In a guest column in the November 5, 2017 edition of the Asheville Citizen Times by Marsha Fretwell, M.D., she has concluded that she might be the last happy doctor.  This is because she had practiced as a geriatrician and thus had only Medicare to interact with as more than 96% of her patients were covered by Medicare. This allowed Dr. Fretwell to spend the 30 minutes per patient that she feels she needs to properly listen to and care for her patients. The predictable [compared to for profit insurance companies?] reimbursements from Medicare allowed her to reduce her staff as they did not need to spend longer periods of time with for profit insurance companies to get reimbursed for her services. 

Dr. Fretwell also indicated that our country's Surgeon General reported that second only to the opioid addiction crisis, physician burnout is the next most critical issue in health care. Even though Family Practice, Psychiatry and Internal Medicine are typically paid 50% of what other medical specialties are paid, the most often cited factor in burnout was not inequality of pay but the paperwork demands of insurers that took them away from direct patient care. The ability to form relationships with their patients was felt to be critical to providing quality health care and critical to the satisfaction of patients and physicians.  

I firmly believe and have seen in my practice how important spending time with my patients is.  That is why I do not accept payment from insurance companies.  I have maintained a minimum of 30 minutes with my patients and will often spend 60 to 75 minutes depending on the needs of each patient.  Without a relationship with my patients it is much harder to help them to recover from their anxiety, depression, flashbacks, difficulty concentrating, etc. and experience an improved quality of life that they desire.

Dr. Fretwell goes on to advocate for universal health care as she notes that since for profit health insurance providers have been on the scene, overall health care has declined in the United States.  Dr. Fretwell believes that universal health care will lead to less expensive care, better outcomes, and happier patients and physicians. 

What do you think?



We own more than 310 million guns [2009 National Institute of Justice report]. This is the most of any nation in the world with India coming in second with an estimated 46 million guns. So, we have more than seven times the number of guns compared to the second place country. We are also the world leader in gun violence. Every day 93 people die from guns in our country and this number includes 7 children and adolescents.  Congress continues to refuse to expand background checks [make it universal] before gun purchases even with evidence that this would save lives.  There are gun suppliers who can review their store cameras and see people who bought a gun and then are in the paper the next day having killed themselves with the gun that was sold to them the day before. Of course, owning guns is dangerous to children and adolescents.  According to the Centers for Disease Control and Prevention [CDC] in 2015, 26,252 of us in our country died from gunshot wounds and this included 2824 children and adolescents who died from unintentional shootings and firearm homicides. So, why won't congress pass legislation mandating background checks [representing a delay before a gun can be purchased] when it is so clear that many of us can not manage owning guns safely and it is estimated that more than 90% of us want universal background checks. Is Congress' reluctance related to the fact that the National Rifle Association [NRA] provided more than $50 million to the campaigns leading up to the election of Donald Trump.  Mr. Trump got more than $30 million for his campaign. 

Do we need to let our congress know that we want them to expand background checks or they will risk not being re-elected?  Do we care enough to speak out? Is it the right thing to do? What do you think? 



I've had several patients tell me that they couldn't forgive people who had abused them but they were no longer troubled by thinking about them. Then a few other patients told me that they were finally able to forgive their abusers and felt more at peace about it now.  So, do we need to forgive those who abuse us to be able to not be troubled by these events anymore?  What is forgiving? Some definitions focus on it being deciding to stop feeling anger towards someone and others mention a willingness to allow room for error or weakness. Others use words like:merciful, lenient, compassionate, magnanimous, humane, softhearted, forebearing, tolerant, indulgent, etc. as ways to decribe someone who is forgiving. Now lenient, softhearted, tolerant and indulgent don't sound so good.  It makes it seem that forgiviing someone is being too kind and is letting them get away with it. What are they or have they gotten away with? They know that they have violated you and you know that you were violated.. They have to live with this and if you forgive them then maybe you won't have to live with it anymore. You will be able to shed the weight of this memory and let go of any lingering feeling of responsibility. 

So, it seems that we forgive to help ourselves be released from the anger and hurt that really is our problem and won't be resolved until we can stop reacting to something that is in the past.



I have recently been thinking about the idea that wisdom is connected to knowing that we don't know anything. I was aware of this idea from reading that after Socrates was called the wisest person in ancient Greece he at first doubted this until he realized that his wisdom was because he knew that he didn't know anything. The socalled Socratic method involves asking quesions and listening to the answers until an understanding happens. The person asking is not reacting to what is being said or correcting, giving advice, but merely asking questions to clarify the responses that are being given. There are no conclusions drawn based on previous experience nor any judgement made about what is being said. So, it is like knowing that you don't know anything as you are listening to learn about someone and refusing to think you know them. Thinking you know them allows you to judge or criticize them. 

So, if you listen to someone without your own reactions, judgments or criticisms, isn't this being empathic? Isn't this like being with someone and sharing their experience without substituting your own experience. Isn't it hard or even impossible to do this and also judge them or compete with them or reject them. So if we all listen to each other without judging or criticizing then we will all feel and be connected to each other and will all get along.

What do you think?



The nocebo effect is the opposite of a placebo effect, so it is a negative response to a sham treatment where the person believes that they are getting the treatment but actually are not. What is amazing is how powerful expectations and outlook are as the placebo response is often close to that for those who actually received the treatment.  This has been true for studies of antidepressants used for depression. This has led some researchers to conclude that the antidepressants are not effective because the placebo response is so strong. What seems to be not understood is that for a placebo response to occur people have to believe they are getting the treatment. So, you can only have a placebo or a nocebo response if there is also treatment occuring.  

What is critical is to understand what happens in our brains when we have either a placebo or a nocebo response.  Nocebo responses are especially concerning. To understand these reponses researchers have looked at expectations and beliefs and their impact on treatment responses and overall health. Years ago a large study by the National Heart Association was conducted in Framingham, Massachusetts on 5290 men and women ages 30-62. They found that women who thought that they were "prone" to heart disease were four times more likely to die from heart disease than those women who did not feel that they were at risk for heart disease. So, is it possible that feeling prone to heart disease can kill you? It seems like it. It is as if we can create our own reality regarding our health in amazing and potentially frightening ways.

There is plenty of evidence from research that chronic stress increases negative outcomes for illnesses that we might have. Stress does not create illnesses such as heart disease or cancer but will make them worse and make for a worse prognosis. This reflects increased negative health outcomes related to the impact of chronic stress as this stress contributed to both a negative outlook and a feeling of hopelessness. This makes it similar to a nocebo effect. Turning to a positive outcome, a study by Crestwell in 2007 showed that breast cancer survivors who wrote affirming statements about their life had fewer side-effects and better overall outcomes compared to those who wrote negative statements. So, a more positive outlook as demonstrated by more positive statements without any prompts, leads to better outcomes. 

Since what we believe and expect can have significant impact on our lives why not be positive and hopeful?