Absolute coronary heart disease incidence is projected to increase by 26%, prevalence by 47%, mortality by 56%, and costs by 41%, due to the aging of the U.S. population from 2010-2040. Focusing on Health People 2010/2020 goals for risk factor control could offset some of the projected increase.
Abstract
Background
The demographic shift toward an older population in the United States will result in a higher burden of coronary heart disease, but the increase has not been quantified in detail. We sought to estimate the impact of the aging US population on coronary heart disease.
Methods
We used the Coronary Heart Disease Policy Model, a Markov model of the US population between 35 and 84 years of age, and US Census projections to model the age structure of the population between 2010 and 2040.
Results
Assuming no substantive changes in risks factors or treatments, incident coronary heart disease is projected to increase by approximately 26%, from 981,000 in 2010 to 1,234,000 in 2040, and prevalent coronary heart disease by 47%, from 11.7 million to 17.3 million. Mortality will be affected strongly by the aging population; annual coronary heart disease deaths are projected to increase by 56% over the next 30 years, from 392,000 to 610,000. Coronary heart disease-related health care costs are projected to rise by 41% from $126.2 billion in 2010 to $177.5 billion in 2040 in the United States. It may be possible to offset the increase in disease burden through achievement of Healthy People 2010/2020 objectives or interventions that substantially reduce obesity, blood pressure, or cholesterol levels in the population.
Conclusions
Without considerable changes in risk factors or treatments, the aging of the US population will result in a sizeable increase in coronary heart disease incidence, prevalence, mortality, and costs. Health care stakeholders need to plan for the future age-related health care demands of coronary heart disease.
To read this article in its entirety, please visit our website.
-- -- Michelle C. Odden, PhD, Pamela G. Coxson, PhD, Andrew Moran, MD, MPH, James M. Lightwood, PhD, Lee Goldman, MD, MPH, Kirsten Bibbins-Domingo, PhD, MD
This article originally appeared in the September 2011 issue of The American Journal of Medicine.
Rabu, 31 Agustus 2011
Selasa, 30 Agustus 2011
Choosing a Physician
How do patients choose a new physician?
From personal referrals to diplomas on the wall to communication styles to what the doctor is wearing-- patients use many types of information to make a decision about a new physician.
A recent article in the LA Times discusses the doctor-shopping process and quoted a 2005 American Journal of Medicine study about physician dress. From the LA Times....
In a 2005 study published in the American Journal of Medicine, 400 men and women were presented with pictures of physicians in four different styles of dress. When asked what style they preferred, 3/4 of the study participants said they preferred their doctors in professional attire, complete with white coat. Less than 5% want to see a physician dressed casually. They also reported that they'd be more likely to share their problems with a doctor who was dressed professionally.
The bottom line: Finding a good doctor is no easy feat. It often requires looking beyond the diplomas to the person who earned them.
To read What to wear today? Effect of doctor’s attire on the trust and confidence of patients by Rehman et al, click here.
Senin, 29 Agustus 2011
The Ten Most Annoying Things That Happen During My Work Day—and Perhaps in Yours as Well
Irritation Number 1: Form letters from insurance companies suggesting alternative medications for me to prescribe for my patients. I cannot imagine that a functionary sitting at a desk in an insurance company office, someone who has had no contact with my patient, could possibly have anything interesting or valuable to say to me concerning the carefully considered therapeutic program that I have ordered for my patients. I have never found even one of these letters useful. They are a waste of paper and postage. And what is more, they never add to a fund of useful knowledge about the product. I am always open to learning more, but these letters fail to accomplish even the most basic rule of communication.
Irritation Number 2: Direct-to-consumer advertisements on television for various drugs that the announcer suggests should be “discussed with your doctor.” These ads are frequently misleading in their implications, and physicians have too little time now to spend with patients. Conversations about drug advertisements on television only shorten the really important time that needs to be spent discussing the patient's clinical condition and therapeutic options. Not once in the many years that these commercial messages have been advertised have I written a prescription as a result of these conversations. Patients are invariably taking similar agents already or the drug is contraindicated.
Irritation Number 3: The need to remember or, at least, maintain a constantly changing list of passwords to gain access to various clinical and nonclinical websites. Our hospital and university are constantly requesting changes in these passwords. Although I understand the need for security, there seems to be very little thought behind how to manage this process so that the busy clinician can get to the most important function they fulfill: taking care of patients. I look forward to the day when retinal or fingerprint scans will become the norm for these security measures.
Irritation Number 4: Requiring multiple signatures on various hospital and practice documents. Many of you must also be asked to sign the many orders, statements, and communications that pass across our desks. I have found that electronic signing takes even longer than doing this activity manually. All we can do, I guess, is to hope that some technical advance will obviate the need to sign my name continuously.
Irritation Number 5: Patients who lie to me. These lies often involve the use of illegal street drugs. Of course, the lie becomes immediately evident when we run urine or blood toxicology screening tests. Perhaps I should tell patients up front that we always discover when such agents have been used, and so the best policy is to be truthful right from the beginning of our interaction. These lies, whether based on drug use or not, often prevent me from giving the best medical care as quickly as possible.
To read this article in its entirety, please visit our website.
-- -- Joseph S. Alpert, MD, editor-in-chief, The American Journal of Medicine
This article originally appeared in the September 2011 issue of The American Journal of Medicine.
Jumat, 26 Agustus 2011
People Were Staring...
A 27-year-old man with a medical history of atopic dermatitis presented with a progressively disseminating non-pruritic rash that had been present for 3 days. The rash had begun on the left cheek and had spread quickly to involve the rest of the face and body. The patient had no other complaints, and the rash was not painful or irritating, but the fact that “people were staring” when he went to the grocery store bothered him so much that he sought medical care at our emergency department.
To read this article in its entirety and learn why people were staring, please visit our website.
-- Maryrose Laguio, MD, Glynis Scott, MD, Mary Gail Mercurio, MD, Peter Mariuz, MD
This article originally appeared in the September 2011 issue of The American Journal of Medicine.
Rabu, 24 Agustus 2011
Black Hairy Tongue: If You're Tongue Looks Like This, Brush It More Often
A 62-year-old man, known for alcohol and tobacco abuse, was diagnosed with laryngeal squamous cell carcinoma in 2008. He underwent curative radiotherapy (70 Gy), delivered to the laryngeal and oropharyngeal area as well as the neck. Follow-up 4 months after this treatment showed recurrence, for which we performed total laryngectomy and bilateral neck dissection.
Eight months after surgery he was doing well and presented no recurrence, but physical examination showed thick black hairy lesions on the back of his tongue (Figure). These lesions had appeared and quickly evolved 4 weeks before the consultation, with no associated symptoms such as pain, dysphagia, or dysgeusia. The patient had not received antibiotics in the last months. Bacterial and fungal cultures of tongue swab were negative. Basic blood tests showed no particularity. Thus, we diagnosed the patient with black hairy tongue.
To read this article in its entirety, please visit our website.
-- Lluís Nisa, MD, Roland Giger, MD
This article originally appeared in the September 2011 issue of The American Journal of Medicine.
Sabtu, 20 Agustus 2011
AJM Editor-in-Chief previews the September issue (video)
What new research will be featured in the September 2011 issue of The American Journal of Medicine? Click on this video update by Editor-in-Chief Joseph S. Alpert, MD, and find out.
Jumat, 19 Agustus 2011
Elsevier Health Careers: A Comprehensive Collection of Resources
Elsevier Health Careers has the biggest collection of healthcare and medical jobs listings from all around the world. Search for your next healthcare job by specialty or discover available medical jobs within a geographic region. Also check out the website's free CME and other career advancement resources... here.
Senin, 15 Agustus 2011
Attributable Risk Estimate of Severe Psoriasis on Major Cardiovascular Events
Patients with severe psoriasis have an additional 6.2% absolute risk of major adverse cardiac events compared to the general population. This finding could have important therapeutic implications for cardiovascular risk stratification and prevention in patients with severe psoriasis.
Abstract
Background
Recent studies suggest that psoriasis, particularly if severe, may be a risk factor for major adverse cardiac events, such as myocardial infarction, stroke, and mortality from cardiovascular disease. We compared the risk of major adverse cardiac events between patients with psoriasis and the general population and estimated the attributable risk of severe psoriasis.
Methods
We performed a cohort study in the General Practice Research Database. Severe psoriasis was defined as receiving a psoriasis diagnosis and systemic therapy (N=3603). Up to 4 patients without psoriasis were selected from the same practices and start dates for each patient with psoriasis (N=14,330).
Results
Severe psoriasis was a risk factor for major adverse cardiac events (hazard ratio 1.53; 95% confidence interval, 1.26-1.85) after adjusting for age, gender, diabetes, hypertension, tobacco use, and hyperlipidemia. After fully adjusted analysis, severe psoriasis conferred an additional 6.2% absolute risk of 10-year major adverse cardiac events.
Conclusion
Severe psoriasis confers an additional 6.2% absolute risk of a 10-year rate of major adverse cardiac events compared with the general population. This potentially has important therapeutic implications for cardiovascular risk stratification and prevention in patients with severe psoriasis. Future prospective studies are needed to validate these findings.
To read this article in its entirety, please visit our website.
-- Nehal N. Mehta, MD, MSCE, FAHA, YiDing Yu, BA, Rebecca Pinnelas, BS, Parasuram Krishnamoorthy, MD, Daniel B. Shin, BA, Andrea B. Troxel, ScD, Joel M. Gelfand, MD, MSCE
This article originally appeared in the August 2011 issue of The American Journal of Medicine.
Abstract
Background
Recent studies suggest that psoriasis, particularly if severe, may be a risk factor for major adverse cardiac events, such as myocardial infarction, stroke, and mortality from cardiovascular disease. We compared the risk of major adverse cardiac events between patients with psoriasis and the general population and estimated the attributable risk of severe psoriasis.
Methods
We performed a cohort study in the General Practice Research Database. Severe psoriasis was defined as receiving a psoriasis diagnosis and systemic therapy (N=3603). Up to 4 patients without psoriasis were selected from the same practices and start dates for each patient with psoriasis (N=14,330).
Results
Severe psoriasis was a risk factor for major adverse cardiac events (hazard ratio 1.53; 95% confidence interval, 1.26-1.85) after adjusting for age, gender, diabetes, hypertension, tobacco use, and hyperlipidemia. After fully adjusted analysis, severe psoriasis conferred an additional 6.2% absolute risk of 10-year major adverse cardiac events.
Conclusion
Severe psoriasis confers an additional 6.2% absolute risk of a 10-year rate of major adverse cardiac events compared with the general population. This potentially has important therapeutic implications for cardiovascular risk stratification and prevention in patients with severe psoriasis. Future prospective studies are needed to validate these findings.
To read this article in its entirety, please visit our website.
-- Nehal N. Mehta, MD, MSCE, FAHA, YiDing Yu, BA, Rebecca Pinnelas, BS, Parasuram Krishnamoorthy, MD, Daniel B. Shin, BA, Andrea B. Troxel, ScD, Joel M. Gelfand, MD, MSCE
This article originally appeared in the August 2011 issue of The American Journal of Medicine.
Sabtu, 13 Agustus 2011
The Church: Organism or Organization?
Part One: A series on the church
What does the Word of God teach regarding the church in its form, function and expression? Anyone who ponders this issue begins at the point of asking the question from one, if not all three of these areas. This question surfaced many years ago in my life because of the struggles I was having in applying Biblical rational to a career in full time ministry.
Coming from the perspective as a professional pastor I had to wonder why church leadership was so difficult to implement and maintain. Ministry was rewarding at times yet filled with many complications that had no biblical explanation or justification. One day those irreconcilable differences piled so high I decided to start from scratch and revisit the meaning of the church. The physical church, of which I was a part and the professional job I sought so diligently to acquire, wasn't representing what I would see from New Covenant thought and early church activity. I continued to wrestle through this period of confusion, having the Lord point out many areas within the church that had become important frameworks for business maneuvering, yet made no sense biblically. So I set out to find answers to my questions.
To begin answering these questions I looked around at what the church had become in the 21st Century and contrasted it with the days of the Apostles and their first Century writings. The dissimilarities were obviously shocking. I noted how our contemporary church had incorporated a business style or institutional structure within its daily existence. Amazingly this strategy has permeated the church in almost every area of form, function and expression. Today's "ministry box" is well defined and almost unquestionably accepted as a legitimate role model. As I spoke to others about my doubts and discoveries, I found the majority of people uninterested in the topic of "Do we need another Reformation?" To have someone question the current model and suggest we might be out of step biblically was usually looked upon with suspicion. My prayer for those who read this article is to eliminate cultural suspicion and rediscover the core values and simple patterns of ministry that made the early church a life changing force twenty-one centuries ago. My hope is that you are enlightened from scripture and not from years of unsupportable Christian tradition.
Is The Church an Organism or an Organization?
One day I had a break-through in trying to understand the nature of the church by asking myself this fundamental question, "Is the church an organism or is it an organization?" If you answered "organism," your home-study doctrinal certificate is ready to be mailed out. We hear it regularly taught that it is indeed an "organism," but which is it really today, an organism or an organization? Truthfully, I believe God designed it to be an organism, but man in his limited wisdom redesigned God's original intent and converted it into an organization. I had to be honest with myself and admit I had been part of the problem. Not knowing it, my years in professional ministry were spent giving lip service to the expression "organism," but living out my Christian life in the "organization." Every question and every problem I was having with the church found its way back to the fact that I was trying to benefit from the best of both worlds. Like most, I had fallen into the trap of thinking "organized religion" was a good thing.
Oddly, many of us have the assumption that organized religion is a positive addition to society. The word "religion," as defined in Webster's Dictionary, means "that which binds." If it consistently binds people together and compliments people's beliefs we deem it as a positive quality. But, let me ask you this question. What if it doesn't bind people together, but separates people into their protected religious worlds? If so, is "organized religion" a good thing then? Perhaps a better interpretation for "that which binds" would be "that which binds people up." Like a lawn mower bound-up and stalled from trying to cut tall grass, organized religion serves to restrict people into religious sub cultures, defending religious laws and mandates while trying to protect religious organizations. If one willingly enters the "binding category" you are gladly received as an accepted member. But what if others look upon all of this as foolishness, because the end result produces a collective of "bound-up" and stall-out assemblies of world religions and fractured denominational Christian groups? Is organized religion then perceived as a meaningful addition to society? I would answer "no" to that question since the "big picture" belief of Jesus' mission was to eliminate organized religion by taking on the most bound-up and rule based religion of the day, the Jewish faith. No world religion could hold a candle to the legalism and religious expectations Judaism offered. Is it any wonder the Jewish religious leaders regularly confronted Jesus on the reasons for "why" or "when" He healed, taught or served others? Every time He was directed by the Father to do something supernatural it resulted in a direct violation of religious law or tradition.
In addition, have you ever thought about and concluded that Christianity is the only faith birthed on the planet with no sacred rules and traditions, no sacred individuals and no sacred spaces besides God Himself? Given this premise, Christianity isn't a religion or a system but is the only offer to mankind to form a simple and personal relationship with God through Christ free from the interference of "organized religion" and powered by an inward Life-the law of the spirit of life in Christ Jesus.This intentional vision by God, designed within the framework of the New Covenant, came about so that homes, courtyards, market places, privately owned public buildings, schools and roadsides would become fluid meeting places for an organic movement that would surpass the influence of the Roman Empire and sweep around the world. So how does God implement His plan?
You Are the Church
The term (ekklesia-translated church in English) was never applied to a building or hand-built temple, but instead it was an expressive title given by the grace of God to describe His holy people. Take note on how Paul drives this point home to the Corinthian church as they were struggling to realize God's new plans. For we are God's fellow workers, you are God's field, God's building (1 Corinthians 3:9). There are three points he is making that he hopes they will understand. If you are of the institutional mindset then you are probably thinking of three points that would be opposites of Paul's. Your thoughts might fall along these lines; the first is hire staff, the second is purchase property, and the third would be to construct a building.
Take careful observation of how God's plans differed under the New Covenant. The first point is that there is no staff. Paul and everyone else were fellow workers. They were all spiritually and equally employed in God's kingdom with gifts, talents and time. The second point is that no one needed to go out with a realtor to purchase land. He makes it clear that they were now the field. Every world religion sought property to own, but the early church was going to stand out from the rest as ambassadors of a heavenly kingdom. And the third point is that they were to resist the temptation of hiring an architect and raising money for the purpose of constructing a building. God's ideas for the church were much simpler-they, as believers, were the building! In just a few more sentences Paul finishes his radical presentation by saying, "do you not know that you are the temple of God, and that the Spirit of God dwells within you?" (1 Cor 3:16) Surprisingly Paul's question, "do you not know?" applied to me! For years I did not know. When God revealed these concepts to my mind and heart they shattered the roadblock that hindered me from understanding the true nature of the church. In simple to understand terms, every believer in Christ became the church!
I believe a key reason the church is less effective today than in those early years is that we have taken a very important spiritual identity, "the church"and for the most part, misnamed it and misrepresented it as a building with nicely designed church signs facing the street. Place a cross near the top of the building and you have a legitimate church structure. To reassure this Old Covenant concept we hear people everyday calling the building "the house of God, the Lord's place, or the sanctuary," Given this, we now have created the artificial need for everyone to incessantly, "get to church." Unlike Jewish believers, the first and second century converts never asked the question "Where do you go to church?" That would have been a ridiculous question in those days. They were aware of the fact that you couldn't attempt to go to a place when you were that place (the church).
In today's culture, Christian reaction to the knowledge that we are the church is not necessarily liberating and life changing information. Most believers have the impression and the experience of being the church only when they are in a marked church building and actively participating in an officially prescribed church service. Upon departing that experience, most disconnect themselves from their true "identity in Christ" as people who are the church and they slide comfortably into more understandable roles as husband or wives, fathers or mothers, employers or employees and relatives and friends. "Worldly boxes" for daily living become just as rotational as "spiritual boxes" for supernatural living. So a cultural tradition has come about where we believe we are only the church when we are in a "big box" called the church building. Since we are in the mega church era, the bigger the box the more successful that church looks to the rest of the world.
I would like to illustrate my observations about this cultural tradition because it is now the norm rather than the exception. Imagine if the only time men and women understood or experienced their respective genders was when they visited buildings designated as "Men's or Women's Restrooms." What if Christian leaders misinformed the populace for centuries with the message that men or women, which ever the case, would only have the capacity to think, act and enjoy their masculinity or femininity after they entered and stayed for a time in the "Men's/Women's Restroom"? How much productive time, living as men and women apart from the "Restroom Facility," would be lost due to a false expectation and tragic misconception of reality? Can we conclude this misunderstanding is clearly the case today as most live out their Christian lives? The majority of believers perceive of themselves as the church when they are trained to visit a building marked "The Church." How much valuable time and quality of spiritual life is lost with that misplaced identity? Thus, many don't authentically experience who they are on a continual basis so they remain ignorant or sheltered from the "abundant life" offered to those who know who they are in Christ as the church. Is it any wonder why frustrated pastors are passionately preaching week-after-week for their congregants to get off the sidelines as spectators and participate on the field. Either knowingly or unknowingly, professional ministers have created and defined the spectator sidelines with refreshments and comfortable benches where everyone can sit and watch power point presentations about what they could do for the Lord if they were only given the opportunity to get onto the field. If people were set free to be themselves in Christ as the church, the organized religious sidelines and power point presentations would be over and a thing of the past. There would be many unemployed professionals set free from the bondage of organized religion to be blown about by the Spirit of God to new and more purposeful endeavors.
Organized religion has always tried to justify and legitimize their belief systems with buildings. The early church lived around the religions of their day with buildings containing committed followers. With that awareness, they understood that God had decided to do something incredibly creative by discarding the template of buildings as temples and churches. His alternative plan came about by miraculously creating within each believer the knowledge and the ability to stand on their own or corporately, as "temples of God." Jesus, the High Priest, placed His Spirit into believers twenty-four hours a day, performing His worship service within their hearts and minds. What did this do for them?
For one thing, this gave the church the needed mobility and flexibility to go anywhere and minister. Have you ever wondered how the words spoken by Jesus to Nicodemus would apply to the church? Let me remind you of part of that conversation so that you will see how it fits into this discussion. "The wind blows where it wishes and you hear the sound of it, but do not know where it comes from and where it is going: so is everyone who is born of the Spirit." (John 3:8). Can you see what you have been created to do? God's people were literally designed to be blown through neighborhoods and around the world by the Holy Spirit like leaves being scattered about by the wind. They were not meant to be confined and tied down to a business model for the purpose of producing spiritual results. Instead, supernatural productivity would be the result of spiritual transformation with radically different ways of existing in the kingdom building process.
Living in Christ with a Divine Nature
Since the church is spiritual, it was designed to be organic in form, function and expression. We are told in I Corinthians 12 that God made this possible by including every believer into a supernatural body that is identified as Christ's (I Corinthians 12:27). To make that work effectively He gave us new natures by being born again, "...putting on a new self, which in the likeness of God has been created in righteousness and holiness of the truth." (Ephesians 4:24). Peter says that as a result of this we are now partakers of the divine nature free to function in the world with His spiritual DNA. How is this manifested and employed?
When operating in the nature of God's DNA, as did the early church, we see a freedom to function and display signs of spiritual life. For example, an organic church model is free from ritual, hierarchical leadership and a group dependent upon one key leader or professional staff with a building to maintain. It generates relationships of brotherly love and a commitment to one another. Those gathered together are inquisitive seekers asking questions and forming biblically based ideas that apply to individual and corporate living. It fosters mutual appreciation of each other's contributions in an open participatory body. It believes Godly living is dependent upon Christ's life living in and through each believer and not upon a set of moral or ethical codes or principles or rules. One will see men and women who have discovered their spiritual makeup is understood through their identity in Christ. Lastly, Biblical teaching communicates that Christians are now under the New Covenant which revoked the Old Covenant and made it obsolete.
Any form of institutional worship, service or practice can not be recognized as spiritually innate and genetically driven by God. What is seen as traditionally religious must be ignored and set aside in order to hear the word of God and trust the Holy Spirit to freely manifest Christ in our life. Religion should never be an allowable substitute for the freedom we can experience in Christ. This was why the Apostle Paul cautioned fellow believers with the following words to the Galatians. "It was for freedom that Christ set us free; therefore keep standing firm and do not be subject again to a yoke of slavery." (Galatians 5:1). In this setting the yoke of slavery was Jewish legalism that distracted people from their freedom to live in the life of Christ and trust Him fully for godly living. Organized religion has an abundant supply of what looks good on the surface, enticing men and women into traditional, religious Christian lifestyles instead of an authentic life in Christ. Adopting such practices will always suffocate God's expressive DNA within a person by building a trust and dependence upon man instead of God. What can we anticipate when believers gather together freely with Christ as the source of our life as the cornerstone for our uncontained living?
Gathering Together Organically
When believers "go to church" within an institutional setting are they benefitting spiritually? Are they being built up and edified as God would desire? Is there a biblical basis for what takes place so that the experience is authentic and fruitful? These are tough questions to ask any person who is attached to the organizational model, but they must be asked if one views scriptural principles as fundamental for gathering together. Where do we start if we are open to discovering answers to these questions? Let's look at the early church model and see how close we are in following their lead.
As I stated before, the early church had an organic element to it. The gathering times were fluid as it allowed and benefitted from the expected and unexpected contributions of its participants. Jesus Christ was the focus of the meeting, as He is the Head of the Church (Ephesians 5:23). There was an expectation and a trust that He would lead during those times of assembly. He would be the "senior pastor" organizing the fellowship and all aspects of worship, which involves all facets of our life.
Along with this, He has placed each of us as members of His body to function just as He has desired (1 Corinthians 12:18). There was a belief that as God brought people into His body of believers each would have a valuable role to play within the assembly. Therefore, organic church life trusted the Holy Spirit to provide the freedom to express what the Lord had taught each member through the week. Paul's words describe the organic church movement when he says, "What is the outcome then, brethren? When you assemble, each one has a psalm, has a teaching, has a revelation, has as a tongue, has an interpretation. Let all things be done for edification." (1 Cor 4:26). What stands out as God's blueprint for collective worship?
First of all, if you have roots in the organized church movement then you are going to have problems trying to apply these instructions. Paul directs the church assembly to include each one who attends as a participant rather than as an observer. Everyone was a leader by the very nature of the priesthood of the believer. There were no divisions within the group in terms of clergy/laity or professional and non professional status. For example, God's voice would not be restricted to a "worship minister" with a background choir in colorful robes and a one man bible message delivered by a "senior pastor" week after week.
The second point, if we are to apply these words then we must believe each member has learned something very important about God and the Christian life through the week. Given this, it may mean Jesus Christ might lead that person to contribute what he has learned for the benefit of all. I think we can also assume God has built within each person the desire and need to participate in a meaningful way. Within our spiritual DNA, as born again believers, we are wired for spiritual participation and a passion to build each other up. When not given this opportunity, we are left unfulfilled during the gathering times and the assembly is worst off because of it. What can we anticipate with each member being a participant?
I believe the creative and edifying energy of God's plans for worship surpasses anything humanly structured because of its potentially rich content. The meetings might have familiar songs or new ones freshly written and taught for all to learn and sing. Visual artwork, poems and drama can also be the expressive elements in worship. Teaching, planned and unplanned (i.e. topical or expository), along with testimonies and prophetic insights (casting light upon truth and life), will be additional witnesses to the Gospel. Anything glorifying Christ is to be anticipated through the prayers, the lyrics, the teachings and the participation of those attentive to the Lord's voice. And let me add, this comes about when young and old are blended together to share in each other's unique gifts and contributions to the church body. Young and old need each other to grow in the Lord.
In contrast, the institutional church will seldom allow and present this type of freedom and liberty for those attending. The risks for a professionally led church, designed to run on a business model are too great if operated organically. The following are some of these risks and probable reasons for keeping tight control over what occurs during primary gathering times. Perhaps some of these observations and experiences have been yours as well.
• When there are many contributors to edify the body of Christ a very healthy spiritual atmosphere can be developed. Thus, when gifted leaders surface and mature, paid staff can be threatened by job insecurity due to the lack of being the primary visionaries for the church.
• A meeting designed and orchestrated by God can be unique and unwieldy. For example, the amount of time when people gather together may be longer than conventional church settings might allow. In addition, one never knows what to expect from those attending a fellowship which is Christ driven instead of staff driven.
• Those in attendance actively participate instead of being compliant bench-warmers waiting to be spoon-fed or entertained. Each weekly meeting is different because of the variety of those attending and contributing.
• No one can be manipulated into joining ministries that directly support the vision of a structured church environment. Out-of-the-box ministries are started and sustained amongst those who are led and indwelt by Jesus to meet the needs of those in their communities and the world.
• Financial support will be by faith (believing God sustains His work and supports His workers) instead of by sight (line item budget supported by an Old Covenant tithing system).
• When a person views the church as an organism, those attending are not members who are comfortable with attendance roles and numbers being sent to church offices and denominational headquarters for methods of evaluating a spiritually active community. Growing in the grace of God and trusting Him for all things spiritual are the practical expressions of church life. People are free to come and go as Christ leads. There is nothing employed as a way to control commitment or size within a group.
• In contrast to the organically driven church, professional pastors are faced with the daily pressure to keep what has been built sustained and to grow the base spiritually and numerically. Every paid staff person knows these two stated goals are what guarantee and safeguard their jobs. Therefore, in an institutionally driven church any number of problems can occur. Workaholic schedules, competitive atmospheres, strained relationships due to unrealistic expectations and excessive worry are just a few downsides that immediately come to mind. If the church chooses to run as an institution then the world's standards for success will also produce problems associated with career accomplishment.
• Every institutionally minded purpose, goal and structure is at risk when an individual or a group of people decides to live their lives based on an organic church model. What has been achieved organizationally may not fit or work within an organic model. When making the shift to the organic model one must always be mindful that a foundation laid by man will usually be unharmonious with plans set by Jesus Christ. (I Cor 3:12).
The organizational church methods have had centuries to develop and regretfully most Christians do not believe or realize there is another way. There are many who proclaim the organic model will never work in today's culture. My response is twofold. First, why go to the trouble of teaching anything in the Bible if human nature and its needs have changed from that of the first century? And secondly, if we believe our culture will not accept and flourish with an organic model, then what can we say about the success terrorist groups are having by using it? Everyone in the news media acknowledges the organic nature of terrorism and the inability to define, locate and extinguish it. Amazingly Satan saw the success of the early church and decided to use the technique for his own destructive purposes. He possibly had the following thought centuries ago. "If the church is not going to use it, then I will."
My hope is for biblical discovery that takes the church into a modern day, second Reformation. Clearly, the first one started with high expectations but never completed the job. If given the opportunity by God, we shall all have the revelation to see ourselves as God views us. We are the church, designed to live freely in His spiritual DNA and given the tremendous ability to minister organically in an organizational world culture. My prayer is that it will happen in my lifetime and yours as God calls out more believers from organized religion into organic church.
What does the Word of God teach regarding the church in its form, function and expression? Anyone who ponders this issue begins at the point of asking the question from one, if not all three of these areas. This question surfaced many years ago in my life because of the struggles I was having in applying Biblical rational to a career in full time ministry.
Coming from the perspective as a professional pastor I had to wonder why church leadership was so difficult to implement and maintain. Ministry was rewarding at times yet filled with many complications that had no biblical explanation or justification. One day those irreconcilable differences piled so high I decided to start from scratch and revisit the meaning of the church. The physical church, of which I was a part and the professional job I sought so diligently to acquire, wasn't representing what I would see from New Covenant thought and early church activity. I continued to wrestle through this period of confusion, having the Lord point out many areas within the church that had become important frameworks for business maneuvering, yet made no sense biblically. So I set out to find answers to my questions.
To begin answering these questions I looked around at what the church had become in the 21st Century and contrasted it with the days of the Apostles and their first Century writings. The dissimilarities were obviously shocking. I noted how our contemporary church had incorporated a business style or institutional structure within its daily existence. Amazingly this strategy has permeated the church in almost every area of form, function and expression. Today's "ministry box" is well defined and almost unquestionably accepted as a legitimate role model. As I spoke to others about my doubts and discoveries, I found the majority of people uninterested in the topic of "Do we need another Reformation?" To have someone question the current model and suggest we might be out of step biblically was usually looked upon with suspicion. My prayer for those who read this article is to eliminate cultural suspicion and rediscover the core values and simple patterns of ministry that made the early church a life changing force twenty-one centuries ago. My hope is that you are enlightened from scripture and not from years of unsupportable Christian tradition.
Is The Church an Organism or an Organization?
One day I had a break-through in trying to understand the nature of the church by asking myself this fundamental question, "Is the church an organism or is it an organization?" If you answered "organism," your home-study doctrinal certificate is ready to be mailed out. We hear it regularly taught that it is indeed an "organism," but which is it really today, an organism or an organization? Truthfully, I believe God designed it to be an organism, but man in his limited wisdom redesigned God's original intent and converted it into an organization. I had to be honest with myself and admit I had been part of the problem. Not knowing it, my years in professional ministry were spent giving lip service to the expression "organism," but living out my Christian life in the "organization." Every question and every problem I was having with the church found its way back to the fact that I was trying to benefit from the best of both worlds. Like most, I had fallen into the trap of thinking "organized religion" was a good thing.
Oddly, many of us have the assumption that organized religion is a positive addition to society. The word "religion," as defined in Webster's Dictionary, means "that which binds." If it consistently binds people together and compliments people's beliefs we deem it as a positive quality. But, let me ask you this question. What if it doesn't bind people together, but separates people into their protected religious worlds? If so, is "organized religion" a good thing then? Perhaps a better interpretation for "that which binds" would be "that which binds people up." Like a lawn mower bound-up and stalled from trying to cut tall grass, organized religion serves to restrict people into religious sub cultures, defending religious laws and mandates while trying to protect religious organizations. If one willingly enters the "binding category" you are gladly received as an accepted member. But what if others look upon all of this as foolishness, because the end result produces a collective of "bound-up" and stall-out assemblies of world religions and fractured denominational Christian groups? Is organized religion then perceived as a meaningful addition to society? I would answer "no" to that question since the "big picture" belief of Jesus' mission was to eliminate organized religion by taking on the most bound-up and rule based religion of the day, the Jewish faith. No world religion could hold a candle to the legalism and religious expectations Judaism offered. Is it any wonder the Jewish religious leaders regularly confronted Jesus on the reasons for "why" or "when" He healed, taught or served others? Every time He was directed by the Father to do something supernatural it resulted in a direct violation of religious law or tradition.
In addition, have you ever thought about and concluded that Christianity is the only faith birthed on the planet with no sacred rules and traditions, no sacred individuals and no sacred spaces besides God Himself? Given this premise, Christianity isn't a religion or a system but is the only offer to mankind to form a simple and personal relationship with God through Christ free from the interference of "organized religion" and powered by an inward Life-the law of the spirit of life in Christ Jesus.This intentional vision by God, designed within the framework of the New Covenant, came about so that homes, courtyards, market places, privately owned public buildings, schools and roadsides would become fluid meeting places for an organic movement that would surpass the influence of the Roman Empire and sweep around the world. So how does God implement His plan?
You Are the Church
The term (ekklesia-translated church in English) was never applied to a building or hand-built temple, but instead it was an expressive title given by the grace of God to describe His holy people. Take note on how Paul drives this point home to the Corinthian church as they were struggling to realize God's new plans. For we are God's fellow workers, you are God's field, God's building (1 Corinthians 3:9). There are three points he is making that he hopes they will understand. If you are of the institutional mindset then you are probably thinking of three points that would be opposites of Paul's. Your thoughts might fall along these lines; the first is hire staff, the second is purchase property, and the third would be to construct a building.
Take careful observation of how God's plans differed under the New Covenant. The first point is that there is no staff. Paul and everyone else were fellow workers. They were all spiritually and equally employed in God's kingdom with gifts, talents and time. The second point is that no one needed to go out with a realtor to purchase land. He makes it clear that they were now the field. Every world religion sought property to own, but the early church was going to stand out from the rest as ambassadors of a heavenly kingdom. And the third point is that they were to resist the temptation of hiring an architect and raising money for the purpose of constructing a building. God's ideas for the church were much simpler-they, as believers, were the building! In just a few more sentences Paul finishes his radical presentation by saying, "do you not know that you are the temple of God, and that the Spirit of God dwells within you?" (1 Cor 3:16) Surprisingly Paul's question, "do you not know?" applied to me! For years I did not know. When God revealed these concepts to my mind and heart they shattered the roadblock that hindered me from understanding the true nature of the church. In simple to understand terms, every believer in Christ became the church!
I believe a key reason the church is less effective today than in those early years is that we have taken a very important spiritual identity, "the church"and for the most part, misnamed it and misrepresented it as a building with nicely designed church signs facing the street. Place a cross near the top of the building and you have a legitimate church structure. To reassure this Old Covenant concept we hear people everyday calling the building "the house of God, the Lord's place, or the sanctuary," Given this, we now have created the artificial need for everyone to incessantly, "get to church." Unlike Jewish believers, the first and second century converts never asked the question "Where do you go to church?" That would have been a ridiculous question in those days. They were aware of the fact that you couldn't attempt to go to a place when you were that place (the church).
In today's culture, Christian reaction to the knowledge that we are the church is not necessarily liberating and life changing information. Most believers have the impression and the experience of being the church only when they are in a marked church building and actively participating in an officially prescribed church service. Upon departing that experience, most disconnect themselves from their true "identity in Christ" as people who are the church and they slide comfortably into more understandable roles as husband or wives, fathers or mothers, employers or employees and relatives and friends. "Worldly boxes" for daily living become just as rotational as "spiritual boxes" for supernatural living. So a cultural tradition has come about where we believe we are only the church when we are in a "big box" called the church building. Since we are in the mega church era, the bigger the box the more successful that church looks to the rest of the world.
I would like to illustrate my observations about this cultural tradition because it is now the norm rather than the exception. Imagine if the only time men and women understood or experienced their respective genders was when they visited buildings designated as "Men's or Women's Restrooms." What if Christian leaders misinformed the populace for centuries with the message that men or women, which ever the case, would only have the capacity to think, act and enjoy their masculinity or femininity after they entered and stayed for a time in the "Men's/Women's Restroom"? How much productive time, living as men and women apart from the "Restroom Facility," would be lost due to a false expectation and tragic misconception of reality? Can we conclude this misunderstanding is clearly the case today as most live out their Christian lives? The majority of believers perceive of themselves as the church when they are trained to visit a building marked "The Church." How much valuable time and quality of spiritual life is lost with that misplaced identity? Thus, many don't authentically experience who they are on a continual basis so they remain ignorant or sheltered from the "abundant life" offered to those who know who they are in Christ as the church. Is it any wonder why frustrated pastors are passionately preaching week-after-week for their congregants to get off the sidelines as spectators and participate on the field. Either knowingly or unknowingly, professional ministers have created and defined the spectator sidelines with refreshments and comfortable benches where everyone can sit and watch power point presentations about what they could do for the Lord if they were only given the opportunity to get onto the field. If people were set free to be themselves in Christ as the church, the organized religious sidelines and power point presentations would be over and a thing of the past. There would be many unemployed professionals set free from the bondage of organized religion to be blown about by the Spirit of God to new and more purposeful endeavors.
Organized religion has always tried to justify and legitimize their belief systems with buildings. The early church lived around the religions of their day with buildings containing committed followers. With that awareness, they understood that God had decided to do something incredibly creative by discarding the template of buildings as temples and churches. His alternative plan came about by miraculously creating within each believer the knowledge and the ability to stand on their own or corporately, as "temples of God." Jesus, the High Priest, placed His Spirit into believers twenty-four hours a day, performing His worship service within their hearts and minds. What did this do for them?
For one thing, this gave the church the needed mobility and flexibility to go anywhere and minister. Have you ever wondered how the words spoken by Jesus to Nicodemus would apply to the church? Let me remind you of part of that conversation so that you will see how it fits into this discussion. "The wind blows where it wishes and you hear the sound of it, but do not know where it comes from and where it is going: so is everyone who is born of the Spirit." (John 3:8). Can you see what you have been created to do? God's people were literally designed to be blown through neighborhoods and around the world by the Holy Spirit like leaves being scattered about by the wind. They were not meant to be confined and tied down to a business model for the purpose of producing spiritual results. Instead, supernatural productivity would be the result of spiritual transformation with radically different ways of existing in the kingdom building process.
Living in Christ with a Divine Nature
Since the church is spiritual, it was designed to be organic in form, function and expression. We are told in I Corinthians 12 that God made this possible by including every believer into a supernatural body that is identified as Christ's (I Corinthians 12:27). To make that work effectively He gave us new natures by being born again, "...putting on a new self, which in the likeness of God has been created in righteousness and holiness of the truth." (Ephesians 4:24). Peter says that as a result of this we are now partakers of the divine nature free to function in the world with His spiritual DNA. How is this manifested and employed?
When operating in the nature of God's DNA, as did the early church, we see a freedom to function and display signs of spiritual life. For example, an organic church model is free from ritual, hierarchical leadership and a group dependent upon one key leader or professional staff with a building to maintain. It generates relationships of brotherly love and a commitment to one another. Those gathered together are inquisitive seekers asking questions and forming biblically based ideas that apply to individual and corporate living. It fosters mutual appreciation of each other's contributions in an open participatory body. It believes Godly living is dependent upon Christ's life living in and through each believer and not upon a set of moral or ethical codes or principles or rules. One will see men and women who have discovered their spiritual makeup is understood through their identity in Christ. Lastly, Biblical teaching communicates that Christians are now under the New Covenant which revoked the Old Covenant and made it obsolete.
Any form of institutional worship, service or practice can not be recognized as spiritually innate and genetically driven by God. What is seen as traditionally religious must be ignored and set aside in order to hear the word of God and trust the Holy Spirit to freely manifest Christ in our life. Religion should never be an allowable substitute for the freedom we can experience in Christ. This was why the Apostle Paul cautioned fellow believers with the following words to the Galatians. "It was for freedom that Christ set us free; therefore keep standing firm and do not be subject again to a yoke of slavery." (Galatians 5:1). In this setting the yoke of slavery was Jewish legalism that distracted people from their freedom to live in the life of Christ and trust Him fully for godly living. Organized religion has an abundant supply of what looks good on the surface, enticing men and women into traditional, religious Christian lifestyles instead of an authentic life in Christ. Adopting such practices will always suffocate God's expressive DNA within a person by building a trust and dependence upon man instead of God. What can we anticipate when believers gather together freely with Christ as the source of our life as the cornerstone for our uncontained living?
Gathering Together Organically
When believers "go to church" within an institutional setting are they benefitting spiritually? Are they being built up and edified as God would desire? Is there a biblical basis for what takes place so that the experience is authentic and fruitful? These are tough questions to ask any person who is attached to the organizational model, but they must be asked if one views scriptural principles as fundamental for gathering together. Where do we start if we are open to discovering answers to these questions? Let's look at the early church model and see how close we are in following their lead.
As I stated before, the early church had an organic element to it. The gathering times were fluid as it allowed and benefitted from the expected and unexpected contributions of its participants. Jesus Christ was the focus of the meeting, as He is the Head of the Church (Ephesians 5:23). There was an expectation and a trust that He would lead during those times of assembly. He would be the "senior pastor" organizing the fellowship and all aspects of worship, which involves all facets of our life.
Along with this, He has placed each of us as members of His body to function just as He has desired (1 Corinthians 12:18). There was a belief that as God brought people into His body of believers each would have a valuable role to play within the assembly. Therefore, organic church life trusted the Holy Spirit to provide the freedom to express what the Lord had taught each member through the week. Paul's words describe the organic church movement when he says, "What is the outcome then, brethren? When you assemble, each one has a psalm, has a teaching, has a revelation, has as a tongue, has an interpretation. Let all things be done for edification." (1 Cor 4:26). What stands out as God's blueprint for collective worship?
First of all, if you have roots in the organized church movement then you are going to have problems trying to apply these instructions. Paul directs the church assembly to include each one who attends as a participant rather than as an observer. Everyone was a leader by the very nature of the priesthood of the believer. There were no divisions within the group in terms of clergy/laity or professional and non professional status. For example, God's voice would not be restricted to a "worship minister" with a background choir in colorful robes and a one man bible message delivered by a "senior pastor" week after week.
The second point, if we are to apply these words then we must believe each member has learned something very important about God and the Christian life through the week. Given this, it may mean Jesus Christ might lead that person to contribute what he has learned for the benefit of all. I think we can also assume God has built within each person the desire and need to participate in a meaningful way. Within our spiritual DNA, as born again believers, we are wired for spiritual participation and a passion to build each other up. When not given this opportunity, we are left unfulfilled during the gathering times and the assembly is worst off because of it. What can we anticipate with each member being a participant?
I believe the creative and edifying energy of God's plans for worship surpasses anything humanly structured because of its potentially rich content. The meetings might have familiar songs or new ones freshly written and taught for all to learn and sing. Visual artwork, poems and drama can also be the expressive elements in worship. Teaching, planned and unplanned (i.e. topical or expository), along with testimonies and prophetic insights (casting light upon truth and life), will be additional witnesses to the Gospel. Anything glorifying Christ is to be anticipated through the prayers, the lyrics, the teachings and the participation of those attentive to the Lord's voice. And let me add, this comes about when young and old are blended together to share in each other's unique gifts and contributions to the church body. Young and old need each other to grow in the Lord.
In contrast, the institutional church will seldom allow and present this type of freedom and liberty for those attending. The risks for a professionally led church, designed to run on a business model are too great if operated organically. The following are some of these risks and probable reasons for keeping tight control over what occurs during primary gathering times. Perhaps some of these observations and experiences have been yours as well.
• When there are many contributors to edify the body of Christ a very healthy spiritual atmosphere can be developed. Thus, when gifted leaders surface and mature, paid staff can be threatened by job insecurity due to the lack of being the primary visionaries for the church.
• A meeting designed and orchestrated by God can be unique and unwieldy. For example, the amount of time when people gather together may be longer than conventional church settings might allow. In addition, one never knows what to expect from those attending a fellowship which is Christ driven instead of staff driven.
• Those in attendance actively participate instead of being compliant bench-warmers waiting to be spoon-fed or entertained. Each weekly meeting is different because of the variety of those attending and contributing.
• No one can be manipulated into joining ministries that directly support the vision of a structured church environment. Out-of-the-box ministries are started and sustained amongst those who are led and indwelt by Jesus to meet the needs of those in their communities and the world.
• Financial support will be by faith (believing God sustains His work and supports His workers) instead of by sight (line item budget supported by an Old Covenant tithing system).
• When a person views the church as an organism, those attending are not members who are comfortable with attendance roles and numbers being sent to church offices and denominational headquarters for methods of evaluating a spiritually active community. Growing in the grace of God and trusting Him for all things spiritual are the practical expressions of church life. People are free to come and go as Christ leads. There is nothing employed as a way to control commitment or size within a group.
• In contrast to the organically driven church, professional pastors are faced with the daily pressure to keep what has been built sustained and to grow the base spiritually and numerically. Every paid staff person knows these two stated goals are what guarantee and safeguard their jobs. Therefore, in an institutionally driven church any number of problems can occur. Workaholic schedules, competitive atmospheres, strained relationships due to unrealistic expectations and excessive worry are just a few downsides that immediately come to mind. If the church chooses to run as an institution then the world's standards for success will also produce problems associated with career accomplishment.
• Every institutionally minded purpose, goal and structure is at risk when an individual or a group of people decides to live their lives based on an organic church model. What has been achieved organizationally may not fit or work within an organic model. When making the shift to the organic model one must always be mindful that a foundation laid by man will usually be unharmonious with plans set by Jesus Christ. (I Cor 3:12).
The organizational church methods have had centuries to develop and regretfully most Christians do not believe or realize there is another way. There are many who proclaim the organic model will never work in today's culture. My response is twofold. First, why go to the trouble of teaching anything in the Bible if human nature and its needs have changed from that of the first century? And secondly, if we believe our culture will not accept and flourish with an organic model, then what can we say about the success terrorist groups are having by using it? Everyone in the news media acknowledges the organic nature of terrorism and the inability to define, locate and extinguish it. Amazingly Satan saw the success of the early church and decided to use the technique for his own destructive purposes. He possibly had the following thought centuries ago. "If the church is not going to use it, then I will."
My hope is for biblical discovery that takes the church into a modern day, second Reformation. Clearly, the first one started with high expectations but never completed the job. If given the opportunity by God, we shall all have the revelation to see ourselves as God views us. We are the church, designed to live freely in His spiritual DNA and given the tremendous ability to minister organically in an organizational world culture. My prayer is that it will happen in my lifetime and yours as God calls out more believers from organized religion into organic church.
Kamis, 11 Agustus 2011
Blonde In China
Big Apple to Chrysanthemum City
I am a New Yorker who in 2007 had just one goal - not to spend another miserable and freezing winter in Manhattan. The very thought of trying to live through the raw, wet, windy, icy, cold and snowy horror that we call winter was more than I could handle. No, I wouldn't handle it. I am one of those people who can layer and layer, wear hats, scarves, fur boots and gloves and still be cold. Just thinking about the coming of winter drove me to depression.
I'd been hearing about the plethora of teaching jobs available in China for native speakers of English so I went online and began to explore. There was something else that was driving me as well. I was approaching my 60th birthday and there appeared to be a fork in the road ahead. Sixty signals the onset of old age and I refused to go there. If I died while in China, well, at least I wasn't doing the little old lady thing (while freezing my ass off.) No! No! No! I wasn't about to embrace old age without a fight. The truth is that on both counts, being cold and being old, I was desperate to avoid them.
I sent my resume out, looking specifically for opportunities that would enable me to spend no more than six months (most standard teaching contracts demanded a full year) on this crazy escapist voyage. I had taught English at two colleges so I wasn't exactly inexperienced. I had also written a wildly popular book and been interviewed by Katie Couric on the Today Show. I had some very impressive credentials, so it was with considerable confidence that I looked for an opportunity to utilize them fully-in a warm climate and among people who would look up to and appreciate me. I didn't know, then, how delusional I was.
When an offer from an exotic region of southern China presented itself, I leapt at the chance, never mind that I didn't speak a word of Chinese. I was ready for six months of adventure, warm weather and an opportunity to share my considerable expertise with the English language. Little did I know that China would be the minefield of profoundly outrageous (and often hilarious) challenges to everything I wanted or expected.
My new employer, James Zhang, the owner of the Bridge Language School, happened to be in HK when I arrived and offered to accompany me on the ferry from Hong Kong to Zhongshan, where I'd be living. HK is sort of like Las Vegas on steroids, with bright and colorful neon lights flashing and strobing everywhere. As in NYC there are sightseeing ferries in HK and people take them at night to see the beautiful city and harbor lights. But the 90 minute-ride to the mainland was totally dark. There were no lights to be seen anywhere throughout the trip, no lit up skylines of cities, or even towns. There was nothing but pitch darkness. The ferry was overly air conditioned and I was cold. Mr. Zhang asked the stewardess for a blanket for me. They didn't have blankets so she brought me a towel instead, which I draped over my shoulders. It really felt like I was entering another world.
Mr. Zhang was a well-educated and mild mannered middle-aged Chinese man who lived with his wife and young son in Vancouver, BC. As I learned later, he only visited his schools in China twice a year. It was comforting to have him make the trip with me; I could ask questions and show off a bit too. He should know and appreciate what a gem he'd hired. I had no inkling of what a crook he was at that early stage of the journey, though my sense of uneasiness began when we arrived in Zhongshan. We were met at the ferry landing by James' driver, Sparky, who, James suddenly announced, would take us the additional 45 minute drive to the town of Xiaolan, where I was to be housed. This was news to me. I thought I'd be living and teaching in Zhongshan. Throughout that drive James talked about how lovely Xiaolan was and how there were many different kinds of beautiful trees along the road as well as in the town. Still, I thought for just a brief moment that I should have been informed of this change earlier; the thought made me uncomfortable but I was exhausted and James appeared to be so respectable that I just put it away somewhere...
***IF YOU'RE GOING TO CHINA TO WORK FOR AN EMPLOYER BE SURE THAT ALL THE DETAILS OF WHERE YOU'LL BE LIVING IS IN YOUR CONTRACT - IN WRITING!
My apartment was in a high rise building. It was night when I arrived and I immediately became aware that though the apartment was sparsely furnished everything in it was hard. There was nothing cushy in the place. My mattress could have been made of concrete (which is true of all Chinese mattresses, as I learned later.) The living room sofa was a big piece of ornately carved wood-but without a single cushion, hard as a rock and very uncomfortable to sit on. The dining table was made of steel and glass. There were no closets and I wondered where I was going to put my clothes. There was a TV but no remote and I couldn't figure out how to turn it on (though as I learned later all the programming was in Chinese so it hardly mattered.) I knocked myself out with a sleeping pill that night.
The next morning, and every day from then on, I couldn't help but notice that the sky was gray instead of blue and the air had a greasiness to it that felt strange. The bathroom in the apartment had a western toilet (which I'd been told I could expect,) a sink and a shower contraption against the wall, but there was no demarcation between the bathroom floor and the shower. There was a drainage hole in the floor. So I took a shower standing on the bathroom floor. When I turned the water off everything in the bathroom was soaking wet, towels, toilet paper, etc. I learned to remove everything from the bathroom before I showered and then put it all back later after the room had dried out a bit. I had to towel dry the toilet seat after every shower too.
My apartment was only a five minute drive from the Bridge school, where I would be teaching, and I had no car, which wasn't a problem as there were plenty of motorbike taxis and they were both reliable and cheap. With motorbike taxis you just climb on behind the driver and go. If there are two or three of you, you all climb on and squeeze yourselves onto the very small back of the motorbike. I would regularly see two, three, even four adults squeezed very close together on the back of a motorbike, as the motorbike drivers routinely carry as many as five people, including toddlers and even infants.
***TAXI DRIVERS IN CHINA DO NOT SPEAK OR UNDERSTAND ENGLISH. MAKE SURE THAT SOMEONE WHO CAN WRITE CHINESE CHARACTERS WRITES YOUR DESTINATION ON A PIECE OF PAPER, WHICH YOU CAN SHOW THE DRIVER. BE SURE YOU ALSO HAVE THE CHINESE CHARACTERS WRITTEN DOWN TO GET YOU BACK TO WHERE YOU STARTED FROM.
Xiaolan is known as the Chrysanthemum City because it produces tens of thousands of Chrysanthemums each year for its nationally known Chrysanthemum Festival. I wouldn't have guessed that agriculture is officially the main form of industry in Xiaolan, but it is due to the enormous number of flowers that are grown there. Factories that produce stereos, DVDs, high-tech digital audio equipment, loudspeakers, laser heads, circuit boards and other computer parts also abound in this very small (at least by Chinese standards) town. But while there are many foreign companies operating in the area, there don't seem to be a lot of westerners, certainly not blonde ones, in this part of China. My hair made me the object of tremendous curiosity. People stared openly at me, gaping and pointing, and even those driving cars and trucks would take their eyes off the road to fix them on me; I was, from my first day in Xiaolan, the cause of some very close calls.
Little kids would run up to me and shriek "hello," then start giggling, screaming and jumping up and down excitedly when I said hello back. Every so often an elderly passerby on a bicycle yelled out a Chinese word that I found out means "foreigner." I didn't get the feeling that it was said in a "you imperialist pig" kind of way, just a spontaneous outburst expressing the person's shock at actually seeing someone who wasn't Chinese. For the most part I found the people to be quite friendly.
I was surprised to find that the town is actually very pretty and, at least in the center, didn't look at all like an industrial site. I saw broad boulevards and lots of different kinds of trees. There are a lot of cars, trucks, and buses; bicycles, two- as well as three-wheelers; donkey carts, homemade motorized contraptions and, of course, rickshaws, many of which are motorized although most of them are pedal powered. But more than anything else there are motorbikes - everywhere.
I noticed right away that there didn't appear to be traffic lights or stop signs anywhere in Xiaolan, nor did there seem to be any recognizable rules of the road. Everyone honks their horns non-stop. Cars, buses, motorbikes, bicycles, rickshaws and gigantic trucks all barrel full speed into the intersections at the same time, from every direction. Once they get within an inch of crashing into each other they slow down and somehow manage to negotiate around each other and move forward. Pedestrians, including very old people, mothers carrying infants, and schoolchildren just step into the road and add to the incredible chaos. But the negotiation happens, amazingly, without anyone shouting, yelling, cursing, or getting out of their vehicles to threaten anyone. A very far cry from what happens at most intersections in New York, even those with traffic lights.
***DON'T TRUST TRAFFIC SIGNALS, EVEN WHERE THEY DO EXIST. WAIT UNTIL THERE ARE NO VEHICLES COMING BEFORE CROSSING THE STREET.
My date to start teaching was approaching when I discovered that I was being placed in a local middle school, an unexpected turn of events as I was expecting to teach adults. Actually, James Zhang had told me that I wouldn't have any actual teaching to do. He assured me that each class (which I had also expected would be held at the Bridge school) had a Chinese English teacher and that they would be teaching, testing and grading the students, and essentially acting as my assistant. As a foreign English teacher my job would be to mostly motivate the students and provide a role model for correct pronunciation. I was also led to believe that my students would be a combination of mostly adults, with some secondary (including middle school) students thrown in. None of it turned out to be true.
***MAKE SURE THAT YOUR CONTRACT SPECIFIES EXACTLY WHAT YOU'LL BE DOING - AND WITH WHOM!
I observed almost immediately, that some of the other foreign teachers employed by Bridge were not native English speakers and that some of them spoke very imperfect English. I knew that I was being somewhat judgmental when I also noted that some of the other native speaker teachers were from Britain, Scotland, and Australia and that they had very strong regional accents. Some things were stacking up that began to make me feel uneasy, but I decided that I would just see how things went; I did, after all, have a round trip airline ticket and could just up and leave if things became unbearable, which at this point they definitely were not. Part of me didn't want to run home and have to admit that I had acted stupidly and I just couldn't handle things, and then there was also the fact that I was making very good money by renting out my New York apartment while I was away. Admitting defeat, especially this early into the adventure, was not an option. I let it go, deciding that I was just being my usual too critical self.
The Bridge school had assigned me two 'organizers,' young Chinese English teachers who also had the responsibility of helping me to acclimate and find my way around. One of them, Sharon, spent two days taking me around town, showing me the markets, the road which I could use to walk to school, the park, etc. Though Sharon was a certified English teacher in China, her English was difficult for me to understand. The other 'organizer,' Trina, was supposed to assist me with all teaching-related issues, and though her English was a bit better, it was a struggle to communicate effectively with either of them.
***EVEN IF YOU'VE TAKEN A COURSE IN MANDARIN DON'T EXPECT THAT COMMUNICATION WILL BE ANY EASIER. THERE ARE 57 DIFFERENT LANGUAGES OR DIALECTS SPOKEN IN CHINA. I HAVE OBSERVED PEOPLE FROM NEIGHBORING TOWNS BE UNABLE TO COMMUNICATE WITH EACH OTHER BECAUSE THEIR DIALECTS WERE DIFFERENT.
Accompanied by Trina, I visited the middle school to which I'd been assigned, to meet the principal and the head of the English department before I started teaching. We got there by both of us climbing onto the back of a motorbike taxi. Arriving at the school my first thought was that we were at the wrong address. The place looked like a country club with enormous, beautifully landscaped grounds, palm trees everywhere and a huge sports arena. But it was the school. The kids were all wearing their school uniforms-identical red, white and blue athletic suits. Neither the principal nor the vice principal spoke a word of English but the head of the English department had enough skills to enable us to communicate. After we left I asked Trina if this was some private school for rich kids, but she said no, it was a typical middle school. She said that the Chinese government was very committed to education and that it spends the money to ensure that all children have the best resources available. Finding a motorbike to get us back to town was another challenge as we stood on the empty road waiting and hoping that a motorbike taxi would come along, which eventually it did. On the ride back I saw another beautiful complex, which Trina said was an elementary school. This was not like anything I'd ever seen in New York. But, just like in NYC, I discovered very quickly that Chinese middle school kids are not exactly well behaved.
On my first day at the school I realized that I was the only foreign teacher there, and the only blonde most of the kids had ever seen in the flesh. They were all over me, yelling hello (everyone in China, it seems, has learned the word 'hello' and people will repeat the word over and over in what they must perceive to be a conversation, as did a lot of the kids at the school) and reaching out to touch my hair. The big difference between these kids, though, and the ones back home is that there was absolutely no threatening vibe there. The kids were excited and had a lot of energy but I never felt as if anyone wanted to kill me.
I was assigned a cubicle in the teacher's room, and a desk with an ancient computer on it, which I was looking forward to using for sending and receiving emails from home. I spent part of my first day at the school visiting all the women's bathrooms on the campus, hoping to find one with western facilities, but there weren't any. I would have to learn to squat. None of the bathrooms contained any toilet paper, soap or towels. There were stalls with doors that had holes in the floor - but which you could flush - and there were sinks. Women using the bathroom just wet their hands in the sink and walked out. I made a mental note to go to the supermarket that evening to stock up on toilet paper, as I would have to start carrying a roll with me in my bag. The stalls didn't have any hooks either, so I would have to put my bag on the floor - or leave my bag in my cubicle and just walk around carrying a roll of toilet paper every time I had to go. I'd been in China for a week and could see that the Chinese take health and exercise very seriously. TV commercials frequently exhort people to eat a balanced diet in order to build a stronger, healthier nation. I was amazed that basic hygiene wasn't part of the national 'let's all get healthy' program.
***CARRY TOILET PAPER AND BABY WIPES IN YOUR PURSE. IF YOU'RE A MAN, CARRY A PURSE.
A very major challenge early on was finding real coffee. There was Nestle's instant in the supermarket but no ground coffee or coffee beans. Except for oatmeal, I couldn't find any breakfast cereal either. I had brought a package of bran cereal with me but I didn't know what I was going to do when that was gone, a minor concern, for sure, although not finding coffee was beginning to make me panic. There was an enormous and ultra modern supermarket right across the street from my building, but of course all of the labels were written in Chinese so, except for the fresh produce, I didn't know what anything was. Another supermarket item I hadn't seen in any of the stores I visited (and was starting to obsess about) was hair color in any shade of blonde. Though I'd brought a couple of months supply with me I was already worrying, based on what I'd seen so far, about what I would do when I ran out. Meanwhile, though, I had bigger problems.
***IF YOU MUST HAVE FRESH BREWED COFFEE FIRST THING IN THE MORNING IN ORDER TO FUNCTION, BRING SEVERAL MONTHS SUPPLY WITH YOU (AS WELL AS FILTERS OR OTHER COFFEE MAKING NECESSITIES.) YOU CAN GET COFFEE IN CHINA, BUT SOMETIMES IT'S CHALLENGING TO FIND IT.
My first classes at the middle school gave me an immediate glimpse of what I'd gotten myself into. When I arrived in the morning hundreds of kids were outside doing their perfectly synchronized morning exercises. Several hundred kids, all wearing identical track suits, doing organized calisthenics. There was a Honda factory along the road leading to the school and as we passed it I could see hundreds of workers, all wearing identical white uniforms, doing the same.
I arrived at the school and was escorted to my first class and introduced to the students by a Chinese English teacher who then left the room, leaving me alone with a group of over 50 students. I'd been told by James Zhang that Chinese students all had pretty advanced English language skills, but as I tried saying a few things I realized right away that these kids' command of English was zero, never mind that they'd been studying it for at least five years. All of the classes were huge - with 50 or more students in each class, sometimes with not enough seats, forcing some of the kids to stand in the back of the room - and I had no help, no Chinese assistant, nothing. The kids were completely disruptive, restless and showed no sign of interest in learning English. At 13 and 14 years old these Chinese middle school kids were as impossible as the worst of this age group back home. I didn't know what I was going to do but, like a new young bride in an abusive marriage, I was determined to figure out a way to make it work.
I am a New Yorker who in 2007 had just one goal - not to spend another miserable and freezing winter in Manhattan. The very thought of trying to live through the raw, wet, windy, icy, cold and snowy horror that we call winter was more than I could handle. No, I wouldn't handle it. I am one of those people who can layer and layer, wear hats, scarves, fur boots and gloves and still be cold. Just thinking about the coming of winter drove me to depression.
I'd been hearing about the plethora of teaching jobs available in China for native speakers of English so I went online and began to explore. There was something else that was driving me as well. I was approaching my 60th birthday and there appeared to be a fork in the road ahead. Sixty signals the onset of old age and I refused to go there. If I died while in China, well, at least I wasn't doing the little old lady thing (while freezing my ass off.) No! No! No! I wasn't about to embrace old age without a fight. The truth is that on both counts, being cold and being old, I was desperate to avoid them.
I sent my resume out, looking specifically for opportunities that would enable me to spend no more than six months (most standard teaching contracts demanded a full year) on this crazy escapist voyage. I had taught English at two colleges so I wasn't exactly inexperienced. I had also written a wildly popular book and been interviewed by Katie Couric on the Today Show. I had some very impressive credentials, so it was with considerable confidence that I looked for an opportunity to utilize them fully-in a warm climate and among people who would look up to and appreciate me. I didn't know, then, how delusional I was.
When an offer from an exotic region of southern China presented itself, I leapt at the chance, never mind that I didn't speak a word of Chinese. I was ready for six months of adventure, warm weather and an opportunity to share my considerable expertise with the English language. Little did I know that China would be the minefield of profoundly outrageous (and often hilarious) challenges to everything I wanted or expected.
My new employer, James Zhang, the owner of the Bridge Language School, happened to be in HK when I arrived and offered to accompany me on the ferry from Hong Kong to Zhongshan, where I'd be living. HK is sort of like Las Vegas on steroids, with bright and colorful neon lights flashing and strobing everywhere. As in NYC there are sightseeing ferries in HK and people take them at night to see the beautiful city and harbor lights. But the 90 minute-ride to the mainland was totally dark. There were no lights to be seen anywhere throughout the trip, no lit up skylines of cities, or even towns. There was nothing but pitch darkness. The ferry was overly air conditioned and I was cold. Mr. Zhang asked the stewardess for a blanket for me. They didn't have blankets so she brought me a towel instead, which I draped over my shoulders. It really felt like I was entering another world.
Mr. Zhang was a well-educated and mild mannered middle-aged Chinese man who lived with his wife and young son in Vancouver, BC. As I learned later, he only visited his schools in China twice a year. It was comforting to have him make the trip with me; I could ask questions and show off a bit too. He should know and appreciate what a gem he'd hired. I had no inkling of what a crook he was at that early stage of the journey, though my sense of uneasiness began when we arrived in Zhongshan. We were met at the ferry landing by James' driver, Sparky, who, James suddenly announced, would take us the additional 45 minute drive to the town of Xiaolan, where I was to be housed. This was news to me. I thought I'd be living and teaching in Zhongshan. Throughout that drive James talked about how lovely Xiaolan was and how there were many different kinds of beautiful trees along the road as well as in the town. Still, I thought for just a brief moment that I should have been informed of this change earlier; the thought made me uncomfortable but I was exhausted and James appeared to be so respectable that I just put it away somewhere...
***IF YOU'RE GOING TO CHINA TO WORK FOR AN EMPLOYER BE SURE THAT ALL THE DETAILS OF WHERE YOU'LL BE LIVING IS IN YOUR CONTRACT - IN WRITING!
My apartment was in a high rise building. It was night when I arrived and I immediately became aware that though the apartment was sparsely furnished everything in it was hard. There was nothing cushy in the place. My mattress could have been made of concrete (which is true of all Chinese mattresses, as I learned later.) The living room sofa was a big piece of ornately carved wood-but without a single cushion, hard as a rock and very uncomfortable to sit on. The dining table was made of steel and glass. There were no closets and I wondered where I was going to put my clothes. There was a TV but no remote and I couldn't figure out how to turn it on (though as I learned later all the programming was in Chinese so it hardly mattered.) I knocked myself out with a sleeping pill that night.
The next morning, and every day from then on, I couldn't help but notice that the sky was gray instead of blue and the air had a greasiness to it that felt strange. The bathroom in the apartment had a western toilet (which I'd been told I could expect,) a sink and a shower contraption against the wall, but there was no demarcation between the bathroom floor and the shower. There was a drainage hole in the floor. So I took a shower standing on the bathroom floor. When I turned the water off everything in the bathroom was soaking wet, towels, toilet paper, etc. I learned to remove everything from the bathroom before I showered and then put it all back later after the room had dried out a bit. I had to towel dry the toilet seat after every shower too.
My apartment was only a five minute drive from the Bridge school, where I would be teaching, and I had no car, which wasn't a problem as there were plenty of motorbike taxis and they were both reliable and cheap. With motorbike taxis you just climb on behind the driver and go. If there are two or three of you, you all climb on and squeeze yourselves onto the very small back of the motorbike. I would regularly see two, three, even four adults squeezed very close together on the back of a motorbike, as the motorbike drivers routinely carry as many as five people, including toddlers and even infants.
***TAXI DRIVERS IN CHINA DO NOT SPEAK OR UNDERSTAND ENGLISH. MAKE SURE THAT SOMEONE WHO CAN WRITE CHINESE CHARACTERS WRITES YOUR DESTINATION ON A PIECE OF PAPER, WHICH YOU CAN SHOW THE DRIVER. BE SURE YOU ALSO HAVE THE CHINESE CHARACTERS WRITTEN DOWN TO GET YOU BACK TO WHERE YOU STARTED FROM.
Xiaolan is known as the Chrysanthemum City because it produces tens of thousands of Chrysanthemums each year for its nationally known Chrysanthemum Festival. I wouldn't have guessed that agriculture is officially the main form of industry in Xiaolan, but it is due to the enormous number of flowers that are grown there. Factories that produce stereos, DVDs, high-tech digital audio equipment, loudspeakers, laser heads, circuit boards and other computer parts also abound in this very small (at least by Chinese standards) town. But while there are many foreign companies operating in the area, there don't seem to be a lot of westerners, certainly not blonde ones, in this part of China. My hair made me the object of tremendous curiosity. People stared openly at me, gaping and pointing, and even those driving cars and trucks would take their eyes off the road to fix them on me; I was, from my first day in Xiaolan, the cause of some very close calls.
Little kids would run up to me and shriek "hello," then start giggling, screaming and jumping up and down excitedly when I said hello back. Every so often an elderly passerby on a bicycle yelled out a Chinese word that I found out means "foreigner." I didn't get the feeling that it was said in a "you imperialist pig" kind of way, just a spontaneous outburst expressing the person's shock at actually seeing someone who wasn't Chinese. For the most part I found the people to be quite friendly.
I was surprised to find that the town is actually very pretty and, at least in the center, didn't look at all like an industrial site. I saw broad boulevards and lots of different kinds of trees. There are a lot of cars, trucks, and buses; bicycles, two- as well as three-wheelers; donkey carts, homemade motorized contraptions and, of course, rickshaws, many of which are motorized although most of them are pedal powered. But more than anything else there are motorbikes - everywhere.
I noticed right away that there didn't appear to be traffic lights or stop signs anywhere in Xiaolan, nor did there seem to be any recognizable rules of the road. Everyone honks their horns non-stop. Cars, buses, motorbikes, bicycles, rickshaws and gigantic trucks all barrel full speed into the intersections at the same time, from every direction. Once they get within an inch of crashing into each other they slow down and somehow manage to negotiate around each other and move forward. Pedestrians, including very old people, mothers carrying infants, and schoolchildren just step into the road and add to the incredible chaos. But the negotiation happens, amazingly, without anyone shouting, yelling, cursing, or getting out of their vehicles to threaten anyone. A very far cry from what happens at most intersections in New York, even those with traffic lights.
***DON'T TRUST TRAFFIC SIGNALS, EVEN WHERE THEY DO EXIST. WAIT UNTIL THERE ARE NO VEHICLES COMING BEFORE CROSSING THE STREET.
My date to start teaching was approaching when I discovered that I was being placed in a local middle school, an unexpected turn of events as I was expecting to teach adults. Actually, James Zhang had told me that I wouldn't have any actual teaching to do. He assured me that each class (which I had also expected would be held at the Bridge school) had a Chinese English teacher and that they would be teaching, testing and grading the students, and essentially acting as my assistant. As a foreign English teacher my job would be to mostly motivate the students and provide a role model for correct pronunciation. I was also led to believe that my students would be a combination of mostly adults, with some secondary (including middle school) students thrown in. None of it turned out to be true.
***MAKE SURE THAT YOUR CONTRACT SPECIFIES EXACTLY WHAT YOU'LL BE DOING - AND WITH WHOM!
I observed almost immediately, that some of the other foreign teachers employed by Bridge were not native English speakers and that some of them spoke very imperfect English. I knew that I was being somewhat judgmental when I also noted that some of the other native speaker teachers were from Britain, Scotland, and Australia and that they had very strong regional accents. Some things were stacking up that began to make me feel uneasy, but I decided that I would just see how things went; I did, after all, have a round trip airline ticket and could just up and leave if things became unbearable, which at this point they definitely were not. Part of me didn't want to run home and have to admit that I had acted stupidly and I just couldn't handle things, and then there was also the fact that I was making very good money by renting out my New York apartment while I was away. Admitting defeat, especially this early into the adventure, was not an option. I let it go, deciding that I was just being my usual too critical self.
The Bridge school had assigned me two 'organizers,' young Chinese English teachers who also had the responsibility of helping me to acclimate and find my way around. One of them, Sharon, spent two days taking me around town, showing me the markets, the road which I could use to walk to school, the park, etc. Though Sharon was a certified English teacher in China, her English was difficult for me to understand. The other 'organizer,' Trina, was supposed to assist me with all teaching-related issues, and though her English was a bit better, it was a struggle to communicate effectively with either of them.
***EVEN IF YOU'VE TAKEN A COURSE IN MANDARIN DON'T EXPECT THAT COMMUNICATION WILL BE ANY EASIER. THERE ARE 57 DIFFERENT LANGUAGES OR DIALECTS SPOKEN IN CHINA. I HAVE OBSERVED PEOPLE FROM NEIGHBORING TOWNS BE UNABLE TO COMMUNICATE WITH EACH OTHER BECAUSE THEIR DIALECTS WERE DIFFERENT.
Accompanied by Trina, I visited the middle school to which I'd been assigned, to meet the principal and the head of the English department before I started teaching. We got there by both of us climbing onto the back of a motorbike taxi. Arriving at the school my first thought was that we were at the wrong address. The place looked like a country club with enormous, beautifully landscaped grounds, palm trees everywhere and a huge sports arena. But it was the school. The kids were all wearing their school uniforms-identical red, white and blue athletic suits. Neither the principal nor the vice principal spoke a word of English but the head of the English department had enough skills to enable us to communicate. After we left I asked Trina if this was some private school for rich kids, but she said no, it was a typical middle school. She said that the Chinese government was very committed to education and that it spends the money to ensure that all children have the best resources available. Finding a motorbike to get us back to town was another challenge as we stood on the empty road waiting and hoping that a motorbike taxi would come along, which eventually it did. On the ride back I saw another beautiful complex, which Trina said was an elementary school. This was not like anything I'd ever seen in New York. But, just like in NYC, I discovered very quickly that Chinese middle school kids are not exactly well behaved.
On my first day at the school I realized that I was the only foreign teacher there, and the only blonde most of the kids had ever seen in the flesh. They were all over me, yelling hello (everyone in China, it seems, has learned the word 'hello' and people will repeat the word over and over in what they must perceive to be a conversation, as did a lot of the kids at the school) and reaching out to touch my hair. The big difference between these kids, though, and the ones back home is that there was absolutely no threatening vibe there. The kids were excited and had a lot of energy but I never felt as if anyone wanted to kill me.
I was assigned a cubicle in the teacher's room, and a desk with an ancient computer on it, which I was looking forward to using for sending and receiving emails from home. I spent part of my first day at the school visiting all the women's bathrooms on the campus, hoping to find one with western facilities, but there weren't any. I would have to learn to squat. None of the bathrooms contained any toilet paper, soap or towels. There were stalls with doors that had holes in the floor - but which you could flush - and there were sinks. Women using the bathroom just wet their hands in the sink and walked out. I made a mental note to go to the supermarket that evening to stock up on toilet paper, as I would have to start carrying a roll with me in my bag. The stalls didn't have any hooks either, so I would have to put my bag on the floor - or leave my bag in my cubicle and just walk around carrying a roll of toilet paper every time I had to go. I'd been in China for a week and could see that the Chinese take health and exercise very seriously. TV commercials frequently exhort people to eat a balanced diet in order to build a stronger, healthier nation. I was amazed that basic hygiene wasn't part of the national 'let's all get healthy' program.
***CARRY TOILET PAPER AND BABY WIPES IN YOUR PURSE. IF YOU'RE A MAN, CARRY A PURSE.
A very major challenge early on was finding real coffee. There was Nestle's instant in the supermarket but no ground coffee or coffee beans. Except for oatmeal, I couldn't find any breakfast cereal either. I had brought a package of bran cereal with me but I didn't know what I was going to do when that was gone, a minor concern, for sure, although not finding coffee was beginning to make me panic. There was an enormous and ultra modern supermarket right across the street from my building, but of course all of the labels were written in Chinese so, except for the fresh produce, I didn't know what anything was. Another supermarket item I hadn't seen in any of the stores I visited (and was starting to obsess about) was hair color in any shade of blonde. Though I'd brought a couple of months supply with me I was already worrying, based on what I'd seen so far, about what I would do when I ran out. Meanwhile, though, I had bigger problems.
***IF YOU MUST HAVE FRESH BREWED COFFEE FIRST THING IN THE MORNING IN ORDER TO FUNCTION, BRING SEVERAL MONTHS SUPPLY WITH YOU (AS WELL AS FILTERS OR OTHER COFFEE MAKING NECESSITIES.) YOU CAN GET COFFEE IN CHINA, BUT SOMETIMES IT'S CHALLENGING TO FIND IT.
My first classes at the middle school gave me an immediate glimpse of what I'd gotten myself into. When I arrived in the morning hundreds of kids were outside doing their perfectly synchronized morning exercises. Several hundred kids, all wearing identical track suits, doing organized calisthenics. There was a Honda factory along the road leading to the school and as we passed it I could see hundreds of workers, all wearing identical white uniforms, doing the same.
I arrived at the school and was escorted to my first class and introduced to the students by a Chinese English teacher who then left the room, leaving me alone with a group of over 50 students. I'd been told by James Zhang that Chinese students all had pretty advanced English language skills, but as I tried saying a few things I realized right away that these kids' command of English was zero, never mind that they'd been studying it for at least five years. All of the classes were huge - with 50 or more students in each class, sometimes with not enough seats, forcing some of the kids to stand in the back of the room - and I had no help, no Chinese assistant, nothing. The kids were completely disruptive, restless and showed no sign of interest in learning English. At 13 and 14 years old these Chinese middle school kids were as impossible as the worst of this age group back home. I didn't know what I was going to do but, like a new young bride in an abusive marriage, I was determined to figure out a way to make it work.
Rabu, 10 Agustus 2011
The Third Dimension: Newly-posted Article in Press (video)
A 37-year-old man with bipolar disorder and active polysubstance abuse presented with 4 days of fever, chills, drenching sweats, and generalized fatigue. He reported daily inhalational use of both heroin and cocaine and also had a dental extraction in recent weeks. Vital signs were significant for a fever of 41.67°C (101.7°F). Active rigors were noted on initial assessment. Examination of the mouth revealed no evidence of active dental infection, cardiac examination was without murmur, and no cutaneous stigmata of infective endocarditis or active intravenous drug use were present. Laboratory testing was unremarkable. Electrocardiogram was normal...
This case study is currently an article in press on The American Journal of Medicine's website. Check out the rest of this article here and other newly-published articles in press here.
Senin, 08 Agustus 2011
Illicit Drug, Ischemic Bowel
In the young adult or middle-aged patient with abdominal pain and bloody diarrhea, a history of cocaine abuse is an important consideration in the differential diagnosis, as illustrated in this case.
A 44-year-old male construction worker presented to our general medicine clinic reporting 1 year of recurrent, sharp, left-sided abdominal pain associated with frequent loose stools. For a few days before presentation, he had been unable to sleep because of the pain. The painful episodes were associated with some rectal bleeding and a documented weight loss of 40 lb but no nausea, vomiting, abdominal distension, food intolerance, or change in appetite. The patient denied urinary problems (hematuria, frequency, urgency, dysuria) and fever. His medical and surgical history were unremarkable except for an appendectomy 15 years previously; he had never had a colonoscopy. His social history was significant for smoking (20 pack-years) and occasional alcohol use. He denied use of illicit drugs.
To read this article in its entirety, please visit our website.
-- Khaldoon Shaheen, MD, M. Chadi Alraies, MD, Houssam Marwany, MD, Emmanuel Elueze, MD, PhD
This article originally appeared in the August 2011 issue of The American Journal of Medicine.
Selasa, 02 Agustus 2011
Should the Routine Physical Examination Include Squat Maneuvers?
Few primary care physicians or even cardiologists ask patients to squat routinely as part of the physical examination despite evidence that squatting is a quick and simple means of augmenting the cardiac examination.(1, 2, 3, 4) Characteristic hemodynamic changes may occur when patients squat or stand upright from a squatting position; squatting increases left ventricular preload and afterload, whereas rapid standing from a squatting position decreases left ventricular volume by diminishing venous return.(1, 2, 3) These hemodynamic changes manifest in clinically noticeable changes that may be observed on the routine cardiac examination. A 1988 study of the diagnostic accuracy of bedside maneuvers in the evaluation of patients with systolic murmurs found that the intensity and duration of murmurs changed for many patients, especially those with obstructive hypertrophic cardiomyopathy, after they performed a series of squats and subsequently stood upright.3
In addition to improving detection of some murmurs, squat maneuvers may be a useful way of adding important clinical information to the patient-physician encounter. Squatting can unmask inappropriate post-exercise heart rate or rhythm changes after brief exertion. Musculoskeletal problems ranging from balance disorders to myopathies may be identified if patients experience difficulty with performing squats. Specifically, screening for myopathies may be particularly relevant in those being followed on statin therapy, whereas fall risk assessment would be warranted in those on warfarin anticoagulation therapy.
To read this article in its entirety, please visit our website.
-- Nona Ahankoob, Moulin Chokshi, Matthew Feinstein, Neil J. Stone, MD
This article originally appeared in the August 2011 issue of The American Journal of Medicine.
Senin, 01 Agustus 2011
Constipation and Risk of Cardiovascular Disease among Postmenopausal Women
In postmenopausal women, constipation is a marker for cardiovascular risk factors and increased cardiovascular risk. Since constipation is easily assessed, it may be a helpful tool to identify women with increased cardiovascular risk.
Abstract
Background
Constipation is common in Western societies, accounting for 2.5 million physician visits/year in the US. Because many factors predisposing to constipation also are risk factors for cardiovascular disease, we hypothesized that constipation may be associated with increased risk of cardiovascular events.
Methods
We conducted a secondary analysis in 93,676 women enrolled in the observational arm of the Women's Health Initiative. Constipation was evaluated at baseline by a self-administered questionnaire. Estimates of the risk of cardiovascular events (cumulative end point including mortality from coronary heart disease, myocardial infarction, angina, coronary revascularization, stroke, and transient ischemic attack) were derived from Cox proportional hazards models adjusted for demographics, risk factors, and other clinical variables (median follow-up 6.9 years).
Results
The analysis included 73,047 women. Constipation was associated with increased age, African American and Hispanic descent, smoking, diabetes, high cholesterol, family history of myocardial infarction, hypertension, obesity, lower physical activity levels, lower fiber intake, and depression. Women with moderate and severe constipation experienced more cardiovascular events (14.2 and 19.1 events/1000 person-years, respectively) compared with women with no constipation (9.6/1000 person-years). After adjustment for demographics, risk factors, dietary factors, medications, frailty, and other psychological variables, constipation was no longer associated with an increased risk of cardiovascular events except for the severe constipation group, which had a 23% higher risk of cardiovascular events.
Conclusion
In postmenopausal women, constipation is a marker for cardiovascular risk factors and increased cardiovascular risk. Because constipation is easily assessed, it may be a helpful tool to identify women with increased cardiovascular risk.
To read this article in its entirety, please visit our website.
-- Elena Salmoirago-Blotcher, MD, Sybil Crawford, PhD, Elizabeth Jackson, MD, Judith Ockene, PhD, Ira Ockene, MD
This article originally appeared in the August 2011 issue of The American Journal of Medicine.
Abstract
Background
Constipation is common in Western societies, accounting for 2.5 million physician visits/year in the US. Because many factors predisposing to constipation also are risk factors for cardiovascular disease, we hypothesized that constipation may be associated with increased risk of cardiovascular events.
Methods
We conducted a secondary analysis in 93,676 women enrolled in the observational arm of the Women's Health Initiative. Constipation was evaluated at baseline by a self-administered questionnaire. Estimates of the risk of cardiovascular events (cumulative end point including mortality from coronary heart disease, myocardial infarction, angina, coronary revascularization, stroke, and transient ischemic attack) were derived from Cox proportional hazards models adjusted for demographics, risk factors, and other clinical variables (median follow-up 6.9 years).
Results
The analysis included 73,047 women. Constipation was associated with increased age, African American and Hispanic descent, smoking, diabetes, high cholesterol, family history of myocardial infarction, hypertension, obesity, lower physical activity levels, lower fiber intake, and depression. Women with moderate and severe constipation experienced more cardiovascular events (14.2 and 19.1 events/1000 person-years, respectively) compared with women with no constipation (9.6/1000 person-years). After adjustment for demographics, risk factors, dietary factors, medications, frailty, and other psychological variables, constipation was no longer associated with an increased risk of cardiovascular events except for the severe constipation group, which had a 23% higher risk of cardiovascular events.
Conclusion
In postmenopausal women, constipation is a marker for cardiovascular risk factors and increased cardiovascular risk. Because constipation is easily assessed, it may be a helpful tool to identify women with increased cardiovascular risk.
To read this article in its entirety, please visit our website.
-- Elena Salmoirago-Blotcher, MD, Sybil Crawford, PhD, Elizabeth Jackson, MD, Judith Ockene, PhD, Ira Ockene, MD
This article originally appeared in the August 2011 issue of The American Journal of Medicine.
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