Malpractice Isn’t a Sin

Dear physicians, PAs, NPs, nurses, medics, assorted therapists, techs and all the rest:

The great thing about our work is that we intervene and help people in their difficult, dire situations.  We ease pain, we save lives. Our work is full of meaning and joy.  However, we sometimes make mistakes.  But remember, in the course of a career you’ll do far more good than any harm you may have caused.

I know this issue lingers in many hearts.  I know it because it lies in mine.  And I’ve seen it in other lives.  I said this once to a group of young residents and one young woman burst into tears. I never knew the whole story, but I imagine there was some burden of pain she was carrying for an error she had made.

But just in case you too have lingering anxiety or guilt about some error you made in patient care, I feel it necessary to say this: neither honest errors nor even malpractice are sins.  They are mistakes, born of confusing situations, fatigue, inadequate experience or knowledge, overwhelming situations, the complexity of disease and the human body, social situations, systems problems, general chaos.  Born of your own humanity and frailty.  Your ‘shocking’ inability to be perfect at all times, and in all situations.  They do not make you evil, bad, stupid or even unqualified.  (PS If you’re not actually a physician but pretending to be one, you’re actually unqualified so stop it.)

As a Christian physician I have contemplated this over and over and have come to the conclusion that God knows my inadequacies and loves, and accepts me, regardless.  He has forgiven my sins.  I embrace that reality every day.  He forgives my pride, anger, sloth, greed, lust, all of them.  But he doesn’t have to forgive my honest errors.  Because they are not sins. Go back and read that again.  Your honest errors are not sins.

Mind you, all of the brokenness of this world is, in my theology, the result of ‘Sin’ with a capital S.  (Not in the sense of minute, exacting moral rules, but in the sense of the cosmic separation of the creation from the Creator.)

So, my mistakes, my failures are born of Sin, but are not ‘sins.’  If my mistakes, if the harm I may cause, come from rage, vindictiveness, cruelty, gross negligence, murder, drunkenness or other impairment on the job, then they could reasonably be due to ‘sin.’  But even so, those sins can be forgiven, and washed away with confession and true repentance.  (Not platitudes or superficial admissions of guilt, mind you, but genuine heart felt ‘metanoia,’ the Greek for repentance, which means ‘to change direction, or change one’s mind.’)

If you are not a believer, join us!  But if you aren’t interested, I love you too and want you to move forward, not burdened by unnecessary guilt.  If you are a believer, and a practitioner, remember that Jesus (The Great Physician) set the bar pretty high and doesn’t expect your perfection, only your honest, loving best.

Mistakes, even mistakes that rise to malpractice, are not sins.  But even if they rise to sin for reasons listed above, they are no worse than any other.  Which means Jesus atoned for them as well.

Move forward in joy.  You were forgiven before you even started worrying about it.

Now go see a patient. The waiting room is full of people who need you!

Merry Christmas!

Edwin

 

 

EvidenceCare: A Great New Information Tool for the ED

I walked through the halls of the 2016 ACEP Scientific Assembly, marveling at both the new and names-you-know companies that are guaranteed to help me gain control of my time, my practice, or my destiny and be a better, more informed physician.
As EM physicians we have to be focused on unearthing just the information necessary to make swift and thorough, often life-saving, decisions regarding a patient’s health and well-being. Responding at the pace necessary to keep up in a busy ER requires us to keep a ton of information in our heads or know where to go at a moment’s notice.
I came across an EM doc at ACEP who clearly understands, and sympathizes, with our need for accurate, useful information to apply in the chaos of the ED.  As a resident at the University of Virginia, Brian Fengler spent a year researching Pulmonary Embolism and publishing a protocol that was relied upon by many. A few years later, Dr Fengler was working in a busy ER and was faced with a woman who had a massive PE…and was 36 weeks pregnant. He knew exactly what to do for the patient but was puzzled as to the risks to the baby. He did what we do, and turned to Dr. Google for a consult. After 10 minutes of digging, he didn’t find anything more than he already had in his head. He took a chance and made a decision to treat the patient aggressively. Fortunately, it was the right move for that patient and her child. But, just as 80% of the decisions we all make in the ER every day, it wasn’t evidence-based. It was an educated guess. Is that the kind of medicine we want to practice?
Fengler didn’t. He never wanted to face the uncertainty he felt that day again. He went about creating a tool that helps docs like us put our fingers on the guidelines and evidence we need, specific to the patient we are seeing, in about 30 seconds. And, he built it to work how we think. I got to see his tool, EvidenceCare, at ACEP and was at once impressed and covetous.  I wanted to be able to use it!

The treatment guide-lines on EvidenceCare been authored by the best in the business… it’s like taking DeBlieux, Kline, or Mattu to work with you. Even better is the way it helps us connect with our patients by translating treatment recommendations into a language and format that makes sense to them…something that is proven to double patient satisfaction.

Furthermore, the treatment pathway you use on EvidenceCare can be imported into your EMR note to show why you made the decision you did!
Over the decades I have become acutely, sometimes painfully, aware that all the information I need to serve my patients isn’t in my head. While I firmly believe that there are things we should memorize, the volume of information we need to use on a daily basis requires that we use various tools to help us.  In fact, a physician friend made the great point that we should be able to access those tools when we take boards, since practice doesn’t occur in a sterile vacuum.  I couldn’t agree more.

So I encourage you to take a look at EvidencCare, for your own personal use or for your facility.  I’ve been using it and find it simple and elegant. And if you read the blog regularly you know I don’t pitch products very often, so that should tell you something.

EvidenceCare content is free.  But if you subscribe to EvidenceCare using the discount code LEAP, you get 33% off the premium edition which allows you to accrue CME, offers a shared decision make tool for use with patients, and allows you to paste information into the EMR as I mentioned above.

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Edwin

Sports Impairment and My Southern Man-Card

 

This is my column in today’s Herald-Dispatch.  My hometown newspaper in Huntington, WV!

http://www.herald-dispatch.com/opinion/edwin-leap-don-t-worry-you-won-t-lose-your/article_3706dd19-3472-520d-856d-09e3580d3886.html

It’s a terrible confession to make as a Southern male, but here it goes. I don’t care a lick about sports; not leagues, not high school, not college not pro. It feels liberating to say so. I figured I might as well be honest about it, because I’m forever confronting the reality of my sports-impairment in various and sundry ways.
One way my dilemma arises is I’m standing in the check-out line at a store, wearing my WVU t-shirt when another customer asks what I think of the Mountaineer’s chances this year. I usually make some sort of generally non-committal remark about how ‘I sure HOPE they do better this year!’ Which means that at some point in the distant future, if they manage to win a championship, I’ll have to be more careful and say ‘well, if LAST year was any indication this should be a good one!’ I try not to make eye-contact. It’s too uncomfortable.
What I usually want to explain, but never bother, is that I wear the shirt because I grew up and went to school there. And it was awesome and I have wonderful memories (same reason I wear my Marshall shirt). But it’s hard to stop a die-hard sports fan and say, ‘well, the truth is I really didn’t have time for sports because I was studying a great deal, but I’m proud I graduated!’ That makes people go to the next checkout line and shake their heads.
I’ve noticed the same thing at church. I remember finding myself in deacon’s meetings with little to contribute to the discussion at zero dark thirty Sunday morning. As everyone made the rounds of the previous day’s games, it was ‘Ed, Marshall did well yesterday didn’t they!’ ‘Sure did…(I guess).’ I put my head down, ate my biscuits and gravy and (since I live in South Carolina) I just let the orange or garnet wave pass over.


I’m not trying to be a snob, please understand. In my childhood I just wasn’t formally taught anything about athletics. Admittedly, my dad built a basketball court for me in the back yard. All the neighborhood kids and I had a great time there at all hours of the day and evening. But the rules were not exactly formally enforced. It was as much social time as athleticism. I also learned a little about football in the front yard. Specifically, I learned that ‘touch’ can be widely interpreted. I realized that lying on my back gasping for air one day, looking up at the fading blue sky.
I remember once around sixth or seventh grade that I went to the mother of one of my more athletically inclined friends and asked about joining a basketball league. She was kind, in a ‘bless your heart’ sort of way, and said we might be able to cram on the rules but it wasn’t looking good. Age 12 and I was already too old to start. I got the message and moved on without looking back.
Instead I filled my days with walks in the woods, turning over rocks in the creek for crawdads, seining for minnows, riding horses with my grandfather, shooting arrows into bales of straw, carrying my BB gun everywhere, shooting bigger guns whenever the opportunity afforded itself and generally acting like a joyous junior barbarian. Those became my preferred activities, until I discovered martial arts, then girlfriend, in high school.
My wife Jan grew up with brothers playing football. If I don’t understand a game that’s on, I just ask her and she guides me through. Two of my children attend Clemson University, and the other two are also fans, which is great. But they didn’t get it from me. Just recently they were all talking about the season and daughter Elysa said, with surprise, ‘why look at us, talking about sports like a normal family!’
I have great respect for all those devoted to their teams, who can quote stats like chapter and verse of scripture. May your team get all of the touchdowns, field-goals, runs and everything else it needs. But to all those who never got it, who never fell in love with sports, it’s alright. You aren’t alone.
Do your thing. You aren’t less of a Southerner or less of a man. And when the discussion turns to yesterday’s contest, learn to smile, nod and just say this: ‘that was some game!’

The Burning Babe. A Christmas Poem by Robert Southwell.

I posted this last year.  But every year it moves me again.  Merry Christmas.  Of note, the author was a Catholic martyr, killed in 1595. http://www.poetryfoundation.org/poem/174450

By Robert Southwell, SJ 1561–1595 Robert Southwell, SJ

As I in hoary winter’s night stood shivering in the snow,
Surpris’d I was with sudden heat which made my heart to glow;
And lifting up a fearful eye to view what fire was near,
A pretty Babe all burning bright did in the air appear;
Who, scorched with excessive heat, such floods of tears did shed
As though his floods should quench his flames which with his tears were fed.
“Alas!” quoth he, “but newly born, in fiery heats I fry,
Yet none approach to warm their hearts or feel my fire but I!
My faultless breast the furnace is, the fuel wounding thorns,
Love is the fire, and sighs the smoke, the ashes shame and scorns;
The fuel Justice layeth on, and Mercy blows the coals,
The metal in this furnace wrought are men’s defiled souls,
For which, as now on fire I am to work them to their good,
      So will I melt into a bath to wash them in my blood.”
      With this he vanish’d out of sight and swiftly shrunk away,
      And straight I called unto mind that it was Christmas day.

Christmas Poem, G.K. Chesterton

Christmas Poem

G.K.Chesterton

There fared a mother driven forth
Out of an inn to roam;
In the place where she was homeless
All men are at home.
The crazy stable close at hand,
With shaking timber and shifting sand,
Grew a stronger thing to abide and stand
Than the square stones of Rome.

For men are homesick in their homes,
And strangers under the sun,
And they lay their heads in a foreign land
Whenever the day is done.

Here we have battle and blazing eyes,
And chance and honour and high surprise,
But our homes are under miraculous skies
Where the yule tale was begun.

A child in a foul stable,
Where the beasts feed and foam;
Only where He was homeless
Are you and I at home;
We have hands that fashion and heads that know,
But our hearts we lost—how long ago!
In a place no chart nor ship can show
Under the sky’s dome.

This world is wild as an old wife’s tale,
And strange the plain things are,
The earth is enough and the air is enough
For our wonder and our war;
But our rest is as far as the fire-drake swings
And our peace is put in impossible things
Where clashed and thundered unthinkable wings
Round an incredible star.

To an open house in the evening
Home shall all men come,
To an older place than Eden
And a taller town than Rome.
To the end of the way of the wandering star,
To the things that cannot be and that are,
To the place where God was homeless
And all men are at home.

(Gilbert Keith Chesterton)

With thanks to:

http://www.gkc.org.uk/gkc/books/christmas-poem.html

Not only do GKC and I share a name (my first name is Keith, as is my father’s), he is truly one of my great literary heroes.  If you aren’t familiar with his work, please look it up.  His biographies of St. Francis and St. Thomas are very good, and his fiction is always fun; even his serious Christian work is a pleasure.  He was a great influence on C.S. Lewis.  Oh, and he carried a sword cane and pocket pistol with which to defend his treasured wife.  Thanks, GKC, for your gifts to us!

 

Holidays and Holy Days; My Christmas Book

This is a book of columns about Christmas and Easter that I put together with the SC Baptist Courier two years ago.  It’s still available and I think you would enjoy it!

https://www.amazon.com/Holidays-Holy-Days-Grace-Sacred-ebook/dp/B00PBHEF58/ref=sr_1_1?s=books&ie=UTF8&qid=1480385263&sr=1-1&keywords=holidays+and+holy+days+edwin+leap

 

Learning to be Careful; The Hard Way.

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One of the terrible things about being a physician who has spent his adult life working in emergency rooms is that you have a certain terrible clarity about the dangers of this life. It’s why we’re forever pestering our loved ones with phone calls and texts: ‘are you there yet!’ Or telling the children, ‘be careful! After midnight there are too many drunks on the road!’ Met, of course, with rolled eyes.

We see, we have seen, a shocking variety of ways in which people shrug off this mortal coil. However, it’s always a bit of an eye-opener when you walk through the valley of the shadow in person. I can think of a few times I did. Once, coming home from a residency interview, my dad and I nearly went full bob-sled under a jack-knifed tractor trailer driving downhill on an icy interstate in Maryland. There was the time I was almost stuck in the middle of a 10 foot wall of flames in the woods on our property. I ran out but only later realized how close I came to being barbecue. There was also the time I was bent over a tree that fell in an ice-storm, cutting it with a chain-saw. I stood up to stretch and another tree fell right where I had been bent. My doctor brain ran the possibilities and none were pleasant. I know what happens to the human body.

Now here I am, 23 years into my practice following residency, and I had another brush with my mortality. First, a little back-story. Like many families with multiple kids in high school and college, we are afflicted with vehicles. One of these cars (and I use the term loosely) is assigned to my high-school senior son, Elijah. For a few months the car (an automatic) would simply drop out of gear and lose all power. Thus it was consigned to the local transmission expert for a six week spa treatment, after which the transmission issues seemed fully resolved. But then it wouldn’t start.

So, one day last week Jan (my wife) and I decided to push it into a better location to try and jump the battery and trouble shoot. It was also in the way of the propane delivery truck, so it had to be moved. We were pushing it backwards, she at the front and I behind the open driver’s side door, pushing and steering simultaneously.

It’s a light car, an Infiniti I-10. Moving it was fairly easy. What became immediately clear was that stopping it was more difficulty. We pushed it across our driveway into the yard, which (we sadly forgot) slopes away at about 15 degrees.

The car picked up speed as objects on inclines are wont to do. But I was still behind the door. And it was headed for the many trees and stumps of our own forest. Jan yelled for me to be careful as I ran backwards. Then I tried (like the 52 year old fool I am) to jump into the seat and put on the brake. ‘Au contraire,’ said the involved force vector, which was hurtling the vehicle ever faster into the kingdom of the squirrels. And in my attempt, I fell to the side of the moving metal death-dealer, in front of the open door which my paramedic brother later described as a ‘scoop blade’ or some other horrible thing.

In a not very manly manner, I yelled. A lot. Perhaps to increase my strength as we do when lifting. Or perhaps because I knew it wasn’t going very well and I was very scared. I had visions of the car rolling over me and realized I had to push away. Finally, after being struck on the left shoulder and knee by the car door, I hit the ground hard and rolled away. As did the car, about 75 feet downhill into the woods, in the process nearly tearing off the driver’s side door, knocking down several trees and ending with a dent in the rear bumper and trunk.

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Many a small animal suffered panic attacks that day, and several trees crossed the rainbow bridge, or whatever it is trees cross when they are killed by hurtling bits of steel powered by stupidity.

Jan came to my side and I stood up, my pride injured, my arm black and blue, my knee tender and swollen. Nothing serious at all. The car? Less so. It had to be pulled out of the woods with a winch and hauled off on a flat-bed truck. In truth, I was ready to be shy of that car. I always had fears that it would lose power on the Interstate as Elijah pulled in front of a larger vehicle, or something like that. I’m ready to be done with it. I just didn’t realize we’d dispose of it by crashing it into the woods.

Christian that I am, I see divine providence all around. Maybe this was God’s way of making me sell the car; or scrap it. Certainly, God’s hand was in my escape from the Infinity that might well have launched me (somewhat ironically) to eternity. I am convinced that my guardian angel pulled me clear then threw his hands up and walked away for a snack break, or the weekend off. ‘Lord, I can’t be responsible when someone does something so ridiculous,’ he (or she) might have told the Father.

Even as I am thankful to God, I am also glad that I work-out, and so I have reasonable strength and agility. Among the many health problems associated with obesity and a sedentary life-style, one that is seldom mentioned, is that since life is dangerous, we must be prepared to rescue ourselves from said dangers as much as possible. As Rikki-Tikki-Tavi’s mother said, ‘A fat mongoose is a dead mongoose.’ I’ve always tried to live by that maxim. Except of course for not being a mongoose nor regularly encountering cobras.

I do think the lesson also reminded me to be more wary. I’m a guy who works in an emergency room. Not only do we treat the results of dangerous events, we are around the violent, the ill, needles, chemicals, infections and all sorts of things. I have to be diligent. Furthermore, I drive at all hours of the day and night. I work with power tools, including chain-saws. I handle firearms. I have a (sadly neglected) metal smithy where temperatures reach upwards of 3000 degrees F. I wrestle with my teenage sons. It is possible that God was just saying, ‘look, you’re no Spring chicken. I want you to do a lot more stuff for the Kingdom, so please be careful!’ To which I reply with a heart-felt, ‘You bet Lord, and thanks again!’

I shudder to think of the possible injuries I could have sustained the day the car rolled out of our control. They come to me in flashes of anxiety now and then, as I consider the horrific alignment of physics, anatomy and physiology. Head smashed against tree, hip dislocated, femur snapped like a dry branch, ribs broken, lungs collapsed. But the bottom line is I’m here, I’m fine, and God is good.

And I will try to never accuse any future victim of an accident of being stupid. Because bad things, dangerous and deadly things often start off with the most innocent of motives and accelerate much faster than we can imagine. All too often to terrible conclusions.

So we all need to just pay attention and think before we do, well, almost anything. Life is short. As one of my neurosurgeon friends used to say every time I consulted him, ‘hey, be careful out there, OK?’

Coastal Job for PA

Dear Physician Assistant Friends,

I have a friend who is recruiting for a position on the Southeastern coast.  Here’s his ad.  If you’re interested, send me a CV (edwinleap@gmail.com) and I’ll forward it on.  He’s a very nice guy and would be a great employer, in a nice location.

Edwin

 

Comprehensive family care is a family practice with a steady additional walk-in population throughout the year, and picking up in March and peeking in May June and July, averaging, 25 at the low, 55 at the high end. Ancillary staff are medical assistants . Current EMR is Greenway, formerly success EHS, and intend to switch to azalea. Ultimate goal is scribing, with only 25% of documentation currently being accomplished with the use of scribes. Hours are 8 to 5 daily,  Monday to Friday, half a day Saturday during seasonal hours, and will expand to Sunday with 1 to 2 PAs, who had been working 40 hours a week. I try to connect a competitive salary based on experience, and will ultimately arrange partnership track, with plan for buy-in options. Benefit package includes at this time malpractice and contribution toward health plan, but the benefit plan will expand based on productivity and commitment to the practice.

Election Related Illness…

Now that the presidential election is past, national emergency departments are seeing an increase in election-related health problems. While anxiety, depression and homicidal rage are what one might expect, it turns out, according to emergency physician Dr. Chuck McShortridge, the bigger issues seem to stem from people sitting at computers all day long and linking to political posts on Facebook, Twitter, Reddit and assorted other online outlets.
“Just last week we had three patients with massive pulmonary emboli. I asked their spouses about surgery, cancer, fractures, trips overseas, and the common thread was this: ‘No, but he (or she) spent the last six months linking to articles about how Hillary is a crook or Donald is a liar, or something like that.’”
Other physicians have noticed the same. Dr. Maggie McFarris reported another issue: “I keep seeing patients who complain of a constellation of symptoms: blurred vision, sleeplessness, carpal tunnel syndrome and in some cases, acute renal failure. I call it Donald-Clinton Syndrome. They never get off the (expletive deleted) couch. All day long it’s ‘that Hillary is a crook who can’t be trusted’ or ‘he hates women’ and links to dozens of articles a day. They don’t eat, they don’t drink, they don’t exercise, they don’t even have sex.”
One spouse we interviewed in the waiting room of a large ER said, “My wife has lost a lot of weight because she won’t eat! Just the other day I made this great vegetarian dish she loves and all she said was ‘I don’t have time, I just found this incredible piece on Trump at Politico and I have to share it!’ I ate dinner alone. Thank God the election is over say she can finally get the Xanax and IV fluids she needs.”
On a related note, some politically active physicians we met in the course of this article are lobbying to have advocacy counted as CME. Dr. Joseph Mooring, known for his bumper-sticker-laden Subaru, political buttons and frequent presence at online forums, stated: “CME? Who has time for that? I’m trying to save America, and in the process American healthcare! I should totally get credit for the hours I’ve logged trying to save the nation!” American Board of Emergency Medicine representatives said the board might be able to work political advocacy into the new Lifelong education modules.
Practitioners are urged to continue to be diligent in looking for election related illness and injury.

Idols All Around

http://www.greenvilleonline.com/story/opinion/contributors/2016/11/14/commentary-humans-easily-deceived-idols-every-sort/93588762/

One of the consistent themes that runs all through the Bible is the theme of idolatry. And if we can learn anything from its writers down the thousands of years and hundreds of generations since they lived, it’s that humans are easily deceived by idols of every sort.
It’s arrogant for us to laugh off the idea of stone and wooden deities, and shake our heads at the fish or dragons, serpents or elephants that they represented to our ancestors. (That’s right, all of our ancestors!) Because we’re no less susceptible despite our assertions that we are modern and rational. Twenty-first century man remains a remarkably idolatrous creature.
This is rarely as evident as it is during a presidential election cycle, when we believe that vast power, and all our destinies, rest with the office and person we are electing. If only we elect him, or her, all our problems will be solved and our enemies smitten! We elevate candidates and politicians to places they were never meant to be, not by God, nor indeed by the founders of our republic, who doubtless had a much more suspicious view of human character than we do; else they would never have built in so many checks and balances.
In fact, during elections we also make idols of government in general, constitutions, courts and legislative bodies. We worship commentators and media outlets and anyone and everything connected with the process. We idolize our own opinions and spend far more time in our own personal echo-chambers than we do either worshipping God or (for the non-religious) simply pursuing secular knowledge or simple joy. Pity, as our self-adulating tirades and tantrums change few minds.
But it isn’t only politics. We all have our idols. Thanks to social media, young people take constant photos of themselves in a kind of self-worship. Social media have also allowed Americans to make an idol of the approval of others, whether in likes for one’s selfie, or agreement with one’s views. The disapproval of others is a bitter pill whose side effects include exclusion from friendly society; a kind of excommunication for heresy. How many opinions would be shared more honestly if not for the fear of being shunned or attacked en masse online?
Conservatives often idolize guns or military prowess, as if they could save us from all danger. And yet the Bible says ‘Some trust in chariots and some trust in horses, but we trust in the Lord our God.’ (Psalm 20:7) (The chariot being the main battle tank of antiquity, by the way.) And liberals make an idol of choice, as if replacing the word ‘killing’ with a euphemism makes it less like the reality of killing an unborn child, less like a modern adoration of the dark god Molech.
We idolize the freedom of sexual expression and sexual orientation, as if all that mattered in this life were who could have sex with whom. And on the other side, we idolize morality, as if our sanctimonious attitudes about sexual sin were anywhere as important as the forgivingness and redemption offered in the Bible to those who sin sexually, gay or straight. Grace matters more than moralism.
America idolizes the idea of compassion and charity without understanding the moral and spiritual underpinnings that make it reasonable and possible. And yet, we also idolize the American concept that everyone can simply succeed if they try, which is simply untrue. The deck is sometimes stacked and there are those who need our assistance, personally and through state programs. Some idolize capitalism, some idolize socialism, but both can become monstrous deities when not applied with Godly wisdom and caution.
The Decalogue begins with ‘I am the Lord your God who brought you out of slavery, out of the land of Egypt.’ And follows it immediately with ‘you shall have no other gods before me.’ And of course, after receiving the Ten Commandments, the people promptly made a Golden Calf and ignored God, the source of all their good things. You can be an atheist and still see the truth in this tale. This is the story of all mankind. The worship of those things we shouldn’t, and the rejection of those things that are truly, ultimately good.
Whether a citizen is religious or not, we can surely agree that we all have idols we should take from their altars. Maybe it’s a good time to start.