Dr. Barry Dworkin » Geriatrics

Don’t Sweat the Small Stuff

Dr. Barry Dworkin — Sat, 02 Jul 2005 21:43:23 +0000

Published in July 2005 in The Ottawa Citizen

With summer approaching, an understanding of summer heat upon the human body can help prevent heat-related illnesses.

The body has four means of dissipating heat: conduction, evaporation, radiation and convection.

Conduction is the transmission of heat through a substance like blood, water or other tissues. The muscles, warm from exercise, can dissipate heat directly to the skin surface. Blood can absorb great quantities of heat from the muscles and other tissues. It will return to the heart and then circulate to the small blood vessels in the skin. During exercise, the blood vessels dilate to allow greater quantities of blood to transfer heat to the skin surface.

The skin will radiate heat into the surrounding air and environment just like a space-heater. Sweat on the skin surface can absorb the heat and evaporate to reduce body temperature.

As the air warms around the body, it will rise. Cooler air moves in to replace it and absorbs body heat. This cycle is called convection and explains why fans help cool us.

Each mechanism works best within a specific temperature range. At temperatures less than 20ºC, radiation, convection and conduction will dissipate most generated body heat. Above 20ºC, evaporation of sweat is the primary means of heat dissipation.

Children do not sweat as much as adults and produce more heat for the same level of activity. They need to generate greater levels of heat before they do sweat.

Overweight individuals do not dissipate heat as well compared those of normal weight. The elderly have a decreased thirst response, and a reduced ability to circulate blood to the skin surface. Their blood vessels do not dilate as well as younger adults.

Certain medications can contribute to the risk of heat illness.

As temperature and humidity increase, evaporation becomes less effective. On a hot city day, core body temperatures increase because of radiant heat from the sun’s and hot concrete surfaces.

Evaporation accounts for 85 percent of heat loss during vigourous exercise (a 70 kilogram athlete can lose one to two litres of sweat per hour). Failure to replace water and salt loss further compromises conduction and evaporation.

Adapting to the effects of heat during exercise over a specific time is termed acclimatization. This allows one to adapt to the increased demand to dissipate heat. Fluid replacement is essential for this process to work.

The five types of heat-related illness from mild to severe are; heat swelling (edema), heat cramps, fainting from heat (heat syncope), heat exhaustion and heat stroke.

Heat edema occurs in people who have not undergone acclimatization. Fluid leaks out into the tissues of the feet especially when standing for prolonged periods. Leg elevation reverses this process.

Heat cramps are painful abdominal, arm or leg muscle spasms occurring when too much salt and water is lost. This is a warning sign of pending heat exhaustion. Drinking water, juice or sport drinks and eating salty foods will relieve the cramps.

If there is no cool-down period after exercise, fainting is a risk. Blood pressure can drop when quickly transferring from a sitting to standing position. Dehydration worsens heat syncope. Lying flat with legs elevated rapidly reverses this condition.

Heat exhaustion occurs with excessive sweating in a hot humid environment. Body fluid volume is lost. The core body temperature increases from 38ºC to 40.5ºC. Symptoms include profuse sweating, fatigue, headache, dizziness, visual disturbances, lack of appetite, nausea, vomiting, vertigo, chills, muscle weakness, rapid heart rate (tachycardia), low blood pressure (hypotension) and skin flushing.

The person must be moved to a cool area. Applying cool water-soaked cloths helps. Elevate the legs. Those who are alert need one litre of oral fluid replacement per hour for two to three hours. Disoriented or unresponsive people require emergency treatment. All need a thorough medical evaluation at the hospital.

Heat Stroke is the most severe form of heat-related illness. Body temperature exceeds 40.5ºC and leads to multi-organ damage and failure. Altered mental status is a critical determinant of heat stroke. This medical emergency needs prompt evaluation and treatment.

Preventing heat-related illness is straightforward.

Stay in air conditioning if possible.
Drink lots of water before, during and after any outdoor activity.
Avoid drinks with caffeine or alcohol. They will increase fluid loss via urination.
Increase the amount of time you spend outdoors every day little by little.
Take frequent rest breaks while outdoors on hot days.
Avoid direct sunlight and stay in the shade when possible.
Wear light-colored, loose-fitting, open-weave clothes.
Avoid activities that require helmet use.
Try scheduling activities or workouts early in the morning or late evening. Avoid heavy outdoor activity between 10 a.m. and 6 p.m.

Enjoy your summer.

Painful to lose independence

Dr. Barry Dworkin — Mon, 14 Feb 2005 22:38:54 +0000

Originally published in The Ottawa Citizen February 14, 2005

Watching someone we love lose their sense of self has become an all-too-common occurrence in Canada and, indeed, in many parts of the world. Even as adults, our childhood image of our parents is firmly imprinted into our minds. The piece-by-piece loss of this image is painful to witness and frightening to the afflicted.

Although we associate dementia (the loss of intellectual capacity, gradual loss of memory, mood swings, changes in behaviour and inability to perform daily tasks) with the aged, Alzheimer’s disease, the most common form of dementia, occurs throughout adulthood.

How many Canadians suffer from Alzheimer’s? How do you recognize it? What have we learned about this disease? What treatments are available and what progress can we expect in the future?

The most common form of Alzheimer’s disease is Sporadic, involving 90 to 95 per cent of all cases. There is a rare genetically inherited form called Familial Autosomal Dominant that accounts for the remaining five to 10 per cent. Two-thirds of the 280,000 Canadians afflicted are women. One in four Canadians has a family member with the disease. Within the next 25 years, as baby boomers age, the number afflicted will increase to 750,000.

Today, $5.5 billion a year is spent providing nursing-home care, medications and community support services for people with dementia. Annual per person costs proportionally increase with disease severity: $9,541 for those with mild disease to $36,794 for those with severe disease.

We know the disease causes gradual unrelenting brain injury and damage. The brain is organized into different zones, each responsible for a specific function. For example, short-term memory loss, loss of vocabulary skill, and the inability to recognize familiar faces is associated with damage to the temporal lobe and hippocampus.

Despite these changes, people still appreciate, respond to and experience a full range of emotional responses.

Brain tissue becomes damaged because too much beta amyloid protein is secreted into the region. The carrier molecules that usually transport the protein away from the area are overwhelmed. As a result, plaques form and destroy the brain cells (neurons). In addition, twisting choking stringy material within living neurons (neurofibrillary tangles) destroy more of them.

Patients and their family and friends have difficulty pinpointing when the symptoms began because of the slow, progressive nature of the illness. Indeed, many of the treatments available work best in those with mild to moderate disease. An early diagnosis is essential to try to limit the speed of disease progression and improve quality of life.

Although there is no cure for Alzheimer’s disease, there are three cholinesterase inhibitor medications, donepezil (Aricept), rivastigmine (Exelon) and galantamine hydrobromide (Reminyl), available for people with mild to moderate disease that can help improve or slow the decline of cognitive tasks such as memory, language and orientation (knowing the date, time, and who you are). They can stabilize the person’s ability to cope with the responsibilities of daily life.

Notable in Alzheimer’s disease, many of the neurons that are destroyed produce acetylcholine, a neurotransmitter linked to learning and memory. When a neuron activates, it will communicate with the adjacent neuron by sending acetylcholine to it. The acetylcholine in turn will activate the next cell to keep the message going.

These cholinesterase inhibitor medications increase the amount of acetylcholine in the brain by blocking cholinesterase, the enzyme that breaks down acetylcholine, leading to an improvement of some symptoms.

Recently, mamantine (Ebixa), a different class of medication, was approved for use for people with moderate to severe disease.

Cessation of therapy results in symptom relapse after a few weeks. It requires about three months of therapy to see peak improvements. Over the next nine to 12 months, there is a slow return to the original starting point. Thereafter, the decline is slowed compared to those who do not take the medication.

New research is promising. A new drug called Alzhemed, currently in clinical trials, appears to prevent the formation of amyloid plaques and encourages the mopping-up of the beta amyloid before it reaches threatening levels.

Recently, an antibody vaccine against beta amyloid was injected into the brains of mice, and reduced plaque formation.

Although there is no known means to prevent Alzheimer’s disease, there are lifestyle measures that can reduce the rate of onset of the disease: exercise (walking has been shown to delay cognitive decline), smoking cessation, controlling high blood pressure and elevated cholesterol levels, moderate alcohol intake, and healthy eating habits.

Advances will continue as researchers gain more insight into the mechanism of the disease. This is happening now and offers hope to those suffering with this disease and to their families.

The Alzheimer Society of Canada website, www.alzheimer.ca, contains a plethora of information about the disease.

Elderly vulnerable to ill effects of heat waves

Dr. Barry Dworkin — Wed, 02 Jul 2003 22:14:43 +0000

Originally published in The Ottawa Citizen July 2, 2003
Original Title: Sweat Shops

The effects of this current heat wave and high humidity levels are particularly dangerous for children and the elderly. Children have parents who oversee their well-being and protection from the elements. Many elderly people on the other hand do not have this level of care. They remain confined to their residences, nursing homes or apartments, some without the benefit of air conditioning.

What specific difficulties are encountered with age as it relates to heat regulation? The normal response to heat overload is a ramping-up of the body’s heat dissipation mechanisms.

Normally, heart rate increases to deliver more blood to the blood vessels on the skin surface where heat dissipates. The skin will lose heat through the processes of evaporation of sweat, air convection, heat conduction and radiation. These processes are less efficient with the current weather conditions.

The elderly have a decreased thirst response. They are at risk of not replenishing water lost through sweating. With this week’s temperatures it is not unreasonable to assume a loss of a litre of sweat every one or two hours. This rate increases with physical exertion or activity.

Many elderly people are on some type of medication that can increase the risk of heat stroke and dehydration. Diuretics such as hydrochlorothiazide and furosemide (Lasix) are commonly used to treat hypertension and congestive heart failure among other disorders. They promote salt and water loss through their affect on the kidneys.

Alcoholic and caffeinated beverages also have diuretic properties. The use of laxatives, especially the harsher agents can augment fluid loss.

They will rapidly dehydrate should they not adequately replace their fluid loss. Their blood volume will contract because of the water loss. Less blood will flow to the skin surface reducing heat transfer to the skin surface. A reduction of sweating ability compounds the problem.

With age, blood vessels do not dilate efficiently (vasodilatory response).Heart medications such as beta-blockers and certain calcium channel blockers can reduce heart rate and blood pressure reducing the capacity to circulate blood. The elderly’s maximum heart rate is much less compared to a younger adult further reducing blood flow to the skin. This also reduces the body’ ability to dissipate heat from the skin surface.

The elderly tend to be less fit and are not as mobile as younger folks. Some are bedridden or so incapacitated that they have difficultly replenishing their fluid supply. It can be difficult to get to the kitchen.

Since many of the elderly remain indoors, it is difficult to know who needs help. If you suspect someone is at risk, please check up on them. If you live in a non air-conditioned apartment complex and are uncomfortable from the heat be very aware of your risk. Knock on your elderly neighbour’s door to ensure they are safe.

This week’s temperatures and humidex will cause heat gain via heat radiation into the body. Humidity interferes with sweat evaporation. The end result can be swelling, heat cramps, fainting, heat exhaustion and heat stroke.

General recommendations for prevention include:

* Stay in air conditioning if possible.
* Drink lots of water before, during and after any outdoor activity.
* Avoid drinks with caffeine or alcohol. They are diuretics that will increase fluid loss via urination.
* Take a lot of rest breaks if you must go outdoors in hot weather.
* Avoid direct sunlight and stay in the shade when you can.
* Wear light-coloured, loose-fitting, open-weave clothes.
* Change wet clothes.
* Try to schedule activities early in the morning or late in the evening.
* Avoid heavy outdoor activity between 10 a.m. and 6 p.m., when the sun is hottest.

Source: American Family Physician

Please contact your doctor if you have questions about your medication use during this heat wave.

Elderly suffer after lengthy use of anxiety drugs

Dr. Barry Dworkin — Tue, 23 Apr 2002 22:10:43 +0000

Originally published in The Ottawa Citizen April 23, 2002
Original Title: Around the Benz

Mr. T. is a strapping 85 year-old man who suffers with an anxiety disorder. He also cares for his wife who is severely affected by Alzheimer’s. Twenty years ago he was prescribed clonazepam (Rivotril), a benzodiazepine (BDZ). He became dependent upon them to control his anxiety. BDZs and the elderly do not mix well.

Benzodiazepines such as Alprazolam (Xanax), oxazepam (Serax), diazepam (Valium), Rivotril and lorazepam (Ativan) are widely prescribed medications. They are used for the immediate treatment of seizures and convulsions, detoxification from alcohol, muscle spasms, pre-surgical sedation, insomnia and most commonly for anxiety related disorders and conditions. Some people use them for jet lag use or if they have an air travel phobia.

Perusing the product monographs found in the Compendium of Pharmaceutical and Specialties (CPS), the big blue tome in your doctor’s office, benzodiazepines are not indicated for long-term use. Approximately 15 percent of the adult population has taken a BDZ one or more times over the past year. One to two percent has taken them daily Mr. T. is a strapping 85 year-old man who suffers with an anxiety disorder. He also cares for his wife who is severely affected by Alzheimer’s. Twenty years ago he was prescribed clonazepam (Rivotril), a benzodiazepine (BDZ). He became dependent upon them to control his anxiety. BDZs and the elderly do not mix well.

Perusing the product monographs found in the Compendium of Pharmaceutical and Specialties (CPS), the big blue tome in your doctor’s office, benzodiazepines are not indicated for long-term use. Approximately 15 percent of the adult population has taken a BDZ one or more times over the past year. One to two percent has taken them daily for 12 months or longer. Some patients have been using them for decades. The elderly are major consumers of this medication.

Patients prefer them because of their rapid onset of action and that they can be used on an “as needed” basis. They are problematic medications because of their abuse potential and effect on concentration, driving and balance. Long-term daily use over months and years can lead to habituation, dependency and tolerance (needing increasing doses to produce the same effect).

They are responsible for confusion and poor balance especially upon awakening in the middle of the night as many elderly people are wont to do. They have an increased risk of falling that can unfortunately lead to broken hips, internal bleeding and head injuries. Driving the following day is statistically hazardous (doubling the risk of a crash) even after the sedating effects of the medication have waned. Reaction times and reflexes are diminished. This is true for young and old drivers alike.

BDZs are particularly damaging to the sleep cycle. The normal sleep cycle has four stages (1 – 4) plus a dream stage (REM sleep). The first two stages are associated with light sleep followed by the deeper more restful third and fourth stages. We all know these stages quite well. When roused from deep sleep we have that “hung- over” feeling whereas awakening from light sleep is a mere nuisance. Benzodiazepines increase the time spent in stage one sleep and interfere with the deep stages. Although you will sleep, it is not refreshing. Sleep cycles can be damaged by their long-term use. This is another reason why people have such a difficult time stopping BDZs. They become dependent upon them to induce sleep since their brain is now unable to do so independently.

Newer non-addictive medications are available to help people with insomnia such as Zaleplon (Starnoc) and Zopiclone (Imovane). Starnoc helps you fall asleep. Imovane reduces the duration of light sleep but increases the time spent in deep sleep thus preserving sleep architecture (the normal sleep cycle).

Although effective for acute (sudden) anxiety, BDZs do nothing to treat the underlying cause of anxiety disorders. These disorders are interrelated with Major Depressive, Obsessive-Compulsive, Generalized Anxiety and Panic Disorders. All these conditions are treated with non-addictive medications that treat the disease and not the symptoms. Anxiety usually wanes once the underlying cause is treated.

There specific indications for BDZ use. Most physicians do not like to prescribe them especially when other alternatives are available. The problem: Starnoc and Imovane are not covered under the Ontario Drug Benefit program. This leaves many patients and physicians unable to choose this option. Many elderly patients do not have supplementary health insurance. The group most at risk is yet again penalized. Score another point for the short-sighted bureaucrats at the Ministry of Health.

BDZs are relatively contraindicated in patients with current alcohol and drug abuse problems and for those in recovery programs. They should never be used during pregnancy because of the risk of birth defects. It can lead to dependence and withdrawal symptoms in the newborn. Patients addicted to BDZs are advised not to abruptly stop their medication because it can lead to seizures. Withdrawal has to be done slowly and under the direct management and close supervision of a physician.

Mr. T. switched to an anti-depressant medication. Over the course of five weeks he gradually reduced his clonazepam dose until he was able to completely stop. His anxiety has disappeared and my anxiety about a potential disaster abated. He is better able to care for his wife.

If you have concerns about this issue talk to your doctor. If warranted, seek alternative solutions to your problem. And get a good night’s sleep.

Test drivers of all ages to make sure they’re competent

Dr. Barry Dworkin — Wed, 03 Apr 2002 22:33:30 +0000

Originally published in The Ottawa Citizen April 3, 2002

Sunday will mark the fifth anniversary of the death of my brother, Dr. Steven Dworkin, age 32. His senseless death continues to haunt me and I suppose will forever do so.

Earning his PhD in mathematics, an appointment to teach mathematics and physics at Rice University in Houston, married for less than a year and his wife recently accepted into medical school, it had all come together. His life had blossomed. That was until April 7, 1997.

My brother was run down in his bicycle lane near his home in Galveston, Texas, by a 72-year-old woman driving her car at a speed of 100 km/h. She stopped only after his body was thrown 125 metres down the road — this despite a damaged windshield.

The recent inquest by a Toronto coroner’s jury into the death of Beth Kidnie, dragged under the car driven by 84-year-old Pilar Hicks for almost a kilometre, produced three pages of recommendations to the Ontario government.

In these two instances elderly drivers were at fault. However, it is wrong to overgeneralize that all elderly drivers are suspect. There are excellent and poor drivers in every age group. Every driver should be evaluated equally under the law.

That being said, as a physician I know firsthand how the ravages of disease can compromise independence and normal day-to-day functioning. No physician is looking to recommend revocation of a patient’s driver’s licence. Indeed, many doctors fail to comply with the existing law to report “compromised” patients.

The reason is the definition of “compromised” is too broad. Taking a sleeping pill or breaking a leg would, under the law, require a letter to the Ministry of Transport attesting to the patient’s inability to drive.

It is important to be consistent and fair regardless of how painful reality can be. For those whose illness, despite treatment, continues to cause deterioration of their physical and mental capacities, there must be a means to determine their competence to drive. Accepting this premise means that the effects of aging must be taken into account.

It is not ageism to say that with age the incidence of stroke, deteriorating eyesight, slowed reflexes, dementia, heart disease and cancer among others, increase. Is this a reason to single out the elderly? No. It should be acknowledged that the process of aging presents challenging situations. The approach in the assessment of competency should be no different than it is for a younger driver who may suffer from a medical impairment. Driving competence should be viewed as a public health concern. Airline crashes make the headlines, but the carnage of our roadways far exceeds airline fatalities. All of us have a social responsibility to ensure we are prepared for any driving challenge.

The coroner’s jury in the Beth Kidnie case recommended graduated delicensing. This concept has merit for it would restrict driving under situations congruent with the driver’s medical condition irrespective of age. The goal is to maintain independence without compromising safety. The jury also recommended a review of road tests for drivers over the age of 80 and the content of indoor education sessions. They want a standard police form to report drivers suspected of having a medical impairment.

They also want new methods of screening drivers. If it is agreed that each driver is responsible for ensuring his competency to drive, then it follows that testing, education and skills upgrades are an acceptable means to achieve this goal. Drivers should be responsible for the expense just as they assume the cost of insurance and licensing. It is part of the deal.

Reporting a patient to the Ministry of Transport is a difficult process with the usual result being the destruction of the doctor-patient relationship. There has to be an independent means for assessing competency. Just as doctors order diagnostic tests for diseases, why not driver’s tests? If faced with a patient with a medical impairment, how better to assess their ability to drive than by sending them to an accredited driving evaluation facility?

Another approach could be standardized testing every five years for healthy drivers aged 16 to 60, from age 60 to 70, every two years and every year after 70. So long as the driver is able to meet the standard requirements for licensing based on an objective assessment, age becomes irrelevant.

If a person is unfit to drive, it behooves everyone to do the right thing. Denying reality helps no one. It certainly did not help Ms. Kidnie or my brother.

Assuming the worst

Dr. Barry Dworkin — Tue, 31 Jul 2001 20:43:23 +0000

Originally published in The Ottawa Citizen July 31, 2001

In June of 2000 my Dad was hospitalized for some surgery. He related the following story to me that made me stop and think about how we treat our patients and where, perhaps, some of our interpersonal skills come from.

My Dad walked the ward after his surgery whence he came upon an elderly woman near the nurse’s station. She appeared frail having several scars upon her scalp suggestive of old cranial surgery. Tied to her wheelchair by a drape of bed sheeting, he noticed that her right hand was moving. At first he thought these hand movements were involuntary, and yet something did not seem right. He asked the nurses about her but was told that she was demented and was not aware of her surroundings. During this brief conversation he noticed that her hand twitching was more deliberate.

Not a man to accept incongruous answers to observations that demanded a better explanation, he did what any man of science would do, he tested his hypothesis. He approached her and took hold of her hand. He instructed her that if she understood his questions to squeeze his hand once for ‘no’ twice for ‘yes’.

“Do you understand what I have said?’ Two squeezes.

“Can you hear me?” Two squeezes.

“Do you like your doctor?” One squeeze.

“Do you want to sue your doctor?” Two squeezes. (My Dad is also a joker.)

The doctor was skeptical and responded that she indeed was demented. My Dad asked him to take her hand and to repeat what he had done but asking her different questions. Again she responded coherently to each question.

My Dad noticed that the doctor went pale and had a look of horror upon his face. He immediately transferred her to the rehabilitation unit. The doctor asked my father to speak to the other patients on the floor as well.

My father felt “on top of the world” after that incident. He saved a woman from a life of hell, locked inside her body yet fully cognizant of her surroundings and no one hearing her scream for help.

We as physicians can sometimes assume too much. We have all committed this error to varying degrees during our careers. I think we all need a good reminder every so often about how we can effect someone’s life for good or for bad. We at times can be overwhelmed by our workloads and responsibilities that our empathy suffers. We are trying to provide so much to so many in so little time that in our rush to keep up we lose a part of ourselves that made us become doctors in the first place. At times we base decisions upon preconceptions.

My father experienced such joy that it brought him to tears. All of us should keep that feeling close to our hearts. We cannot cure everyone but we can still make a difference to people if we take the time to listen. My father’s simple act of taking someone’s hand changed their life. My father is not a scientist. He has never taken a science course. He sold insurance, drove a taxi, owned a grocery store and is an excellent butcher. He has had to communicate well in all his endeavors. He notices people. We ask ourselves and are asked at times where we learn to be a good doctor. I can proudly say I am my father’s son.

The hidden patient

Dr. Barry Dworkin — Tue, 08 Aug 2000 16:26:02 +0000

Originally published in The Medical Post, VOLUME 36, NO. 27, August 8, 2000

In June, my dad was hospitalized for some surgery. He related the following story to me: My dad walked the ward after his surgery whence he came upon an elderly woman near the nurse’s station.

She appeared frail and had several scars upon her scalp suggestive of old cranial surgery. Tied to her wheelchair by a drape of bed sheeting, he noticed that her right hand was moving.

At first he thought these hand movements were involuntary, and yet something did not seem right. He asked the nurses about her but was told that she was demented and was not aware of her surroundings.

During this brief conversation he noticed that her hand twitching was more deliberate. Not a man to accept incongruous answers to observations that demanded a better explanation, he did what any man of science would do, he tested his hypothesis. He approached her and took hold of her hand. He instructed her that if she understood his questions to squeeze his hand once for “no” and twice for “yes.”

“Do you understand what I have said?” Two squeezes.

“Can you hear me?” Two squeezes.

“Do you like your doctor?” One squeeze.

“Do you want to sue your doctor?” Two squeezes. (My dad is also a joker.)

He saw her eyes light up after this brief contact. He returned to the nurse’s station and demanded her doctor be called to the floor at once.

After a short spat of curt banter the nurse acquiesced and the doctor did indeed present himself. My dad related his observations to the doctor.

The doctor was skeptical and responded that she indeed was demented. My dad asked him to take her hand and to repeat what he had done but asking her different questions.

Again, she responded coherently to each question. My dad noticed that the doctor went pale and had a look of horror upon his face. He immediately transferred her to the rehabilitation unit.

My father felt on top of the world after that incident. He saved a woman from a life of hell; locked inside her body yet fully cognizant of her surroundings and with no one hearing her scream for help.

We, as physicians, can sometimes assume too much.

We have all committed this error to varying degrees during our careers. I think we all need a good reminder every so often about how we can affect someone’s life for good or for bad.

At times we can be so overwhelmed by our workloads and responsibilities that our empathy suffers.

Trying to provide so much to so many in so little time in our rush to keep up, we lose a part of ourselves that made us become doctors in the first place. At times we base decisions upon preconceptions.

My father experienced such joy that it brought him to tears. All of us should keep that feeling close to our hearts.

We cannot cure everyone but we can still make a difference to people if we take the time to listen. My father’s simple act of taking someone’s hand changed their life.

My father is not a scientist. He has never taken a science course. He sold insurance, drove a taxi, owned a grocery store and is an excellent butcher.

He has had to communicate well in all his endeavors. He notices people. We ask ourselves and are asked at times where we learn to be a good doctor.

I can proudly say I am my father’s son.