by the renewal of spring when all is wonderful, colorful and full of renewed life and hope.     I know that the winter of this time of trial will open to a spring of joy and hope. ]]></content:encoded></item><item><title>Doh&#x21;</title><dc:creator>doc@askdrjim.com</dc:creator><dc:subject>askdrjim blog</dc:subject><dc:date>2007-11-09T22:54:00-05:00</dc:date><link>http://www.askdrjim.com/foler/page3/files/nov-2007#unique-entry-id-40</link><guid isPermaLink="true">http://www.askdrjim.com/foler/page3/files/nov-2007#unique-entry-id-40</guid><content:encoded><![CDATA[I am glad that God has such a store of patience!     Without this mankind (meaning me) would be lost.     We would have no hope as He would just wipe us out rather than wait for us to "get it".     Recently I have been really focusing on the fruits of the Spirit and how mine can develop more fully.     I know this is always done through situations that test the very fruit He wishes to produce in us.      As I have said before patience and joy are hard for me.     This is rooted in my need to be in control.     The two fruit are so linked that until I can get a handle on the patience thing I will not have the deep joy He desires for me.


I have started praying during my walks around town for God to bring tests that day to help me learn patience.....then I wince.     The problem is, even though I ask for the test and should know it's coming, it is often at the end of the day that I slap myself and so "Doh!"     I can then see clearly when the test came AND can too often again see how my patience did not hold and I shook my fist and advised God of a better plan of action.     I mean, this scene is repeated daily.      I almost wish I could be Bill Murray in Groundhog day were he gets the chance again and again to live the same day finally understanding the lessons presented after hundreds of failures.


The thing is: God IS patient.     He has no problems saying "again Jim" when I slap my head in frustration.     He wants me to get this right and He is very creative and subtle in the tests.    This week alone there were 3 I counted with one test causing me to rant and rave and just know that His plan was messed up only to be completely and utterly amazed by the actual event and way He achieved His goals.     I felt like Habakkuk who was told after ranting at God to "look and be utterly amazed for I am going to do a thing in you days that you would not believe even if I told you."      I love that verse as it embodies the authority of God, His great creativity AND His desire for us to get the lesson.     With that picture in mind I will keep asking to be tested and will gradually be molded into the man of patience and joy He so desires. ]]></content:encoded></item><item><title>Superbugs</title><dc:creator>doc@askdrjim.com</dc:creator><dc:subject>askdrjim blog</dc:subject><dc:date>2007-11-03T22:02:12-04:00</dc:date><link>http://www.askdrjim.com/foler/page3/files/nov-2007#unique-entry-id-37</link><guid isPermaLink="true">http://www.askdrjim.com/foler/page3/files/nov-2007#unique-entry-id-37</guid><content:encoded><![CDATA[Over the past several weeks I have encountered more cases of staph skin infections.    As you have been reading this bug long a source of skin infections has become progressively resistant to antibiotics.      As we have used more and more broad-spectrum antibiotics, the bacterial genome has adjusted resulting in strains that are resistant to most antibiotics now use.    Early on these bacteria were seen and seemed to live and thrive within intensive-care units within large hospitals.    Gradually we have become aware that they have now migrated out into the general environment, carried within the noses of unsuspecting health-care workers and frequent visitors to hospitals.   


We are seeing these cause both skin infections (often in epidemic outbreaks on athletic teams or in schools) as well as more invasive diseases like lung and kidney infections.    To effectively treat we need to be using multiple antibiotics and often novel ones to see results.    Hospitals are restricting the use of some antibiotics to allow for "weapons" that can be used in the future if they would be needed for a multi-drug resistant staph.  


Other bacteria have also gotten into the act including M. tuberculosis which has recently been in the news on an international level.     All of this brings to mind how very fragile is our current medical approach to infectious disease.    We treat infections but we have very limited understanding why one person in a family will become ill with an infection while another member may be unaffected.    There must be an underlying reason why our bodies become sick from infection.    


Nutrition and the source of our food is a primary reason, I believe.    We eat nutritionally poor food laced with antibiotics processed in factories that use chemicals to remain clean.    Our food supply is making us ill but it has never been more scrutinized or regulated.     I don't know what the answer may be but I am concerned that infections will become more and more deadly in the future. ]]></content:encoded></item><item><title>True Healing</title><dc:creator>doc@askdrjim.com</dc:creator><dc:subject>askdrjim blog</dc:subject><dc:date>2007-11-02T22:52:33-04:00</dc:date><link>http://www.askdrjim.com/foler/page3/files/nov-2007#unique-entry-id-36</link><guid isPermaLink="true">http://www.askdrjim.com/foler/page3/files/nov-2007#unique-entry-id-36</guid><content:encoded><![CDATA[There is nothing more humbling than being a family practice doctor...if you pay attention!     Each day I am amazed at how little I do to move people toward true healing of their bodies, their minds or their spirits.     It is true that there are times when I throw some medications at someone who is sick and they get better.    BUT IF I PAY ATTENTION very few walk away healed by those medications.    I am convinced that true healing must include mind, body and soul.    Too often I spend most of my time with patients discussing their bodies or minds and too little on the health of their spirit or soul.     The reality is that the sickest people I encounter are heart sick...meaning their spirits are broken.    This brokenness may come from families of origin who have tormented them, from relationships that are not feeding them or from jobs or circumstances that have them weighed down.  


At the core, however, is their need to be delivered from the weight of sin and the lack of God in their lives.    In the past weeks I have been consistent about being open to the moment of spiritual need that almost always appears in a medical interview.    It might be a deep sigh or a pause after a statement that demands further questioning.    It  might be eyes that tear up or a joke about spiritual things.     As I have been open to this I have been amazed at how often people hunger to talk about spiritual things....and how empty they feel.     As a Christian the thing is that I believe I know a way out....a way to be set free.


Grace, amazing grace is the heart of the gospel.     Undeserved favor that results in a way out from our sin.    God choosing mercy and forgiveness as a path for us while providing through His Son the payment that justice demanded.     This is liberating.     This is the gospel of which Paul was "not ashamed".    No wonder.     How could one be ashamed of the power to change lives through the amazing mercy that God has offered.    


In my personal life I have had to face my sin squarely in the past months and the man in the mirror appear wretched indeed.     In the act of facing my sin, confessing it and asking for mercy I have felt the power of that amazing grace.     I have had friends that I have severely wronged choose the path of mercy rather than justice and have felt the power of the healing love that is behind their act of grace.     Apart from a living God there is no explanation for either the act itself or the healing that it brought.     I hope I can learn from their mercy and begin to show more mercy myself.   I hope that as I am open to the spiritual sickness of my patients I will be able to bring them to the throne of grace at which the real healing in their life can begin. ]]></content:encoded></item><item><title>I miss home</title><dc:creator>doc@askdrjim.com</dc:creator><dc:subject>askdrjim blog</dc:subject><dc:date>2007-10-30T00:02:59-04:00</dc:date><link>http://www.askdrjim.com/foler/page3/files/oct-2007#unique-entry-id-35</link><guid isPermaLink="true">http://www.askdrjim.com/foler/page3/files/oct-2007#unique-entry-id-35</guid><content:encoded><![CDATA[Growing up in North Dakota not a weekend went by in the fall (and very few evenings during October) when we were not hunting birds.    Today the air was really crisp for the first time in east TN and I missed pheasants.    Before you jump down my throat about the whole hunting bit let me describe the scene.  


The morning is clear, crisp with the huge bright blue Dakota sky pressing down all around on the browns and grays that are prairie and harvested fields.     There are more shades of brown on the fall prairie than you can imagine.    If you are lucky you will also be in "big country" which is the term we use for large tracts of land that are only broken by dry creek beds and car trails.    The land rolls and falls and the wind is a constant causing the grass to move like waves.   


It is still nearly dark as the car pulls up to the starting point for what will be a very vigorous walk.    As you get out you begin to take old and trusted shotguns from their cases.     Hunting weapons you have come to know through years of loving use.    My double is an old Browning whose wood checkering pattern has long since been worn smooth by my hands that have doubled in size since I first fired it.    It is a familiar friend that has waited another year to be carried into the field.     Vests and hats, boots and coats all familiar through the years are put on and the dogs are released to run nervously around jumping up to greet everyone.     Rooster pheasants have a particular early morning call and you start to hear them not so far from where you stand.   


...Partly this is so no one else can shoot the birds I raise and partly because I am proud to be able to move still in the thick brush where the dogs sometimes rush by.   ...  I always have a song on my lips as I begin to breath more deeply.    Then someone says something like "watch her" meaning a dog is working a bird.   


...They will run far before they will fly and they can outrun dogs in thick brush.     But sometimes they stop and wait and the dog echos them freezing and shivering at the same time.   ...  There is no way they can hide and yet they always do.    You walk up to the dog spacing with others without words due to years of hunting together and....nothing happens.  

...Nothing here" an bird larger than you remember thunders out of the bare ground.     The colors catch in the sun and you take a half step back in fear of the noise, the motion and the surprise.     After vaulting 8 feet into the air the bird levels and then flies away at amazing speed.     Somehow in the middle of all this the older hunters again instinctively wait a bit to let the kid recover from surprise and take the first shot.    If everything is perfect they take their first pheasant in front of their older colleagues who all grin and praise the shot, the dog and the day.    The dog even grins as she brings the bird back, proud of her role in this ritual.  ]]></content:encoded></item><item><title>What He Wills</title><dc:creator>doc@askdrjim.com</dc:creator><dc:subject>askdrjim blog</dc:subject><dc:date>2007-10-28T23:03:56-04:00</dc:date><link>http://www.askdrjim.com/foler/page3/files/oct-2007#unique-entry-id-34</link><guid isPermaLink="true">http://www.askdrjim.com/foler/page3/files/oct-2007#unique-entry-id-34</guid><content:encoded><![CDATA[Most of you have gathered from the last few months that my blogging has been a fairly unvarnished look at an emotional and spiritual journey on which I am embarked.   

... A friend told of a writer who pictured life like a ride down a river.    Sometimes there are calm pools and the shore just slips by peacefully.    Other times we are in rapids and are just holding on for dear life knowing that our efforts to change things are minute compared to the power that is moving us.     I would agree with one exception:  those of us who know Christ at least have someone else in the boat with us to help us stay calm if we trust.    This  past week has been so emotionally draining for me I am just holding on.   


It has been a good week of lessons.     I finally received a fairly large check form Medicare about 1 day before I was completely drained of resources.    It had been nearly 7 months without payment from our major payor and I was just hanging on.    I was trembling when I opened the envelope and could not speak as I showed it to my staff.     God had promised to supply what I need not what I want and He did so on the day I needed it.     I was speechless both from relief and from a sense of awe that my God was watching, and knew my needs exactly.  ...  He has drawn me firmly to White Pine over the past month and I am not sure why but given His track record, I am expectantly waiting for that answer.  


I am reading an excellent J I Packer book on the Lord's prayer.    One of the main theses is that God's ultimate end and the essence of His nature is relationship.    Prayer is about extending and affirming that relationship and tuning our hearts to His will.    I find that as I have been going through some personal and family stress that relationships are the thing that makes my life livable.   

...I often manipulate, become envious and controlling or revert to "fighting dirty" by withdrawing, deceiving and pouting.   ...  I want things the way I think I see them needing to be even in relationships with others.    A friend of mine recently highlighted these flaws and then, in a display of Christ-like character, honestly challenged me while not throwing our friendship away.     I glimpsed how Christ wants us to relate to our brothers and sisters:  honest confrontation, love of the person and then firm hope in their ability to rise above their flaws with Christ's help.    God has been so good to lead me to a church that embodies His spirit and to friends who embody Him in their daily lives.    I can only hope I can learn from both groups to be a better man.


...I am not sure what is happening in my life.    I do not know what or who the future holds.     I do know Him and upon that knowledge I will rest for there seems to be some reason to continue my practice in White Pine despite tremendous pressures financial, spiritual and emotional to just give up.  ...  I'm just not sure for whom or for what reason.   ]]></content:encoded></item><item><title>Homecoming</title><dc:creator>doc@askdrjim.com</dc:creator><dc:subject>askdrjim blog</dc:subject><dc:date>2007-10-21T13:46:08-04:00</dc:date><link>http://www.askdrjim.com/foler/page3/files/oct-2007#unique-entry-id-33</link><guid isPermaLink="true">http://www.askdrjim.com/foler/page3/files/oct-2007#unique-entry-id-33</guid><content:encoded><![CDATA[My new church had a homecoming service today.    I don't know all the details but they have been through a half-decade or so of hurt and turmoil that has caused the remaining members to be very open to change, open to the Spirit and open to the voice of their new pastor.    I have felt a healing environment as I have attended and a "nakedness".     By this I mean I feel they are welcoming all of me:  my hurts, my flaws and my gifts.    They seem to say "we almost died as a church so we now know EVERYTHING must be on the table for us to bear each others burdens and rejoice when you rejoice....join us."     This is an amazing feeling in a church when you come with the pain and hurts, the shame and introspection that I did a few weeks ago.    I am so grateful.


I have lived away from family and home since 1981.    My family that remains in ND is quite interrelated doing a lot of things including church together.    I have missed that opportunity and now feel a hunger to have a church family to love and from whom I can be loved.     I have had such people and such churches in my past but I was the one not loving so that's the change.  


The idea of homecoming is sweet.    On the days I feel I cannot go on God seems to say "I don't want this earth to be too nice or you would not groan for heaven."     Boy am I wanting heaven!     For some reason He wants me here now so I can wait.     Paul said to "live is Christ and to die is gain".     I hope I can understand the first phrase better.     I yearn to have that final homecoming when we get a new name and can finally meet the author of our salvation.     Until then the homes we make in church here will have to remind us of what heaven ill be like.    I hope all my patients can look forward to such a homecoming. ]]></content:encoded></item><item><title>My Nickname</title><dc:creator>doc@askdrjim.com</dc:creator><dc:subject>askdrjim blog</dc:subject><dc:date>2007-10-20T16:48:40-04:00</dc:date><link>http://www.askdrjim.com/foler/page3/files/oct-2007#unique-entry-id-32</link><guid isPermaLink="true">http://www.askdrjim.com/foler/page3/files/oct-2007#unique-entry-id-32</guid><content:encoded><![CDATA[Two entries today as I will not have the computer for a while.     I have been through a tremendous amount of stress recently and although my faith has not failed my emotions certainly have.    I have spent a lot of time in prayer beating myself up with my own failures and my character flaws.    These pop out when I think I am doing better and they almost always have at their core satan whispering to me about my worthlessness.    Then I go out a prove him right with my actions hurting those closest to me.     My prayers have been to ENDURE this time....get through it an move on intact or nearly so.


In our church on Wednesdays the women are studying with Beth Moore some of the Genesis stories.    Last week she ended (as she is so good at doing) by recounting the story of Jacob wrestling with the angel and then getting a new name.     His old name spoke of his scheming and the new of his overcoming.      What a wonderful picture.    She then took it to a new and wonderful place.    In Revelation 2:17 we are told that "to those that overcome" will be given a new name....one only God and that person will know.     And that name will mean something to us both.    It will be the nickname that defines us.     Ancient peoples and Native peoples often had naming ceremonies at puberty with the choice of the name being sacred.    It often described the person well in one or two words.     My brother was good at nicknaming folks in our youth.    They sometimes had something to do with physical or emotional traits and sometimes they seemed out of the blue.    But, even if strange, they just seemed to fit the person.


 Some day IF I OVERCOME (NOT JUST ENDURE) my trials, God will welcome me home and whisper to me a name.    This name will speak of the trials, His grace and my triumph through His power.     Then I imaging Him smiling and winking as we know that no one else knows.   You see, no one else was there when we together walked through the fires triumphantly.    The name will mean everything to me and will be out of the blue to everyone else who would hear it.      Just think about it!]]></content:encoded></item><item><title>Rainbow Suprise</title><dc:creator>doc@askdrjim.com</dc:creator><dc:subject>askdrjim blog</dc:subject><dc:date>2007-10-20T16:33:01-04:00</dc:date><link>http://www.askdrjim.com/foler/page3/files/oct-2007#unique-entry-id-31</link><guid isPermaLink="true">http://www.askdrjim.com/foler/page3/files/oct-2007#unique-entry-id-31</guid><content:encoded><![CDATA[This is a bit scattered so stay with me.    This week I was walking early in the morning around White Pine.  ...  Sometimes it's a bit like being on a cell phone while driving as I end the walk not really remembering the visual details.    I have points in my route where I pray certain things.    I start with God, His majesty and creative being and His grace and love for all and for me.    Then I work on my desire for His will to be done in my life, the life of my church and my friends.    Then I look inward at my sin and slowly developing Fruits of the Spirit then a time of thanks for forgiveness.    Then I pray for others in my life both family and friends.    Finally I pray for His help in getting through the day showing Christ in me to my patients and all I meet.     I generally end up with the amen as I enter the office door.   


Well one day this week the sky was dreary.    It looked like rain but the type of clouds made it clear it was only dark but no rain.     My mood was a chameleon to the day.  ...  I was trying to advise God on the best way for Him to move a great burden out of my life....and I felt I was not being successful.    I felt like David complaining that God's face was far from me.     I was unsure where my life was going and I was very lonely.     I walked a bit out of my usual route and was facing east.     Just as I turned around to the west to head to the clinic the sun peeked through.     As I turned, right in front of me, a rainbow suddenly appeared with one end in the middle of White Pine (about where my church is).  ...  In a flash I seemed to understand that God's promise to never abandon me and to always be with me was real.    It was as if He was saying.    "I'm right here behind you watching you walk through this dreary time.  ...  I am with you and will not see you come to harm."     I am so grateful that scripture tells us that this is exactly His attitude toward His children.     In Isaiah 40 we are told He will renew our strength....not that we will be removed from our trials.     The passage before that is the lovely one that recounts the greatness and power of God.     The trials are nothing compared to Him and He is with us.  ]]></content:encoded></item><item><title>Flu Season</title><dc:creator>doc@askdrjim.com</dc:creator><dc:subject>askdrjim blog</dc:subject><dc:date>2007-10-16T22:46:40-04:00</dc:date><link>http://www.askdrjim.com/foler/page3/files/oct-2007#unique-entry-id-30</link><guid isPermaLink="true">http://www.askdrjim.com/foler/page3/files/oct-2007#unique-entry-id-30</guid><content:encoded><![CDATA[Every year about this time there is a mad rush.     Patients and their families begin to call about the availability of flu shots.    We start asking folks if they want them.    We hear the same stories of past allergies and "it gave me the flu."      The government starts to remind us of how important getting the shots are.     And the business of influenza starts.     Influenza is a public health issue and, although the health departments do provide some vaccine to providers and give some themselves,  the vast majority of Americans now will get their shots from hundreds of sites:  mega-stores, pharmacies, schools, senior centers etc.   


This fragmented approach coupled with marketing from middle men who distribute vaccine for a profit is a great example of how the American system fails the public.     Most influenza is spread and fomented by children and in the school systems.    This source then spreads into the community eventually affecting the very young and the very old.     For years the target audience was the one most likely to agree to vaccine (and pay)....the elderly.    Never mind that the response to immunizations as we age is far less than in the young.    Never mind that the young are spreading the disease.     This was pure supply and demand and stores were there to help with the hype.    And in the race to be first (to get the $$ from the anxious public) shots are given earlier and earlier each year.     Never mind that the immunity from the shot wanes after several months so giving too early may still not ensure complete community coverage. 


In the past few years there has been more emphasis on preschool and now finally school children.     This will ultimately be a better use of the fixed dollars but we still have a fragmented system.     I wish the profit was removed.     I wish we had an immunization policy in this country that provided basic immunizations for contagious diseases and epidemic diseases free of charge to all.    I wish that the policy would use the science to distribute the vaccine to those most likely to spread the disease and those most susceptible to it..    I wish my fax machine would stop spitting out "Flu vaccine special price" sheets from middle men.


But this is America.    We eventually get to the right answer after exhausting all other possibilities first!      By the way our shots will be available Oct 24th and 31st in the PM.]]></content:encoded></item><item><title>Fruit Tree</title><dc:creator>doc@askdrjim.com</dc:creator><dc:subject>askdrjim blog</dc:subject><dc:date>2007-10-15T23:20:13-04:00</dc:date><link>http://www.askdrjim.com/foler/page3/files/oct-2007#unique-entry-id-29</link><guid isPermaLink="true">http://www.askdrjim.com/foler/page3/files/oct-2007#unique-entry-id-29</guid><content:encoded><![CDATA[Many of you know the list of the Fruits of the Spirit or character traits that Christians are to have.    I have been struggling with these for several months because I am quite good at seeing others flaws but quite blind to my own.    My actions over time have caused me to have to daily face the aftermath of my lack of fruit and the lives I hurt.


...They come into being by the branches merely doing each day what they are called to do while receiving sustaining life from the roots and main vine.    The result, over time, is that they become more and more like Christ and less and less like the world. 


  Love, Joy, Peace, Patience:  The first 4 are foundational and so hard for me.  ...  Christ's example of dying for us when we were in total conflict with Him seems too high a mark.    I see the key to His love as the incredible forgiveness that it embraced.  ...  Yet He asks me to forgive others because I understand the tremendous amount I have been forgiven by Him.   ...  And can never expect my brothers or sisters to do the same with me. 


Joy, real joy that permeates our being with the perfect contentment God's Spirit can give also seems elusive.  ...  When the joy comes I think the peace that passes our understanding and the resultant patience are easier. 


...Love that expects the best in others and is not so self-centered.    Love that  sees others' flaws as their challenges that God has placed before them to cause them to grow.    The great mystery is this:  God gives the fruit if we rest in Him.   ...  Each time I lash out He says "Do over" and we are back to square one.    But each day we mature there is a bit more of Christ in us.


I am reading a book about learning to find "Safe People" to be in our lives and identifying the Unsafe People that help to keep us in interpersonal and spiritual chaos.    Safe people believe in us, confront us with our sin, empathize with us, bring out the best in us, forgive us in love, move us spiritually in a positive way and unconditionally love us (not what we do but who we are and who we are becoming).    The Unsafe ones blur boundaries, use us, abuse us, cause our baser nature to emerge and center the relationship around their needs.    Often they do these destructive things in very deceptive ways causes us to feel we are the cause of the chaos they create.    I know I can see patterns for me where I have been unable to identify Unsafe people in my life until they have turned me inside out and my world upside down.    The book emphasized the Christ is the ultimate example of a Safe person.  

...So if Christ perfectly embodies the fruits of the Spirit AND is the ultimate Safe person, we should look to Him as our model.    We should look for friends, partners and churches that show the Fruit and His character in their lives.  ...  I must bear the fruit if I am to be a safe friend and I must seek out others of like purpose.    It is only in that collection of "branches" that my fruit will have the best chance to ripen to maturity. ]]></content:encoded></item><item><title>Lessons to learn</title><dc:creator>doc@askdrjim.com</dc:creator><dc:subject>askdrjim blog</dc:subject><dc:date>2007-10-14T22:28:48-04:00</dc:date><link>http://www.askdrjim.com/foler/page3/files/oct-2007#unique-entry-id-28</link><guid isPermaLink="true">http://www.askdrjim.com/foler/page3/files/oct-2007#unique-entry-id-28</guid><content:encoded><![CDATA[I know that much of this blog has been non-medical but I feel lessons learned in all areas of life (not just science) is what makes up a physician.     When I was teaching I had the opportunity to interview potential medical student or potential residents.    I wanted to hear all about their non-science life and I always asked:  "Tell me about a failure in your life that you caused and how it affected you."   ...  I recall one young woman who was at an Ivy League undergraduate program.    She was ALREADY IN CHARGE OF A FEDERALLY SPONSORED RESEARCH LAB.   ...  She was brilliant and attractive and accomplished in some non-science areas.     In response to the question she thought long and hard and then said..."well, one time a boyfriend dumped me before I had a chance to dump him."     I said something like "I'm sorry for you because in your training or your practice you will make an error that will hurt or possibly hasten the death of someone.    If all you have to use as prior experience is being dumped once in your life I don't know if you will come through all right."     I saw young doctors faced with their first failure (not just a wrong answer on a test) do one of three general things:  they could fold up and be crushed (some even dropped out), they could ignore or deny their responsibility (those are the dangerous doctors ) or they could study the pain and failure and learn.


Like many of them I have been blessed almost my whole life with successes.    Luckily I played competitive sports where an air ball or a fumble can ruin a game or a season.    Still I have had a relatively pain-free life.   ...  I have been challenged again and again with not only my interpersonal and character shortcomings but also my failures in my profession.     Recently I saw a Beth Moore tape that stressed that God will keep allowing tests in our life until we "get an A".    She said that if we were having the same test again and again we must not be learning the lesson.    She also said that our greatest tests will involve our greatest loves and will also have the greatest impact for change in us and our world.    

...My current test is the same as previous ones:  to learn patience and trust in God that He will sustain me if I am doing what He calls me to do.    Sure, I know this but I still advise God.    I make alternative plans, try to speed up the process all the while showing very little of the faith I claim to possess.     I have come to understand that I have 3 cores ways of responding to issues:  feeling, thinking and acting.  ...  When I do this (especially when I am tempted by Satan to use the emotions of guilt, despair, anger or shame) I then rivet my thoughts to those emotions driving me deeper in sin.  ...  I have decided that this lesson for me is key...to learn to see when my emotions react to a situation in such a way as to take away my joy, my peace and lessen my faith.     When I see that I can ask God to help me calm the emotion and allow me to recast the situation in His eyes.     This is bringing me peace that I have only hoped for in the past.     The poems I have on the site for today reflect this struggle and capture what I am trying to say.    I hope that I finally understand the test and have a way to get that "A".]]></content:encoded></item><item><title>Growing Pains</title><dc:creator>doc@askdrjim.com</dc:creator><dc:subject>askdrjim blog</dc:subject><dc:date>2007-10-09T22:37:09-04:00</dc:date><link>http://www.askdrjim.com/foler/page3/files/oct-2007#unique-entry-id-27</link><guid isPermaLink="true">http://www.askdrjim.com/foler/page3/files/oct-2007#unique-entry-id-27</guid><content:encoded><![CDATA[Over the past few months I have been under quite a bit of strain due to a delay in a large amount of Medicare payments....like nearly 6 months worth!     My devotional life has been leading me to understand that trials in our lives are pretty specific and allowed by God to bring out the fruits of the Spirit in a believer.   ...  The problem is (as Beth Moore says)  "God's into A's"....not C's!   ...  During this financial crunch I have had to really step out on faith in several areas and it has been very hard.    My prayers have been that my patients and my staff would see Christ in me each day.    I fear that most days they see more Peter (before the open tomb) than Christ.     Emotional, reacting, anxious, triangulating and very self-involved....in other words quite the opposite of our Lord. 


Despite all that the desire to have the practice grow and flourish has been another prayer. ...  As it has done so it is clear that it has very little to do with me or my skill.  ...  I have been blessed with patients who put  up with my quirks and still tell people to check out our practice.  

... In Mary and Holly I have two people that fit their rolls quite well.    Most of my patients have never seen or spoken to Mary as she works when patients are not in the clinic.    Mary came on board in the middle of this financial crunch and (I must admit) I was worried that she might not be of help.    Within a few hours, however, she had changed my bias about electronic billing, calmed my fears about the Medicare and outlined a way to proceed that I would have never dreamt up in, well in forever.    She is stabilizing the ship and putting forward more ideas of how to change some of my bad habits regarding billing.    All my patients know Holly and appreciate her ability to bring smiles to faces, calm to people anxious about referrals and relief to those worried about having blood drawn or shots given.    She juggles phones and office while remembering names and details I could never bring to mind about each patient.      During the sudden increase in volume both of these women have kept the practice going even when I seem to be rowing in a different direction.


...I cannot mention names but I have one dear friend who is a remarkable manager and who has supported and suggested changes to me all the while encouraging the type of personal practice I am trying to achieve.  ...  We have one patient who even keeps us well stocked in jam!    And today a proud grandmother brought an essay her granddaughter had made about our practice!   


My father was a dentist in a small town where he was raised and I saw first hand what that type of practice was like.  ...  I had not really experienced this (or was not open to it) until recently.     I am so grateful that my eyes are now seeing how interrelated patient and practice are.    I am smiling when I think of folks I saw or met for the first time today....they are now part of that fabric.    I am more excited about medicine than I have been in a long time and it is not because of the science.    It is simply that I have started to understand what a wonderful gift God has given me to be involved in helping people when they are in need AND receiving what they give to me in return.   ]]></content:encoded></item><item><title>Screening Scares</title><dc:creator>doc@askdrjim.com</dc:creator><dc:subject>askdrjim blog</dc:subject><dc:date>2007-10-07T22:26:48-04:00</dc:date><link>http://www.askdrjim.com/foler/page3/files/oct-2007#unique-entry-id-26</link><guid isPermaLink="true">http://www.askdrjim.com/foler/page3/files/oct-2007#unique-entry-id-26</guid><content:encoded><![CDATA[Debates occurred about how much money preventive care would save and just when in the timeline of the patient would the payoff occur.    Most research suggested that there was some positive gain from using certain preventive strategies (immunizations and prenatal care) but there was an ongoing debate about mass screening for cancer and heart disease.  ...  Advocacy groups quite vocal in their options, regardless of the research, pushed for all kinds of (in my opinion) harmful strategies.     We initially could not even know as a physician what our patient's test results were.    Patients were issued a private random identifier and would then call in using their number not their name to get results.   

...We taught women breast self exams without fully knowing the impact such training would have (myriad untold women finding benign lumps early in their exams prompting biopsies and anxiety).    We pushed for "yearly" PAP smears when the research showed that certain high risk groups needed that (and maybe more) but low risk groups could get away with much less frequent exams.   ...  Civic groups, pharmacies, health fairs sprung up with folks getting "free screening tests" and then no followup or risk stratification.    Certainly folks with disease were found adding to our certainty of our approach but many others were left scared, confused and without guidance.    While all this was going on we blindly ignored issues like the nutritional damage that was being done at our public schools with poor lunch choice and sweet drink machines.


...Ideally you should screen for a disease that, if caught early (before major symptoms bring it to the patient's or doctor's attention) can be cured, delayed dramatically or modified in some way that will make a major impact on the patient or society.     In other words if you can catch it early, cheaply AND IT MAKES A DIFFERENCE TO THE PATIENT OR SOCIETY.  

...Sensitivity is the ability of a test to identify people with the disease.    If a test is 95% sensitive (pretty good) it would identify 95 of 100 people WHO HAVE THE DISEASE correctly.    This means 5% will think they are ok but the test would be wrong (THIS IS A FALSE NEGATIVE).  ...  If a test is 95% specific (again pretty good) for every 100 people who are without the disease 95 would be correctly identified as disease-free.  

...Well, actually it tests for the level of a protein found to be elevated in most men with prostate cancer.     It can be elevated in other instances as well and LIKE MOST BIOLOGICAL tests that actually measure a level (not merely a + or - by being found present) there is a Bell Curve of results.   ...  Well, actually, a study a couple of years ago showed that nearly 28% of a group of men tested with PSA and then undergoing biopsy had PSA AROUND 2.0 AND WERE FOUND TO HAVE ABNORMAL CELLS THAT LOOKED LIKE CANCER.      There are also men who have PSA's in excess of 4.0 who have negative biopsies and no cancer.


All I can tell men who want PSA's for screening is that when we get the result we can talk more about what it might mean.     I also try to find out if they would want treatment if a cancer was found.  ...  Add to this that we often screen EVERYONE of a certain age and sex for a disorder.     This is like sitting at the soda counter looking for the next undiscovered star to walk in....you might be their a while.     A better approach would be to identify family, social, nutritional and symptom histories that would develop groups of higher risk patients who could be screened.  

...Talk with your doctor about the effectiveness of the testing approach her or she is using and find out if better tests are out there.     ALWAYS BE AN ACTIVE PARTICIPANT IN YOUR CARE EVEN WHEN WE SEEM TO BE SURE WE KNOW WHAT WE ARE DOING!!]]></content:encoded></item><item><title>More random thoughts.</title><dc:creator>doc@askdrjim.com</dc:creator><dc:subject>askdrjim blog</dc:subject><dc:date>2007-10-01T22:22:48-04:00</dc:date><link>http://www.askdrjim.com/foler/page3/files/oct-2007#unique-entry-id-25</link><guid isPermaLink="true">http://www.askdrjim.com/foler/page3/files/oct-2007#unique-entry-id-25</guid><content:encoded><![CDATA[I wonder why, when faced with unhappiness in life is it so important to find a reason or someone to blame?    I am always amazed at the capacity of humans, including myself, to downplay our own weakness.    Daily I see people who, despite being overweight or unfit, blame the lack of time or other people as the cause of their illness.    In fact many seem genuinely disappointed when all lab and x-ray come back without disease.  ...  Stress, poor family life, poor nutrition and tobacco are often the root problem.    When shown the truth of this and the need for change they say that they cannot or that they "have tried" in the past and failed. 


...In the garden Adam blamed Eve for his complicity in sin.  ...  We all desire to be our own god and therefore our compass has to be right and error must come from the outside.    This is why Paul's statement that temptation and sin arise within our own minds first is so stunning.    Maybe I would not be such a good god after all.  


I have been spending a season taking a long and hard look inside myself with the help of some books, a few wise friends and prayer.  ...  I am quick to be hurt and offended but miss the hurts I inflict.    I want others to have infinite patience with me but I have none for them.    Basically given a list of the fruits of the Spirit (love, joy, peace, patience, kindness, goodness, gentleness, faithfulness and self-control) I am the poster boy for the "before" photo.


The puzzle about bearing fruit is that the branch bears by "abiding" rather than doing anything itself.    It needs to be intimately connected to the vine and receptive to what the vine offers.    In other words to get better I need to abide in Christ more fully and more unreservedly.    Not more church, more giving, more work rather more communion and more trust.    This is very hard for someone who likes to act to fix a problem.  

...His miracles and His power arose out of the very intimate communion He had with God the Father.  ...  I have decided that in order to be a good man I must be able to give it all up...all my selfish desires, all my self-centered goals and all my private gods.  


Paul's image of us as a "living sacrifice"...actually placing ourselves on the alter alive (like Isaac) is the model.    To do that I must just live each moment fully for His glory and die to self daily.  ...  It is a freeing vision of life....live now for Him nothing else has priority.    This burns away a lot of the stress of life and helps avoid blaming others for the past or the future.    Maybe that's the approach we need with patients:  Do right by your body NOW.    Past is past and future is not here but NOW you can help yourself.   ]]></content:encoded></item><item><title>How to Make Money in Practice</title><dc:creator>doc@askdrjim.com</dc:creator><dc:subject>askdrjim blog</dc:subject><dc:date>2007-09-30T20:50:29-04:00</dc:date><link>http://www.askdrjim.com/foler/page3/files/sep-2007#unique-entry-id-24</link><guid isPermaLink="true">http://www.askdrjim.com/foler/page3/files/sep-2007#unique-entry-id-24</guid><content:encoded><![CDATA[As we have been looking at the need for the practice to grow the driving issue is revenue.  ...  There are only so many patients you can safely seen in an hour and as you approach that number your income stream flattens out.    You either find ways to increase the income or you become content with it.   ...  This can be done several ways but the most common is to find reasons for people to come in for "routine" followup of conditions we used to see less often.    You could tell women that they need a "yearly PAP" when the research would suggest that low risk monogamous women who have had normal PAP's for 3 straight years need only be tested every 3 to 5 years.   ...  Or patients could be convinced by their doctor or industry that they are sick and need pills which, unfortunately, could cause liver damage.    This means they need to come in more frequently for lab work (some of which can be done in the office generating lab fees).     You could advocate routine  "physicals" for all adults which have been shown to be of limited value.    You could hold "health fairs" where you hope to identify early disease that could be a source of income.    You could order many in-office lab tests based on symptoms because insurance will pay (sore throat = strep test) rather than take a history and use that to identify only those who might benefit from the test.    Finally you could raise a generation of patients who don't want responsibility for their health and know that every ache is dangerous, every stress needs treatment.    You could tell them that you have a pill to fix most things they do to themselves or imagine they do to themselves.  

...Sure, there are times when followup and testing are the right approach but too often the temptation is there to get as much revenue from each patient as possible.    The problem is that insurance companies don't pay well for listening to your patient and working on behavior change.  ...  I don't know what the answer is but our patients should know how uncomfortable I am with unneeded tests and exams.  ...  On the other side of the coin patients seem more and more reluctant to come in for needed care if they have a $15 or more co-pay.    I get calls every day from folks who decline same day appointments for something and request I "call in something for me."    Many then get angry if we suggest that might not be the right way to go.     I don't know the answer so until then I guess I'll just keep working 2 jobs!


...I have been going to a new church in White Pine and have been pleased and blessed by the way God has chosen to help me during a very trying time.    I LOVE hymns and could be in church and just sing them for the whole service.  ...  I was very concerned about this approach (and still worry that hymns will die out) but today when the entire congregation was singing a simple chorus from the heart with tears on our faces it hit home how often I use structure to limit God.  ...  Maybe it's when I use medical words to shorten the conversation with a talkative patient.    Maybe its when I don't spend the time with a lonely older widow who comes in just to have someone touch her hand and smile.    Maybe it's with my friends when I fail to break out of routine and see who they really are, who they are becoming.    I just know that today a simple song brought me face to face with the Holy Spirit in our church and it was good.    I hope you all had good experiences today in church and, if not, look at your own reasons for limiting contact with God. ]]></content:encoded></item><item><title>Recent thougts</title><dc:creator>doc@askdrjim.com</dc:creator><dc:subject>askdrjim blog</dc:subject><dc:date>2007-09-30T00:38:48-04:00</dc:date><link>http://www.askdrjim.com/foler/page3/files/sep-2007#unique-entry-id-23</link><guid isPermaLink="true">http://www.askdrjim.com/foler/page3/files/sep-2007#unique-entry-id-23</guid><content:encoded><![CDATA[I have been a bit out of the loop as far as access to the machine where I blog and upload my web pages so I'm sorry for the stale site.    A lot of things have been going on in the past few weeks and I have a lot of thoughts to put down in the first entry.   


I met a young man recently who was depressed and upset over a relationship currently on the rocks.     As we explored his feeling and history he related a your spent without any male role models as they were ALL in prison.    He had been on the streets and in prison himself and had moved to the area in part due to a relationship and to get away from that past.    He now had a steady job and had been doing well but had difficulty knowing how to act as a father and a partner and the relationship was stressed.    I was amazed at the story and told him that I could not imagine trying to be a doctor without training or role models.    He had done exceptionally in the past months in just that situation.    I urged him to reframe the "failure" he felt into hope and pride that he was on the right track.     He also needed to be in church (and he needed to contact his mother for support).    I am praying that this life can be turned around with Christ's power.


A second thing that happened recently is that a local paper did a profile on our practice.    I hate doing those things (though I have a big ego like most doctors) and having to have a picture taken was even worse.    But it did give me an opportunity to talk about some of my "quirks" and, hopefully, to let folks know about our spiritual bent.  ...  We have had dozens of calls asking to join the practice and that affirmation of our values is gratifying.  


We have spent several months now with difficulty in getting payments from Medicare.    Since this is a large part of the practice, the financial strain has been huge.  ...  Meanwhile I have been learning about tests in our lives.  

...1) Your trials have your name on them:  they are yours....my areas of weakness seem to be courage, patience and letting go of control. 

...2) Your greatest  trials will involve your greatest loves (this one really hits home with me)


3) The greatest trials will have the most wide ranging impact on you and your world.    I can only hope that the current stress will be used to produce great growth in me and praise to my Lord.


...A local church women's group held a "fashion show" for mothers and daughters.  ...  The women also used this idea and went a step further, they shared their faith using fashion as the object lesson.     Before the night was through 8 people made first time decisions to given their lives to Christ and 4 more rededicated themselves to that decision.  ...  We often think we need to do dramatic or "church" things to share our faith.    God is not limited by that approach and these women knew that and did a wondrous thing.  ]]></content:encoded></item><item><title>Careful what you read</title><dc:creator>doc@askdrjim.com</dc:creator><dc:subject>askdrjim blog</dc:subject><dc:date>2007-09-18T20:28:50-04:00</dc:date><link>http://www.askdrjim.com/foler/page3/files/sep-2007#unique-entry-id-22</link><guid isPermaLink="true">http://www.askdrjim.com/foler/page3/files/sep-2007#unique-entry-id-22</guid><content:encoded><![CDATA[With great fanfare the NEJM had a press announcement prior to today's presentation at a national meeting about a new drug for osteoporosis.    I will not go into the details but I would like to talk a bit about how research is now done.    The press release touting the drug and the decrease in death highlighted by the study as being groundbreaking.    Read a bit further and you find:  1) The major drug company sponsored the research 2) the same company pays the lead researcher 3) The researcher and company have the press conference and make statement over the top about praise. 4) the research is released the next day.  


The research showed approximately a 2.5% reduction PER YEAR in fractures and 1/2 that in deaths.     In a nutshell women over 74 who had already had hip fractures (high risk frail women) were given placebo or the drug.    Over 2 years the small differences were found in repeat fracture and deaths and the decrease in deaths was not fully understood.    


This is either groundbreaking OR industry sponsored media hype show a very small improvement with no clear biological explanation which also could be statistical manipulation.    By the time we would find that out the stock would be out the roof and the public clamoring for the drug.    In the end we again buy the Madison Avenue/Big Pharmaceutical alliance that has been so successful in the past 20 years in this country.    THE BOTTOM LINE IS ARE WE GOING TO BE A SIGNIFICANTLY MORE HEALTHY PEOPLE BECAUSE OF THIS?     I THINK NOT. ]]></content:encoded></item><item><title>We are ready</title><dc:creator>doc@askdrjim.com</dc:creator><dc:subject>askdrjim blog</dc:subject><dc:date>2007-09-08T19:26:40-04:00</dc:date><link>http://www.askdrjim.com/foler/page3/files/sep-2007#unique-entry-id-21</link><guid isPermaLink="true">http://www.askdrjim.com/foler/page3/files/sep-2007#unique-entry-id-21</guid><content:encoded><![CDATA[I wrote about our web portal a few weeks ago.    Well, it is up and available.     In order to become a "web-enabled" patient you must either come to the office or call us so we can give you a user name and login password.    With these in hand (after a few hours so the upload can occur) you will be able to log into the portal and look around.    There is a lot of neat things.    We will have forms logged into the site to fill out from time to time, you can email us.    You can look for labs.    You can update your information.    All of this is more secure than going through the doc@askdrjim.com email.     This is an exciting way to build a health community and I am hoping to learn a great deal about how the be a "web doctor".    Many have already made use of the email and it has proven helpful.     I am excited about this.    We will have some handouts soon to show you what you can do on the site.    These should be available at our practice. 


As you know we have been short-handed (pun intended) at the office but I am grateful that Holly is recovering well and back in her usual place helping my patients with their problems.     You don't think about your health care professionals getting sick and we are some of the worst patients in the world.    I know that I often don't practice what I preach but that is fairly typical for doctors.     I hope the problems contacting us during this time of ill health has not been too problematic.


I am working on developing a presence at the local hospitals and hope to soon be more active in the White Pine community.    I feel this is important and know that many of you have voiced that to me.    Thank you for your support through this transition.    I should be more available by cell phone after hours so you will not get as many voice mailbox messages.        I also hope to clear up a problem with access to a computer on which to blog regularly.    I use a iMac for this and hope to have a machine readily available soon that will allow me to blog on a more frequent basis.


Finally I need ideas for a newsletter topic.    I have been on hiatus with the newsletter but with the web portal I will be able to send it out to registered users who have given us their email address.    This has me energized to work on it again.  ]]></content:encoded></item><item><title>Yes in our lives</title><dc:creator>doc@askdrjim.com</dc:creator><dc:subject>askdrjim blog</dc:subject><dc:date>2007-08-18T21:57:38-04:00</dc:date><link>http://www.askdrjim.com/foler/page3/files/aug-2007#unique-entry-id-20</link><guid isPermaLink="true">http://www.askdrjim.com/foler/page3/files/aug-2007#unique-entry-id-20</guid><content:encoded><![CDATA[This week I had several patients that again taught me much about life and being a healer.  ...  One person has been suffering for weeks with a couple of wounds that won't heal.    This would have me going crazy but this patient has always been positive about improvement, confident in the final outcome and trusting in my care.    I probably would have been to 10 doctors, making my friends and family crazy but they are happy and serene.    I think it is because this patient just enjoys living so much that a little ulcer isn't going to stop his joy.  ...  I pray that I can find the joy in being alive every day.


One patient comes regularly for treatment they cannot administer at home.   ...  They could be angry or scared or moody but they are excited to come and see me (well, really to see Holly) and they often bring us cards or notes they have made expressing their affection for our care.    They want to be a doctor or a fireman when they grow up.    The trust and simple love of a child shows me how far short I fall in trusting and loving those around me.    It challenges me to see each patient encounter not as one of solving a puzzle but caring for a person. 


A couple of patients came in from abusive situations.    The pain they have experienced physically and emotionally shows how evil the world can be.    But what I have seen from the two this week is the tremendous courage and strength it took to name the evil and resist it despite the fear they had.     Too often faced with evil I can retreat.    These patients inspire me to dig in and fight.


...I have been walking around White Pine early in the AM before clinic to exercise and pray.    I have become more and more aware that the God of the universe is a creative, loving, sensual being that above all wants to be known and to know.    Too often in our religion we have a list of "No's " that we use as our basis for living (after all the 10 commandments are mostly seen as "Thou shalt nots".   


But further back.....in the Garden there was really only 1 "no" everything else was "yes".    I have been reflecting on how God intends "yes" for us so much more than "no".     He wants us to savor the world he has made.    That includes our ability to interact with others and Him.    It includes the artistry of music and words.  

...Sure, in all those areas there may be prohibitions that when broken threaten our relationship with God.    But there are so many more possibilities for "yes".    I have determined that my life needs to reflect my God and that means figuring out today what "yes" he has prepared for me to savor and to pass on to others.]]></content:encoded></item><item><title>Life is a time-limited gift.</title><dc:creator>doc@askdrjim.com</dc:creator><dc:subject>askdrjim blog</dc:subject><dc:date>2007-08-13T21:47:54-04:00</dc:date><link>http://www.askdrjim.com/foler/page3/files/aug-2007#unique-entry-id-19</link><guid isPermaLink="true">http://www.askdrjim.com/foler/page3/files/aug-2007#unique-entry-id-19</guid><content:encoded><![CDATA[Two things happened today that made me think about what to write.     I had a patient who came in after being AWOL for over a year.    They had a serious disease that was easy to diagnose but difficult to control and in the intervening months had intentionally neglected caring for the problem.    The reason given was financial but we all know about the money we waste on soft drinks, other addictions, cable TV and cell service.    Given the problem I felt this was a slow form or suicide.    Far better to call it that than to blame circumstances that are actually choices even if we do not want to see them.     I thought this person just doesn't get how precious their life is to their family and to their maker.   


The other event was a tornado.     A friend was away from home at a "once a year" outing to a nearby town.    The event really was on a random night and the family was all there.....safe from the tornado that swept past their home leveling neighbors' buildings.    As I write it is still dark so we cannot be sure of all the damage.     In an instant lives may have been lost at the end of a hot sleepy east TN summer day.     No one really could have been thinking "this is my last day, my last minutes before...."   


Our lives are short.     We have much to learn to get us ready for use in eternity.    The tragedy comes when we ignore how short and precious our lives are.    We  participate in things that are wasteful and of no eternal benefit or we engage in habits and practices that tear down the wonderful living body our God gave to us.     Life is a wonderful blink in eternity.    I wish I could convey that to each patient I see.      I am glad my friend's family is alive to live another day....  I'm not sure my patient will be around to do so
]]></content:encoded></item><item><title>Changes Afoot</title><dc:creator>doc@askdrjim.com</dc:creator><category>Practice Issues</category><dc:date>2007-08-09T23:09:27-04:00</dc:date><link>http://www.askdrjim.com/foler/page3/files/aug-2007#unique-entry-id-18</link><guid isPermaLink="true">http://www.askdrjim.com/foler/page3/files/aug-2007#unique-entry-id-18</guid><content:encoded><![CDATA[Those of you that are patients will be seeing a change very soon.    Today we downloaded a "patient portal" from our electronic records vendor.    In non-geek terms a portal is a secure entry point for patients to log in and interact with their chart, our staff and their doctor.  


Patients who desire to do this will be allowed to get their own PIN like at your bank and based on the PIN you will have access to many things.    You will be able to SECURELY email me or my staff (currently emailing me is still theoretically not secure).    You will be able to search for and schedule certain types of appointments.    You will be able to fill out forms, send requests for medication, look at lab results and change your demographics (like when a phone number changes.     All of this can be done without waiting on the phone (or the answering machine) to communicate with us.    This will be a major change and improvement. 


 Of course if you have email we will be able to send you newsletters, updates on drug issues...even a notification if this blog has a new entry!.    You will be able to access the portal directly or through a link on this web site.    I assume in the future your account and payments could even be handled electronically.    This in no way will change the very personal way in which I try to interact with patients.    As you know I answer and return many of your calls.    You get me or my manager without a lot of people in between.    This means you can know I hear your issue.    It does not mean I will always do what you want....  I'm still here to give professional advice not to ask "do you want fries with that antibiotic".     You pay me for expertise and advice not to do anything you ask...that would be dangerous.   


Coupled with the portal we are advertising more both in newspaper and electronically.    This is an attempt to keep our practice financially stable so we can practice the way I want.    As most of you know I give away a lot of care willingly but I still need to make ends meet at the end of the month.    Also a busy vibrant practice keeps me on my toes intellectually and will allow us to expand in the areas of exercise and nutrition that are so important to our patients.  ...  Technology is a wonderful blessing but can also be a curse when it fails.    Let us know how we are doing.  ...  You can also respond to this blog by clicking on the comments link and filling out the form with your ideas.     Thanks for the input we have gotten so far and we look forward to good things in the future. ]]></content:encoded></item><item><title>Hospice</title><dc:creator>doc@askdrjim.com</dc:creator><category>Practice Issues</category><dc:date>2007-07-29T20:50:11-04:00</dc:date><link>http://www.askdrjim.com/foler/page3/files/jul-2007#unique-entry-id-17</link><guid isPermaLink="true">http://www.askdrjim.com/foler/page3/files/jul-2007#unique-entry-id-17</guid><content:encoded><![CDATA[Today a patient of ours passed away after a long bout with colon cancer.    As you may be aware unless we catch these early and surgery is curative the results are still very poor.    Rural areas are prone to delay in seeking care when you have symptoms, long travel to get to specialists and travel issues if chemotherapy is needed.  ...  For this patient, the family firmly desired that she remain independent once it was known that the initial surgery (which they had been told was curative) had not resulted in a cure.    They were faithful in sitting with her, arranging appointments, dealing with chemotherapy and its complications and, finally, dealing with her unavoidable death.0 


 One of the changes in medicine that has been wonderful in the past 2 decades (most of you know my attitude about the lack of much real help for patients during that time of exploding medications and treatments for baby boomer diseases) has been the advent and spread of the hospice model.  

...First the dignity and autonomy of the patient is key.    When you know you will die in a short time and when your loved ones are faced with that fact loss of control was (and still is) a fact of medical life.    Patients and their families are often given false hope or forced down a path of more and more intervention with limited chance of success.    Often families are coerced into treatment protocols because we as physicians just don't want to accept the "defeat" that death brings.    The result is that patients lose control of decisions until they are too ill to make them any longer.     Hospice changes that by bringing patient and family squarely into the decision tree.    If a patient says "no more of that" or "I need to have ..." they are listened to and respected.   


The second goal of hospice is to allow the transition from life to death to be as comfortable and natural as possible.     This may mean that a patient stays at home in a familiar place to spend those last days.    It could also mean that a patient chooses to be in a hospital like environment if that is what they feel would make them happiest.     The hospice tries to deal with those decisions as best as they can.    Certainly urban programs have more resources but rural groups have gotten quite good and addressing these transition issues.


Third, Hospice is about teams that support patient and family.     In few other areas of medicine do the teams of nursing, pharmacy, medicine, social work and pastoral counseling work so closely (and well) together.     The turf that sometimes exists in medicine is much less obvious in hospice and the result is care that flows smoother and is more rapidly responsive to the patient and their needs.    All of medicine has been studying the hospice model and we have much to learn from it. 


End of life issues by their nature force families to talk and force all of us to not only think of mortality but the immortal.    Hospice has always been unafraid of the link between spiritual health and the comfortable death of a patient.     Families often comment on how much the spiritual aspects of their hospice experience helped the survivors with their grief AND their own spirituality.    I am grateful to the doctors, nurses, social workers, pastors and support personnel of our local hospices for the way in which they have helped my patients and their families through the past years.    I am proud of the work they do and they should be too. ]]></content:encoded></item><item><title>In a flash</title><dc:creator>doc@askdrjim.com</dc:creator><category>Learning and decision making</category><dc:date>2007-07-25T21:05:38-04:00</dc:date><link>http://www.askdrjim.com/foler/page3/files/jul-2007#unique-entry-id-16</link><guid isPermaLink="true">http://www.askdrjim.com/foler/page3/files/jul-2007#unique-entry-id-16</guid><content:encoded><![CDATA[  I have been thinking about Malcolm Gladwell's great book "Blink" (hard on the heels of "Tipping Point").    It is a book of stories and research that highlight the difference between the way in which our conscious mind makes deliberate decisions and the "rapid cognition" of our instinctive/uncounscious mind.    In one of this blog's first entries I wrote about how experienced clinicians often correctly make a decision very rapidly based on limited information.    These  are not guesses, these are ways in which skilled clinicians will trust their instinct in a case.  


In the book Gladwell shows how both conscious and the instinctive decisions can be right or prone to be wrong under certain circumstances.    Under extreme physical and emotional distress, for instance, we process much less information that helps us read situations and people.    We revert to stereotype for information and our processing becomes more like that of the autistic mind....unable to read facial or verbal cues which limits the accuracy of our decisions.    At other times thinking through a decision may cause information overload and result in unneeded delay or inaccurate conclusions.    In medicine both of these can happen.  


 When I was teaching actively in the medical school environment, I often told students and residents that if they "just didn't feel right" about a story or a pattern they were seeing they should listen to that feeling.     I recall giving a lecture outlining this principle and THAT VERY AFTERNOON a student came to me in clinic with a gut feeling they were missing something.    She had been interviewing a woman for about 30 minutes and the complaint was common as was the story but something was not right.     I went in the room and introduced myself and recounted a bit of what I had heard from the student.    Then I felt strongly compelled to ask the woman "How long has your husband been abusing you?".    Never before and never since have I started an interview with that question asked that way.    She broke down and related a story of fear and abuse and we started intervention to get her an her family safe.  ...  I just went with my instinct.    But I could not explain why I had done so.  


 Gladwell's book points out research showing a myriad of facial expressions that may be flashed for a few milliseconds may have been what I "heard" from this patient.    In other words it's likely her face flashed me a look of stress/fear that I instinctively recognized without even knowing I had seen it.   ...  Often in medicine we order test after test and trust the tests not the patient or the story and then have too much information to sift though.    The result is more specialist referrals and more tests  NOT necessarily better or more accurate diagnoses.  


In the Epilog he makes a case that major decisions (if not make under extreme emotional/physical distress) may be BETTER made by going with a gut feeling and lower level ones may be better with reasoned thought.     Many of us know about a job, a decision  that we thought through very carefully because it was so important AND WE MESSED IT UP!    Similarly we may have made a decision under stress when reading facial or interpersonal cues was key meaning we could not tap into our rapid cognition or our reason....we just chose to stereotype.    That decision also was wrong.     I have been reflecting on major life choices in the past and facing me now and see how errors were made and wonder if I will do better in the future.]]></content:encoded></item><item><title>Treating Ourselves to Death</title><dc:creator>doc@askdrjim.com</dc:creator><category>Practice Issues</category><dc:date>2007-07-22T23:21:13-04:00</dc:date><link>http://www.askdrjim.com/foler/page3/files/jul-2007#unique-entry-id-15</link><guid isPermaLink="true">http://www.askdrjim.com/foler/page3/files/jul-2007#unique-entry-id-15</guid><content:encoded><![CDATA[This past week a patient of mine became quite ill and needed to be rushed to an emergency room.    The situation looked dire and the symptoms were baffling.     A sudden change in health for no good reason and what appeared to be a life threatening stroke or central nervous system disaster.     I went over in my mind the last visit and wondered what I had missed.    I assumed that I had not paid attention to some subtle symptom and now the result was disaster.    Twenty-four hours later the picture is still murky but what emerged is this: medication given by a caregiver to ease a symptom that was mild likely resulted in severe sedation.    The medication may or may not have been for this particular patient.    This got me thinking about how many American households have stockpiles of old prescription and over-the-counter drugs that are "shared" by well meaning family members for symptoms similar to those for which the medication was initially given.    I really don't blame families (although this is a very dangerous practice).    I blame our medical/pharmaceutical complex that has convinced us that every symptom, every problems has a medicine (or two or three) that should be used to relieve the symptom.    Now I am not saying that drugs do not help people ( I am after all not a herbalist or naturopath) but I am saying that sometimes symptoms tell us that our lives should be changed, should be lived differently.    A century ago if you were tired, you slept.    If you had muscle aches you rested.    Now we pop a pill to eliminate the symptom that may be our body trying to tell us something.    I see many patients (especially the elderly) who come in taking 10 or more medications.     Not regularly for research shows that it is unusual for someone on 2 medications (that are given more than one time a day) to take them every day.    The result is a mish-mash of daily drug therapies.    "I felt my blood was up so I took an extra one of these and skipped that one all together."    We have all become pharmaceutical experts and the ads in the magazines and on the TV just confirm the fact that we know what we need and how to take them.    The problem is, we don't.    More people die from medication errors than car accidents every year in this country....and those are the ones we know about.    People overdose, they go to the ER and almost die, they are sick for a few days but get better all because they are taking mixes of many medications that ALL have potential for harm.    The lesson this week is CLEAN OUT THE CUPBOARD and don't share your medications.    And remember to always ask your doctor if you need to have a pill for that symptom you just mentioned.  ]]></content:encoded></item><item><title>Purpose Driven or Other Driven?</title><dc:creator>doc@askdrjim.com</dc:creator><dc:subject>askdrjim blog</dc:subject><dc:date>2007-07-17T22:07:58-04:00</dc:date><link>http://www.askdrjim.com/foler/page3/files/jul-2007#unique-entry-id-14</link><guid isPermaLink="true">http://www.askdrjim.com/foler/page3/files/jul-2007#unique-entry-id-14</guid><content:encoded><![CDATA[I have been going through The Purpose Driven Life during my devotions for the past several weeks....  I know, I'm behind the times.    I am glad I found the book at last.    Besides being well conceived, written and referenced, the book has nailed the issue of purpose for me right now.     One of the exercises is to develop a life purpose statement.    Although I will keep mine between me and God I would like profess some of the concepts here for patients to see.


1.    Above all else my reason for being is to know and worship my Creator.    All else is secondary.


2.    The gifts He has given me and the personality with which I have been endowed must drive how I serve fellow Christians and reach out to the world.    Not using them is a mockery.


3.    Regardless of the stress and trials they are nothing if I keep eternity in view.


4.    Recognition and success are not to be my drivers, the fruits of the Spirit are to be so.


5.    I must not only worship with fellow Christians, I must study and pray with them in a small support group.


6.    I am called to go and make disciples I cannot do that by hiding in one place.


7.    Although I am not perfect He promises to make me so in eternity.    I need to pray for a more and more holy life each day I have here. 


These are great principles.    They do not choose for me a practice, a place or a way of serving but they should help me solidify my purpose.]]></content:encoded></item><item><title>Those Painful Diabetic Nerves and Pesky Bugs</title><dc:creator>doc@askdrjim.com</dc:creator><category>Comments on Medical Research</category><dc:date>2007-07-15T20:50:57-04:00</dc:date><link>http://www.askdrjim.com/foler/page3/files/jul-2007#unique-entry-id-13</link><guid isPermaLink="true">http://www.askdrjim.com/foler/page3/files/jul-2007#unique-entry-id-13</guid><content:encoded><![CDATA[Two common problems I face were addressed with some good studies in this past week's British Medical Journal (BMJ).    The first involves the treatment of painful neuropathy caused by chronic (and often uncontrolled) diabetes.    The longest nerves in the body are affected soonest so most patients complain of pain in the feet.    The pain can be a severe burning and often does not respond to the usual over the counter pain relievers.     Prevention with weight control and diet and later with tight glucose control is still the best way to deal with this problem but many of my patients still develop pain.    Over the years my best treatment options have been topical (and occasionally oral) capsacin as well as low doses of tricyclic antidepressants or anticonvulsants.    M.   Wong, et al performed a systemic review of research documented in the literature.    The results confirmed what clinicians have known:  Capsacin works for many diabetics and when it doesn't use of tricyclic antidepressants and older anticovulsants worked quite well.    In fact they outperformed the newer drugs with generally lower rates of withdrawl than some of the newer drugs.    The good news is that many of the effective drugs are available as generics.    If you have this problem please ask your doctor about capsacin and tricyclics before taking a sample of one of the newer heavily marketed drugs. 


The second issue is diarrhea caused by antibiotics.    Antibiotic use is widespread and the broad spectrum antibiotics kill gut bacteria along with the disease causing ones.    This often results in diarrhea.    In some cases a bacterium called Clostridium difficile may overgrow and it can produce a toxin that causes a severe diarrhea and colitis.    These problems are especially worse in the geriatric patients who often overuse antibiotics anyway.     For some time there has been evidence that the use of probiotics and even brewer's yeast could treat antibiotic induced diarrhea but that is like closing the barn door after the horse is out.     M.   Hikson et al did  a quite nice double blind placebo controlled study looking at the use of probiotics to help PREVENT antibiotic associated diarrhea.       Their results showed the they were able to prevent 1 case of diarrhea for every 5 persons treated with probiotics and more importantly for every 6 people treated they saw the prevention of 1 case of C. difficile colitis.     Probiotics are inexpensive and readily available.    They are well tolerated and this study confirms that early use of probiotics will prove helpful in preventing a common and potentially dangerous effect of antibiotic use. ]]></content:encoded></item><item><title>Childhood obesity</title><dc:creator>doc@askdrjim.com</dc:creator><category>Nutrition Comments</category><dc:date>2007-07-10T22:32:50-04:00</dc:date><link>http://www.askdrjim.com/foler/page3/files/jul-2007#unique-entry-id-12</link><guid isPermaLink="true">http://www.askdrjim.com/foler/page3/files/jul-2007#unique-entry-id-12</guid><content:encoded><![CDATA[Every TV show seemed to have one "fat kid" that added some type of spice or jokes to the script.    Generally that was 1 kid out of 10 or less.     We now are faced in East TN with rates as high as 33% of the children in grade school not just being overweight but clinically obese.    Recently I saw a preteen who was over 100 pounds OVERWEIGHT.    The scary thing is that as more children (and adults) become obese in this country it becomes harder to compare yourself with any reality.    If we all are obese and we look at each other we think we are "normal weight'.  


I cannot tell you how often I am faced with an obese child who comes into my office with a soda in one hand and a tongue stained by candy.   At the same time the parents swear that the child is eating well.    Most experts would say that obesity in children is largely preventable.    Most children are not GENETICALLY obese.   ...  The parents....we are the ones that develop food and exercise habits in our kids, model behaviors to our children and BUY THE FOOD WITH WHICH WE ARE KILLING THEM AS SURELY AS CIGARETTES WILL.   


As America obsessed about fat and cholesterol (because of our fear of heart disease) we pushed more and more carbohydrates into our children's mouths.     Companies in an effort to profit from our national sweet tooth developed high octane sweeteners like HIGH FRUCTOSE CORN SYRUP.     As we cut the fat we also failed to utilize our satiety feedback system that allows our gut to tell our brain that we are full.    This system relies primarily on fat intake for the feedback.    When high carb/low fat diets are consumed it is not engaged as actively and our brain tells us to KEEP EATING.    The high carb content of the foods our children eat also stimulate their insulin which, in the presence of high calorie intake causes the body to store calories as fat.    So with high carb diets you are hungrier and you more readily store the extra calories you eat as fat....a bad combination.    This high carb intake also causes a roller coaster effect of the blood sugar and people crave the carb/sugars that feed this cycle.


The result has been our children are sucking down sugar and doing it all day long.    This in and of itself is worrisome but when coupled with our general lack of aerobic fitness in our parents and our children we see rapidly expanding waistlines.   


... I would recommend you start with the whole family dramatically decreasing intake of carbohydrates.    For kids this starts with sports drinks and soft drinks.  ...  Studies have shown that diets with whole (as opposed to skim) milk result in fewer calories ingested and better weight control.    Next eliminate the high amounts of potato products (fries, hash browns, tater tots etc) and limit the bread, rice, pasta and of course cookies/cakes/candies.  ...  Push away from video games and TV which are the main source of entertainment for your kids and a large reason they have no time to do healthy activities.  ...  Pledge as a family to each walk for 30 minutes continuous daily.  ]]></content:encoded></item><item><title>July 4th</title><dc:creator>doc@askdrjim.com</dc:creator><category>Community</category><dc:date>2007-07-04T20:39:24-04:00</dc:date><link>http://www.askdrjim.com/foler/page3/files/jul-2007#unique-entry-id-11</link><guid isPermaLink="true">http://www.askdrjim.com/foler/page3/files/jul-2007#unique-entry-id-11</guid><content:encoded><![CDATA[We had a parade in White Pine today to celebrate July 4th.    It was fun to see people lining the streets to wave, get goodies and look at the floats.     We passed out some water bottles and goody bags with our kids helping.   (I'll post pictures soon).     It started me thinking about research on community.    People actively involved in community tend to live healthier and happier lives.    We are not meant to be lone rangers.     We need each other.    At times that means we have to bear each other up emotionally, physically or spiritually.    At times that means putting up with character flaws and habits that are destructive.     People who know me well know that my "issues" often recur even though I say they won't.    I am learning that God forgave those sins of yesterday, today AND tomorrow that He knows I will commit.    He has no difficulty with me coming to Him repeatedly with my flaws as long as I am seeking to be more Christlike each day.     Those around me may not see the attempt to repent and live more like Christ but I am convinced they will eventually.    July 4th is about freedom.    In America we are free to speak, to seek and to work.     In Christ we are free to become the full human He designs us to be.    I don't know what I will be in the end but it will be more like Him.    I'm glad that I have friends and family who can understand that struggle, who put up with me in the midst of my growing pains and who know that the final outcome is sure.    Thanks. ]]></content:encoded></item><item><title>Random Research Thoughts</title><dc:creator>doc@askdrjim.com</dc:creator><category>Exercise</category><dc:date>2007-07-04T19:48:28-04:00</dc:date><link>http://www.askdrjim.com/foler/page3/files/jul-2007#unique-entry-id-10</link><guid isPermaLink="true">http://www.askdrjim.com/foler/page3/files/jul-2007#unique-entry-id-10</guid><content:encoded><![CDATA[I have been reviewing some recent British Medical Journal (BMJ) articles that deal with common questions in primary care.    I will outline a few below.


...What is the best method to encourage exercise in children or adults?     This is interesting.    A systemic review by Ogilivie et al of  a total of 48 studies on the subject showed that almost all interventions resulted in change in exercise patterns in the most sedentary AND the most motivated patients.     This is similar to research in the past that showed approximately 33% of smokers will make an effort to stop after their doctor merely suggesting that they need to do so.     Obviously these initial changes fade with time but it is encouraging to know that by working with our sedentary patients we can have an impact.


...Does low dose aspirin improve women's cognitive function?   ...  Kang et al reviewed data from the Women's Health Study from 1998 to 2004 where nearly 6400 woment aged 65 or more were using placebo or low dose aspirin for a mean of 9.6 years.     OVERALL the cognitive function in the study group was not improved by aspirin use.    There have been some prior observational studies that have shown possible benefit and I believe we still do not know enough about certain subsets (smokers for instance).    Future studies may tease these out. 


...Would a tonsillectomy be better than watchful waiting for recurrent strep throat in adults?    This comes up every week.    Some patients get strep again and again and the risk for more severe disease, although not as common in this day of easy access to meds, does exist.     The study by ).   Alho et al looked at 70 adults who had recurrent strep.    Thirty-six had "instant" tonsilecltomy  and 34 had watchful waiting.     The intervention group was less likely to have further strep throat infection or throat infection or days with throat pain than those without the surgery.     At 90 days strep had recurrent in 24 % of the patients without surgery and only 3% of those who had the surgery.    ...  Waiting to do the surgery will result in more infections and more cost, more days of work and/or school lost.  


...What are the long term effects of restriction of sodium?  ...  Cook et al reviewed date from the TOHP (trials of hypertension prevention)  study that was done in multiple sites on adults aged 30-54 years with pre-hypertension.    They found that in addition to have a slight effect on blood pressure, there was a significant reduction in cardiovascular events during the followup.    I am a fan of using sea salts as better mixes of mineral and salts.    Using them generally causes a reduction in sodium salt reduction.    This may not only help blood pressure but may result in fewer cardiovascular events such as heart attacks.  
]]></content:encoded></item><item><title>Is Soy a wonderfood or a danger?</title><dc:creator>doc@askdrjim.com</dc:creator><category>Nutrition Comments</category><dc:date>2007-06-28T20:42:08-04:00</dc:date><link>http://www.askdrjim.com/foler/page3/files/jun-2007#unique-entry-id-9</link><guid isPermaLink="true">http://www.askdrjim.com/foler/page3/files/jun-2007#unique-entry-id-9</guid><content:encoded><![CDATA[Soy is everywhere these days.     It must be good for you, right?     Soy=tofu right?    Milk formula allergies are common and soy is a good choice, right?    Many of these issues have not been fully explored by research before Americans jump in with both feet (and their wallets).     It is alarming that the public knows so little about a product that is used so widely.     Let's look at some data.    (I recommend a nice brochure with some basics.)   Since the site to which I refer you is so good I will just highlight a few items.     First soy as it was and is traditionally consumed in Asia is FERMENTED soy.    The process of fermentation actually reduces some of the toxic substances found in the processed bean paste.    This renders the product much safer for human consumption.    Second traditional used of fermented soy was as a condiment not a main course.  his means much less soy is consumed in a traditional Asian diet than in a modern Vegan diet.    Third, the osteoporotic benefits of soy are overblown.    Look at some of the items in the link and see how bone formation may actually be harmed by soy intake.    Finally formula....my big worry.      By 1998 almost 25 % of US babies were using soy formula.    That number has now grown.    With the advent  of "reflux" as a fad diagnosis in infants these days misguided WIC and other nutrition advocates for children have pushed soy formula as an alternative.     AT THE SAME TIME we are promoting phytoestrogens (like those found in soy)  as a way to relieve some of the effects of menopause in older women.    We cannot have it both ways.    SOme countries in the European Union agree and have now issued warnings against  the widespread use of soy IN MALE INFANTS.     It seems logical that the estrogen effect of these product on male infants can have widespread and long term effects on males.     MOM READ FIRST before you given your child, especially your male child, a daily continues phytoestrogen dose.]]></content:encoded></item><item><title>Prozac and Pregnancy</title><dc:creator>doc@askdrjim.com</dc:creator><category>Comments on Medical Research</category><dc:date>2007-06-25T21:35:29-04:00</dc:date><link>http://www.askdrjim.com/foler/page3/files/jun-2007#unique-entry-id-8</link><guid isPermaLink="true">http://www.askdrjim.com/foler/page3/files/jun-2007#unique-entry-id-8</guid><content:encoded><![CDATA[This week's issue of the New England Journal of Medicine has 2 articles on the risks of birth defects in children born to women who take "Seletive Serotonin-Reuptake Inhibitors" (SSRI's).    Since depression is common among women of childbearing years and may affect up to 10% of women who are pregnant, the issue of what constitutes safe treatment for mother and developing child is an important topic.    SSRI's became available in the late 1980's and became the dominant medical intervention for depression by the 1990's.    They promised less potential side effects, a possible faster onset of effective action and less potential for death by overdose.     It became logical that women taking SSRI's might become pregnant and early studies suggested that SSRI's could produce omphalocele, craniosynostosis and heart defects.     Obviously no one wants to keep a women on such a teratogen and drug companies want to play down effects that cannot be clearly linked to their products. 


The first study  by Louik et al has been ongoing since 1976.    Five study centers (Boston, Philadelphia, Toronto, San Diego and portion of New York State are involved.    Cases of birth defects are identified and then exposure is assessed using an interview within 6 months of delivery that questions mothers about demographics, reproductive and medical factors, cigarette smoking and the consumption of alcohol and caffeine.    Medication (both prescription and over the counter), vitamin, mineral and herbal intake are also reviewed.    Pregnancy history including questions about specific conditions occurring in pregnancy and the medications used for those conditions is reviewed.  

...The current paper from this study looked at women whose last menstruation was between 1/1/93 and 12/31/04.    Cases of defects excluded those who had know inherited disorders, syndromes, defects with known causes and metabolic disorders (like PKU).    About 23% of the case mothers did not participate as did about 25% of the control mothers.   An additional 15% of case mothers and controls did not respond or were unavailable to interview. 


The researches looked specifically at exposure in the first trimester which they defined as use of any SSRI from 28 days before the last menstrual period through the fourth lunar month (112 days after the last menstrual period.)    Of note the researchers excluded 79 women who took MORE THAN ONE SSRI during this period.     A total of 9849 infants with malformations and 5860 control infants were included in their statistical analysis.  


Although overall use of SSRI's by their analysis was not shown to increase the overall risk of the birth defects described above, the authors do point to an associated risk of the use of sertraline and omphalocele and septal defects as well as an increased association between paroxetine and right ventricular outflow tract obstruction.     Of note was the fact that overall risk of defects was quite small.   


The second study by Alwan et al used a more exhaustive list of defects and data.    They also found little association with the defects mentioned in the first study but noted a potential association between SSRI use and the occurrence of anencephaly , crainiosynostosis and omphalocele.   This study outlines some of the theories as to why an association with these conditions may exist.


...As with most conditions during pregnancy you must carefully weigh the risks of treatment vs non-treatment.     Depression with potential for suicide, poor nutrition, abuse by spouse and other likely unknown effects on the mother and fetus must be weighed against the drug risks.     In this case we know the risk, as it appears to exist, is relatively small.    Careful use of medications and use of those least linked to these defects is the most prudent course of action. 
]]></content:encoded></item><item><title>Here Comes the Sun</title><dc:creator>doc@askdrjim.com</dc:creator><category>Nutrition Comments</category><dc:date>2007-06-24T09:30:58-04:00</dc:date><link>http://www.askdrjim.com/foler/page3/files/jun-2007#unique-entry-id-7</link><guid isPermaLink="true">http://www.askdrjim.com/foler/page3/files/jun-2007#unique-entry-id-7</guid><content:encoded><![CDATA[Check out our featured web site this week.    The site is the Vitamin D Council.    At their site they nicely summarize many of the scientific studies that  have been in the news recently.    Vitamin D deficiency that causes rickets is well know but unusual in this day and age.     Vitamin D deficiency causing other previously unrecognized illness has not been so widely known.     Recent credible research now links low vitamin D levels with increased risk of cancer and a myriad of mental health/neurolocial conditions including ADHD, Depression and Alzheimer's disease.   Check out the site and read about the research.


One very interesting fact is that humans can make vitamin D with the help of the sun on their skin.    Covering up and coating ourselves with sunscreen, however block our body's natural ability to create vitamin D.    Our paranoia about skin cancer has caused large numbers of us to be depleted in this important vitamin.    As little as 15 minutes of full midday summer sun on the torso can give you the vitamin D you need.    Of particular interest is the cancer link.    In a future blog I will talk about melanoma and the potential link of getting TOO LITTLE SUN as a potential cofactor in its development.    For today just sit back and get your 15 minutes....it IS good for you.    If you feel you cannot get in the sun supplements are available but must be absorbed through the gut.    I recommend at least 1200IU of vitamin D per day although mega-doses weekly are also used.    Good quality cold processed cod liver oil is an excellent source of vitamin D. ]]></content:encoded></item><item><title>B12 Fact or Fiction?</title><dc:creator>doc@askdrjim.com</dc:creator><category>Nutrition Comments</category><dc:date>2007-06-22T22:27:06-04:00</dc:date><link>http://www.askdrjim.com/foler/page3/files/jun-2007#unique-entry-id-6</link><guid isPermaLink="true">http://www.askdrjim.com/foler/page3/files/jun-2007#unique-entry-id-6</guid><content:encoded><![CDATA[Vitamin B12 is a unique molecule as it contains a carbon bonded to a metal, cobalt which gives it its red color. .    It is the largest known biomolecule.     Vitamin B12 is involved in many of our body functions (often in conjunction with folic acid) like development of red blood cells, insulation of nerve cells, and nerve conduction.     When depleted anemia (known as pernicious anemia) and neurological complaints like numbness, burning, muscle fatigue, irritability and memory loss may occur.    Absorption of B12 is quite complex and involves pepsin, hydrochloric acid, intrinsic factor and a protein known as R-protein.    Deficiency of any of these substances can result in suboptimal absorption and deficiency.     Recent studies in England have shown larger than expected numbers of elderly women lacking substances that aid in B12 absorption.    Chronic use of antacids or other mediations used for gastric reflux may also contribute to lower than needed absorption. 


Since B12 is mostly found in animal tissues.    Foods especially dense in B12 include bivalves (clams, muscles and oysters),liver, kidney, eggs and milk products.    Unfortunately pasteurized milk while containing B12 has much less and has fewer intact proteins to aid in its absorption).    Because of these facts, vegetarians must be extra careful to get adequate B12 from their diet by using eggs and milk products.    Children are especially at risk when on diets low in B12 so parents encouraging children to vegan or vegetarian diets must be careful to supplement B12.


B12 can be measured in the blood but most laboratory assays have wide ranges of normal.    Deficiency generally is said to occur with blood levels lover than 200 pg/mL but most experts would encourage keeping a blood level higher than 500 pg/mL.     Although traditionally supplemented with injections for pernicious anemia, there is a solid body of literature that supports the use of oral supplementation for people at risk of deficiency.     Doses ranging from 100 mcg per day or higher have been touted.    Levels can be checked to assess efficacy. 


Since B12 deficiency due to poor diet, medications and aging is more common that previously appreciated, you should ask you doctor to assay your level and, if appropriate supplement.    You can avoid B12 deficiency by eating more liver, shellfish (one serving per week), avoiding over intake of spirulina and soy, antacids or acid blocking medications.     Medications like metformin may interfere with absorption.     Remember that excessive folic acid intake may block B12 absorption as can artificial Vitamin C products.    Smoking will deplete B12 as can oral contraceptives.  


Finally, if you exhibit fatigue, weakness, infertility, tinnitus, numbness/tingling of the hands, anemia, irritability ask your doctor if B12 could be the cause.  ]]></content:encoded></item><item><title>Body&#x2c; Mind AND Soul</title><dc:creator>doc@askdrjim.com</dc:creator><category>Spirituality and life</category><dc:date>2007-06-09T22:38:25-04:00</dc:date><link>http://www.askdrjim.com/foler/page3/files/jun-2007#unique-entry-id-5</link><guid isPermaLink="true">http://www.askdrjim.com/foler/page3/files/jun-2007#unique-entry-id-5</guid><content:encoded><![CDATA[I have been going through a period of spiritual seeking and reawakening.  ...  Americans purchase large amounts of books on the subject, films dealing with spiritual issues have been box office hits and political debates around moral issues continue to get large amounts of press.     My own recent journey was initiated by stresses at work, at home and in the lives of people for whom I care deeply.    During these times of stress we either reach out spiritually and grow or we sit in the dust like Job and question.  ...  I find it easy to tell myself lies and hopeless stories rather than searching for victory in the midst of pain.  


As a physician I too often become numb to the pain and suffering of my patients and those around me.    This develops because caregivers tend to try to shield themselves from pain to avoid the burnout that often comes in our profession.    All my patients will die from the infant that comes in for vaccines to the 98 year old who comes in because her family made her do so.  ...  Many will suffer long and painfully before they leave this earth and others will depart quickly.     When I seen death and disease as the enemy I fail because they are inevitable.


...I can see my life and the lives of my patients as journeys during which lessons are learned and relearned.    The natural cycle of God's creation involves birth, growth, diminution and death followed by renewal and birth again.   ...  I am there to help my patients along their life journey.    Sometimes I help with the selection of a drug or test or consultant that will treat a condition.  ...  I can coach someone trying to change a habit and I can just listen sometimes to the worry of a parent.  


Much of my role is working with physical and mental health issues but as a Christian who is trying to learn and grow, I also must be aware that the spiritual health of my patients (and myself) are crucial to the way their journey progresses.    In my own case my recent spiritual drought caused sleepless night, irritability and emotional upheaval.  ...  They were praying and supporting me even though I was not very lovable.     My partner in the practice, Holly, had just had a spiritual reawakening and her example lifted me up allowing me to get out of the dust.   


Recently, I went home where our farm is experiencing a climatic drought and as I was trying to water our pasture with a hose (doomed to failure) a downpour of rain like we hadn't had in months suddenly appeared dwarfing my attempts to water.     It was as if God, in response to my questions about my spiritual drought had shown me just how much more He was willing to give me if I just was open to His blessing.  

...I hope that in the future I will continue to grow closer to the God who loves me so much He sent His Son to die in my place.    I know the journey will not be smooth.    I also know that the bumpy times can teach more than the smooth times.    I hope that I will be able to show that love to my family, friends and patients.    I know that my spiritual health, just like the spiritual health of my patients is key to living a full and joyful life.     I hope that you will see and feel that love when you enter our practice.   
]]></content:encoded></item><item><title>Why Consuming Health Care Is Bad</title><dc:creator>doc@askdrjim.com</dc:creator><category>Comments on Medical Research</category><dc:date>2007-06-03T19:24:57-04:00</dc:date><link>http://www.askdrjim.com/foler/page3/files/jun-2007#unique-entry-id-4</link><guid isPermaLink="true">http://www.askdrjim.com/foler/page3/files/jun-2007#unique-entry-id-4</guid><content:encoded><![CDATA[If we are number one at anything in the world it is consuming.  ...  We became a healthcare consuming nation with the rise of three things that grew in the 1960's and 1970's namely specialized medical care, technological advancements (including pharmaceuticals) and advertising/marketing.     These advancements were coupled with an aging population and the rise of baby boomers (who in general were the world's most prolific consumers) moved us from a nation who used health care to one that consumed it.    We began to seek out care for issues related to aging or to rectify the effects of poor lifestyle or to delay diseases that the health care industry and Madison Avenue were only too happy to shake in our faces.    Early on many people were still covered by legacy insurance or government programs that shielded them from the actual costs of their consuming.     Most doctors as well were blissfully unaware of costs that their increasingly high tech care were generating.    In fact under older fee-for-service systems physicians and hospitals could be paid based on their charges meaning that if a patient stayed longer in the hospital it generated more income.    In a perverse way then doctors who were substandard and slow in their decision making could actually generate more revenue than doctors who were efficient and effective.   


Naturally the rising costs eventually caused industry and government to slowly respond.     Chrysler said it could not compete with Japan because our health care costs in America were adding too much to the sticker price of their cars.    Managed care (not managed competition like most industry) was born and the impression that prevention and wellness would be the goal rather than "illness care" was promoted.    We had too many consumers, sick aging non-workers and diversity to allow this approach much traction and the industry of health care found the areas of profit and skimmed it until the public made its hatred of managed care and HMO's clear.     All the while we had not addressed the basic issue:  MORE SPENDING ON HEALTH CARE AND MORE CONSUMING OF HEALTH CARE HAS NOT BEEN SHOWN TO PRODUCE GAINS IN POPULATION HEALTH THAT MAKE THE SPENDING WORTHWHILE.


Let's take the drug industry as an example.    We all know people who have been saved or have had their lives prolonged due to an intervention with a drug.    We also know that medical errors (Mainly Drug errors) cost America as many lives as traffic accidents.    We do not make the connection beyond intellectually.    Just go to a local pharmacy or supermarket to see the rows and rows of over the counter drugs that complement the pharmacy that most stores now have.    In the small town of near my home we have (by my count) 5 major pharmacies that are chains or in supermarkets AND we have 5 small private pharmacies.     This roughly a pharmacy for every 800 folks AND THEY ALL ARE BUSY.     Residents take medication....lots of medication and we are not a healthy city by any measure....but we take our drugs.      I frequently see patients who are on 10 or more meds:  for sleep, for restless legs, for impotence, for osteoporosis, for depression, for irritable bowel, for obesity as well as for other diseases.    AND THEY ARE RELUCTANT TO STOP OR CUT BACK BECAUSE THEY HAVE BEEN CONVINCED THAT THEY ARE ILL AND NEED MEDICATION.    Most do not or have not exercised, smoke, eat poor processed and carbohydrate-laden foods and will not change lifestyle as long as they can get their medications.


I want you to think about consuming health care vs living healthy.    Living healthy means drinking clean water, exercising DAILY, eating fresh fruits and vegetables, cutting back on carbohydrates and trans-fats and living in community with meaningful work.     Many of our "illness" would go away and maybe I would be out of a job!  ]]></content:encoded></item><item><title>Teams and what they teach us. </title><dc:creator>doc@askdrjim.com</dc:creator><category>Practice Issues</category><dc:date>2007-05-30T20:46:45-04:00</dc:date><link>http://www.askdrjim.com/foler/page3/files/may-2007#unique-entry-id-3</link><guid isPermaLink="true">http://www.askdrjim.com/foler/page3/files/may-2007#unique-entry-id-3</guid><content:encoded><![CDATA[We've been watching some of the NBA playoffs lately.    This time of year you often find one of two types of teams.   The first I will call the "MJ" team.    These are the ones with a dominant superstar who can do it all and often does in the 4th quarter of games winning or losing placed squarely on his shoulders.    The second is the coach favorite "Team" team.    This is one with good role players who seem able to rise to the occasion as the match ups dictate.     These teams are difficult to defend and are pesky....and oftentimes are the winners.    In healthcare we work as a team.    The physician is a most visible player but is really no more important than all the others on the team.    He or she just has a different skill set but not the only one.    In fact often the physician merely provides the most visible interaction while all the others really create the magic.    Management specialists often point to a movie production as the ultimate in creative teamwork.    Experts and line workers with specific skills are brought together for intense and purpose-driven activities.    Their is a director but the entire production could hinge on a dog trainer or a script writer.    The actors are the most visible but the makeup artist makes them look bad or good as the scene dictates.    After the production is over the entire team disbands and may never come together again in the exact same way again.     I am often amazed at how many folks are involved in my care for one patient for one problem.     From the receptionist to the pharmacist, from the lab phlebotomist to the nurse we all are focused on the problem and its resolution.     The entire team may never work together again on another problem.    What I have learned from this is that RESPECT FOR THE SKILLS AND IMPORTANCE OF ALL TEAM MEMBERS and CLEAR COMMUNICATION are key to a team working well.    It's no good to throw a lob pass if no one is there to dunk it home!


I hope that you will see a team in action when you use our facility.    If you don't please contact us.     Remember YOU are also part of the team as much of medicine depends on people changing lifestyles, working with medications and following up with communication about how a treatment plan is working.     Let's all work together to win when it comes to your health. ]]></content:encoded></item><item><title>Practice&#x2c; Practice&#x2c; Practice</title><dc:creator>doc@askdrjim.com</dc:creator><category>Practice Issues</category><dc:date>2007-05-26T22:22:37-04:00</dc:date><link>http://www.askdrjim.com/foler/page3/files/may-2007#unique-entry-id-2</link><guid isPermaLink="true">http://www.askdrjim.com/foler/page3/files/may-2007#unique-entry-id-2</guid><content:encoded><![CDATA[I just got back from a bluegrass concert.    Living in East TN you need to be at least familiar with this musical style and it is one of my favorites.    Although I play a bit of guitar, banjo, fiddle and mandolin I will never achieve the quality of what I heard tonight.    There has been some research that shows that to be excellent at any skill you need to put in roughly 10.000 hours of practice (unless you have some super gift).    This applies to almost any skill.    In medicine we talk about "practicing" medicine.    There has been research supporting the fact that doctors who frequently do a procedure at hospitals that have high volumes of a procedure tend to do better with less complications and better outcomes.    Other studies support the observation that with experience doctors in fields where "pattern recognition" is important become better.    I recall asking an older colleague to interview a particularly difficult case early in my carrier only to have him as one question and then take me out of the room to tell me the correct diagnosis.    I was astonished and asked how he knew.     "I've seen it before" was the response.    He meant that his pattern recognition of that disease was superior to mine because of his experience.    In primary care practices we have to be cautious about becoming to smug and keeping patients too long before we consult another physician.     The key is knowing when you need that help and understanding it is not a flaw in your skill set.     We hope that when you see us we always refer you in a timely fashion to colleagues with skill sets that will enhance ours and result in better care for you and your family.    ]]></content:encoded></item><item><title>Finally up and running</title><dc:creator>doc@askdrjim.com</dc:creator><category>Practice Issues</category><dc:date>2007-05-23T22:40:58-04:00</dc:date><link>http://www.askdrjim.com/foler/page3/files/may-2007#unique-entry-id-1</link><guid isPermaLink="true">http://www.askdrjim.com/foler/page3/files/may-2007#unique-entry-id-1</guid><content:encoded><![CDATA[It has taken a while but I finally got the hang of how to post information to our site.    I am excited about how this will aid in our practice communicating with our patients.    I have developed an interest in exercise and nutrition and have always been open to complementary medicine approaches.    With the news daily of drugs being recalled due to harmful side effects I can only say that any approach the you have to health that DOESN'T  HURT YOU is certainly no worse than what we often offer with  medications. 


For existing patients you have noticed some new changes around the practice.    Stacy Harbin has been added to help with billing and the phone traffic.    As she gets more familiar with our practice we hope she will prove a useful addition our family.     Holly has been give more management responsibilities and, for those of you who know her, she is up to the task.     She will help us with strategic planning, outreach and education and improving our lab and communication with patients.     VERY SOON NOW we hope to have a "Portal" to our electronic medical record that will be available through a secure internet site.    This will allow patients to log in and make appointments, ask questions, request refills and do other useful things.    We are excited about this and hope it will be up and running by the end of the summer.      Thank you for being a visitor and if you are a patient, thank you for your support. ]]></content:encoded></item><item><title>Welcome to askdrjim.com blog</title><dc:creator>doc@askdrjim.com</dc:creator><category>askdrjim answers</category><dc:date>2007-05-18T23:16:17-04:00</dc:date><link>http://www.askdrjim.com/foler/page3/files/may-2007#unique-entry-id-0</link><guid isPermaLink="true">http://www.askdrjim.com/foler/page3/files/may-2007#unique-entry-id-0</guid><content:encoded><![CDATA[Glad you found this site.    I'm hoping my patients and others interested in health and wellness will use this a source of information, meeting and inspiration.     Working in a solo practice in this day and age is again becoming viable for family physicians.    We can link to our patients in many ways and have the world at our fingertips.    Our team believes that using appropriate technology like integrated electronic medical records, fax servers and wireless communications give us more time to do the "old fashioned" things like talk to our patients!]]></content:encoded></item></channel>
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