This column was originally published in Yiddish at the Yiddish Forward, and is published here in translation by arrangement with them.

Dear Dr. Berger,

Sometimes I’m nauseous after exercising -- then my head hurts the whole day, and sometimes I get dizzy. Yesterday was awful. In the morning I did 50 minutes of cardio. I was fine while I was jumping, but right afterwards my head started hurting. I drank water, ate a healthy breakfast and waited till my headache went away. But it stayed, and after lunch I had to go home. I went to bed shaking and even threw up a couple of times, which helped.

What’s going on? Believe me, I’m not the type who likes to exert myself, I just want my heart to be healthy enough so I can get the bus. If I get sick when exercising, should I not do it?

Thanks,
Throwing Up in Baltimore

Dear Throwing Up,

I’m sorry to hear that you feel bad when you exercise! From your symptoms it is difficult to detect the exact reason, but it may be that your body’s reaction was more or less normal. When the body exerts itself, the heart often beats faster, with a concomitant increase in blood pressure to bring more oxygen to the organs. So the question is, why were you feeling so bad?

Several reasons come to mind. It may be that not all have a connection to your situation. (And with this I do not say that you are at fault - different people are differently affected by strenuous exercise.)

1. Some people are easily dehydrated (dried out), and this can lead to nausea and dizziness, even fainting. It may be worthwhile drinking water or other fluffiness before you get into the gym.
2. When  the heart starts to beat faster, blood can be drawn away from the brain to provide oxygen to other organs, which can cause dizziness.
3. Occasionally, drinking too much fluid without electrolytes (minerals), for example, plain water, can lead to significantly decreased levels of sodium, which might infrequently lead to serious consequences.

As is often the case, the correct approach is dependent on how much you are affected by the episodes. If they come to you every time you exercise, you ought to talk to a doctor.

Dear Dr. Berger,

How can doctors and patients understand what is meant by "quality of life"?

Amy Allara, Maryland

Dear Ms. Allara,

It depends on the context, of course. The term "quality of life" is naturally unclear, so one has to ask some serious questions even to find out what is being referred to. There are several possibilities. Is the situation that of a terminally ill person, who might not have long to live, when the question is: Are there any things that are so impossible to bear, that it is better not to live?

Perhaps “quality of life” refers to the outcome of a procedure or operation as reflected in the health of the person who underwent it?  In this case, we can get help defining the "quality" by asking other patients who have also undergone the procedure in question.

Or maybe something else is being discussed: life with chronic illness, with a potential goal to increase such quality of life. How can one achieve a certain quality of life while dealing with a disease? Different people define definitely what makes life worthwhile and imbues it with “quality.” Some would emphasize meaningful activities and achievements; others, time spent with family and friends; a third group would classify symptom minimization as most important.
​
Numerically estimating quality of life is a complicated topic in itself, but such an approach often starts with asking the following question: "How much time out of your life would you give away so as *not* to live with such a disease?" Such figures  can be used to calculate "quality adjustments" that affect life with a certain health problem. With such calculations, you can compare different illnesses and their effects on life, though such an approach has its detractors.

I'm an internal medicine doctor, which means I see adult patients in Baltimore. Today I saw one of my favorite patients. She has chronic pain and a particular gastrointestinal syndrome which leads to frequent hospitalizations. Both make it very difficult, and really -- in practicality -- impossible for her to work. Her disability is taking a while to come through, because "chronic pain" and "back pain" are too often not considered as "real disease" by the powers that be. She can't afford many of her prescriptions because she lacks an income. She might get evicted any day.
I realized today what medical intervention would help her the most.
You know what prescription she needs?
Money. She needs money.

This originally appeared in the Forward newspaper.

I stood, legs apart and face to the wall, in the Capitol Police Vehicle Maintenance Division. In other words, a garage. And I thought: I want to shake the hand of the person who invented plastic zip ties. They’re probably doing extremely well for themselves.
But let’s start from the beginning. How did I get here, hands cuffed behind my back, and why did I still feel, all in all, pretty good?
I’m a doctor who’s been in practice almost 10 years. During my training I wasn’t that involved in politics, and after 2009 even less involved. I was complacent after Obamacare passed.
In the following years it became evident that more and more patients were able to seek me out and start seeing me as their new doctor because of the insurance available through the Affordable Care Act. Sure the legislation wasn’t perfect. Everything can always be improved. I even rolled my eyes and acted supercilious at those who wouldn’t shut up about single payer. Why rock the boat? Then Trump happened. During the run-up to the election I understood the abstract possibility that he could win. Though I’m certainly no prophet and I didn’t come near to predicting what eventually happened, I was really worried that a President Trump would wipe out the progress of the past few years: the millions more Americans with insurance; the decrease in the rise of healthcare costs, the improvements in population health.  
I was shocked in November, and after the inauguration it was as if I had woken up from a long nap. With mounting fear and panic I understood that the priorities of Trump and his Congress collaborators are different from mine, and those of my doctor and nurse colleagues — and certainly different than what my patients think is important. Many Republicans believe that government should not help the sick, because being ill is a moral failing. The sick need freedom to cure themselves.
As a response, I founded a social media group called Doctors Against Trump which later, with the help of expert friends, I converted to a political action committee to support candidates who believe in progressive health policies. I started calling my Congressmen and Senators regularly,  and I made use of various on-line tools that connect blue-state voters with red-state constituents, urging them in their turn to call their elected officials.
This was something, but it didn’t feel like enough to me. I wanted to physically and concretely demonstrate support for my patients (sick, weak, old, marginalized), that I wasn’t sitting doing nothing while people were trying to take away their insurance. Once or twice I went and had a polite discussion with a senator’s health aide. That didn’t hit the spot either.
I saw that two separate groups were collaborating in a Senate protest action: those from various faith traditions (priests and ministers, rabbis, ordinary Jews and Christians; probably others too), on the one hand, joined also by health professionals: doctors, nurses, dentists; together with patients ready to tell moving stories for an audience and media. I joined them on a sunny morning in Washington, DC, at a Lutheran church not far from the Capitol and Union Station.
First we joined in prayer (as a Jew, I was happy that specific Christian expressions were deliberately avoided, and no one invoked Jesus’ name). I put on tefillin as a sign of serious piety in the public sphere defending the principle in the Biblical verse “you shall surely heal.” I was also thrilled to meet doctors and others who I had met before only on social media.
After a press conference at which we forcefully articulated our belief, as religious people and doctors, that health is a human right, we started off in a long, stately procession, slow and steady, to the Capitol building, two by two.
Good things come to those who wait, and protesting is no exception. They let the tourists up to the Senate galleries quite quickly, but apparently it was obvious to everyone that we were planning something different.
We finally got to the gallery, looking down at the Senate. It was like a Kabuki theater, Democratic and Republican statues frozen in their feigned gravity while true realities of life and death play out on the other side of the Capitol walls. When the number of the bill was called, we stood up and shouted, “Kill the Bill! Shame!”
Though we don’t yet know, while I write these words, if the terrible bill is truly dead, I am very happy with our work. We used our privilege as doctors and bearers of faith to march against the greed and cruelty of an unfeeling administration. As part of a group of activists I felt the collective frisson that many Jews have experienced in a minyan that davens with intention: the surety that all is not lost even when the hour is very dark. We are powerful precisely because we maintain, even under attack, our beliefs in healthcare and the needs of patients.
So maybe that’s why, when I stood feet apart in the police garage, the zip ties didn’t bite as much as I thought they would.
Read more: http://forward.com/writing-trumps-america/378864/faith-leaders-and-doctors-disrupt-the-senate-for-the-sake-of-health-insuran/

We're all sick of the health care debate. But those who are sick, trying not to get sick, or taking care of others who are sick don't have the luxury of absenting themselves from this debate.

They (we) are looking on in horrified fascination as the GOP makes its plan known: dismantling Obamacare and leaving millions without insurance -- replacing it with stopgap subpar underfunded skimpycare.

The so-called "skinny plan" is chockfull of real harm. 15 million more uninsured. 20% premium increases. And that's before the skinny bill is stuffed even more full with add-ons designed to pacify the elements in the GOP who take moral exception to Medicaid. (The poor should refrain from getting sick, you see. Government should not be involved in healthcare. We should go back to the good old days, whenever and wherever those were.)

It's as if the check-engine light was blinking on your dashboard, and in response your mechanic doused the car with gasoline and set it on fire.

If you have a Republican senator, call them and tell them your healthcare story. Ask them if they came to Washington to harm the sick. If you have a Democratic senator (or if your senator is Collins or Murkowski!) call and thank them for standing up for what's right. You can also go to the Indivisible website to be patched through to those in red states, whom you can connect directly with their senators. (I've done it. It's addictive.) https://www.indivisibleguide.com/hubdialer-signup/
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Yes, life is full of complications. Things are hard. There's plenty to do besides this sort of advocacy. You have work to go to, kids to raise, doorknobs and toilets to fix. If you are involved in whatever else you have to do, no one should criticize. But if you can just take a moment to speak up, you'll feel good, and we'll all thank you.

This Is Just the AHCA
I have taken 
the insurance
that covered 
your children
with which
you were probably
buying
medicine
Forgive me
I think suffering
is so sweet
and so cold

Every week I precept (teach and supervise) in the residents' internal medicine clinic at the Outpatient Center of Johns Hopkins Hospital, on Caroline Street in Baltimore. The patients are mostly Baltimoreans, mostly African Americans, though an increasing number are Spanish-speaking immigrants. 

I tried something new these past couple of weeks. Whenever a resident presented a patient to me (as is required), I listened to the introduction, smiled, and then let myself interrupt with the following request:

"Please tell me one non-medical thing about the patient."

You see, most often, the patient is presented this way: "Mr. S. is a 69 year old man with CKD [chronic kidney disease], bipolar [disorder], CAD [coronary artery disease],  hypertension and hyperlipidemia, here for followup." But I was interested in knowing something about the patient as a person, when he's not in clinic. 

The residents' responses to this request of mine seemed to fall into one of several categories.

There were those who had clearly never thought of such an approach; one said, "The patient is very pleasant. Does that count?" No, I said. A number of residents seemed to recognize that they might indeed ask about, for example, where the patient lives or what they do, but they hadn't had time.

Still others had asked about such things, but needed to be given permission, so to speak, to talk about such things right up front - to give the patient's love of crossword puzzles, devoted membership in her church choir, and collection of giraffe figurines the same pride of place as her creatinine and medication adherence. 

(There was even one resident who gave a laugh and went right on with her presentation -- I'm not sure if she didn't understand, or was just ignoring me.)

None of the residents gave such personal  information about the patient in the lead-in to their presentation before I asked for it. Only certain kinds of knowledge of patients are allowable - their biomedical data, their physiological malfunctions, and (some of) their symptoms. But not their personal lives, not what makes their lives -- to them -- worth living. Not them as people.

Of course, the criteria of allowable knowledge are transmitted only implicitly in medical school and residency. But they are powerful. They are an atmosphere all around a doctor in clinic - so much so that even I, several rungs above residents in the hierarchy, feel self-conscious asking them to give me one (just one!), apologetically named "non-medical thing," about a patient. And even then, I must justify it -- "It's about seeing the patient as a whole person."

What non-medical thing have you asked your patient about, or shared with your doctor?

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