Is It My Heart, Doc?

This is an important question.  And I have to try to answer it every day. Sometimes several times a day.  Patients come to the emergency department with pain in the chest, or some other symptoms that make them worried about a heart problem.  Maybe walking up steps and getting winded, with some aching in an arm at the same time.  People worry about their hearts, and for good reason. The body doesn't work very well if the heart doesn't.

The answer can be straightforward.  It may be quite obvious that it's really not a heart attack but indigestion.  Some acid produced by the stomach has escaped upward into the esophagus.  The lining of the esophagus doesn't have the stomach's natural protection against that acid, and inflammation, with a burning pain, ensues.  Reflux esophagitis.  No, it's not your heart.  Pain from a diseased gall bladder can also mimic a heart problem.  And we can often tell the difference fairly easily.  Sometimes pain in the ribcage can be worrisome to the patient yet readily distinguished by the astute clinician.

It would make my job so much easier if the answer were always obvious.  When it really is the heart, it can be quite clear.  Anyone who has been a paramedic, or a nurse or doctor who takes care of emergency patients for years, can often tell when first laying eyes on such a patient.  Uh-oh.  Some heart attack patients just have that look.  And then the story, and the findings on physical examination, and the appearance of the electrocardiogram (ECG) just confirm the initial impression.

Sometimes the story and the examination are not clear-cut, but the test results give us a definite answer.

Yet patients with symptoms suspected of being of cardiac origin are a constant challenge because the initial evaluation in the ED - history, examination, ECG, lab tests - still leaves us uncertain about whether this is really a heart problem.  And the patient will require further evaluation.  Uncertainty is not a good thing when what we're uncertain about could be life-threatening.  People expect - and it seems to me a very reasonable expectation - a high level of diagnostic certainty when there is concern about something that could kill them.

Just what level of certainty should we be going for?  I have written before about the quest for diagnostic certainty, and about how we - and by "we," I mean both doctors and patients - should be asking ourselves whether it makes sense to devote a lot of time, effort, and money to additional testing to raise the level from 93% to 97%.  But remember, if it's 93%, that means being wrong roughly one time out of fourteen.  I'm OK with being wrong one time out of fourteen for some things. For example, if I think you have strep throat and want you to take penicillin, and I think it's unnecessary to waste time and money on a confirmatory test, what happens if I'm wrong?  The penicillin is very unlikely to cause any harm.  Serious reactions are quite rare, and I don't worry much about increasing bacterial resistance to it, because most bacteria are already resistant to it.  The strep that causes throat infections just happens to be an especially dumb bug, so penicillin still works.

But I don't think it's OK to be wrong one time out of fourteen about whether you have something that could cause severe, permanent disability or sudden death. Neither do most of my colleagues or most of my patients.  I guess some people are OK with that level of risk, but then some people jump out of airplanes, too. Yes, I realize that the frequency of the parachutes not opening is far less than one out of fourteen, but when it happens, the results are ... well, you know.

So we tend to be very cautious with ED chest pain patients.  We have all sorts of "tools" at our disposal to try to figure out what's wrong with them, and in particular whether it's a heart problem.  This is an area of intense clinical research: what is the best strategy for assuring that, if we send somebody home from the ED, the likelihood of something bad happening is vanishingly small?  (Or at least down in the 1% range, because no strategy that involves human beings is going to be right 100% of the time.)  We have a standardized name for the "something bad happening," too: MACE, which stands for Major Adverse Cardiovascular Events. Our medical journals have many published papers on strategies for evaluating ED chest pain patients to assure that the likelihood of MACE in the next 30 days (the most commonly used time period) is as low as possible.  Oh, and just in case you are worried about day 31, which I am, the better studies keep track of the patients out to a year.

You probably won't be surprised to learn that most of the patients we worry about turn out not to have heart disease as the cause of their symptoms.  That's what happens when you try to make sure you aren't missing anything.  The more diligently you pursue the goal of catching every potential life-threatening problem (thus avoiding the "false negative" result of your evaluation), the more false positives you are going to get: we were worried about your heart, but all of the tests are normal, so we're now as certain as we can be that it's not your heart. The perfect strategy for evaluating anything would have no false negatives and no false positives.  Unfortunately, that doesn't exist.

You probably also won't be surprised to find out that there is pushback.  All of this evaluation, and especially some of the more sophisticated testing, costs money. If you are a legislator, a regulator, a bean counter, or for any other reason interested in controlling health care expenditures, you are going to take a hard look at a part of the health care system that devotes significant resources to a specific patient population and seems to have a "low yield" relative to dollars spent.  An editorial in the New England Journal of Medicine last year said this:

The underlying assumption ... is that some [more definitive] diagnostic test must be performed before discharging these low-to-intermediate-risk patients from the emergency department.  This assumption is unproven and probably unwarranted.

Now, I'm as much of an enthusiast as anyone I know for the cost-efficient practice of medicine.  And so I'm torn between two impulses here: the first impulse is to agree with an editorialist who clearly shares my bias in favor of a cost-efficient approach.  The second impulse is the one that always seizes me, making me rub my hands with glee, any time I find that one of the world's most prestigious journals has published something stupid.  Remember, I'm a critic. And this statement is most assuredly stupid.

Guess who has the job of "stratifying" risk in this patient population?  Yes, 'tis I, your faithful blogger.  I'm the one who has to separate the high-risk patients from the rest and then decide what to do with the low-risk and the intermediate-risk patients.  And so I read the journals, always looking for the best strategy.  There are certainly some low-risk patients who can go home after a simple, brief, and relatively inexpensive evaluation.  Everyone else needs more.  And it's my responsibility to identify the cut-point.  Sometimes it's not straightforward.  I have a conversation with the patient about my risk analysis.  Some patients are worriers and very nervous even about fairly low-risk situations.  They are afraid to go home from the hospital without a higher level of diagnostic certainty.  And I respect that.  Other patients are skydivers.  They want to stay in the hospital as much as I want to go to ... oh, pick something, because whatever I pick (say, Wagnerian opera), I'll offend somebody who likes it.  "Doc, your best guess is that it's probably not my heart?  That's good enough for me.  I'll call my doctor Monday and then she and I will decide about further testing."

Recently one of the emergency medicine residents (doctors in training) I supervise had a patient with chest pain.  The initial results came back, and we agreed the patient should stay in the hospital overnight for further evaluation.  The resident called the hospitalist - an internal medicine specialist whose practice consists of taking care of hospitalized medical patients - and found that the hospitalist thought the patient should be discharged.  But he came to the ED, saw the patient, and arranged for him to stay the night and have further testing.  He gave the EM resident a copy of a paper published in a major journal on this very subject, to support his opinion.

Last week we had Journal Club, that monthly gathering at which we discuss important papers from medical journals that might have implications for the practice of our specialty.  This particular resident and I quickly agreed that we should include this paper.  By now you can tell that, after my first quick read, I was rubbing my hands with glee.  It was the worst paper I'd ever read on the subject.

Let me reiterate: I am an enthusiastic proponent of the cost-efficient practice of medicine.  The percentage of our Gross Domestic Product that we spend on health care is now in the high teens.  At the beginning of my career it was in the low teens.  The upward slope cannot go on indefinitely.  We have to find ways of getting better health outcomes for less money.  And I believe we can do that.  But we have to be smart about it.  I volunteer for the job of deciding what's smart.

Medical Marijuana & Junk Science

Let me begin by denying having any expertise on medical marijuana.  I will also point out that the term "junk science" has been badly overused, and has been used to cast aspersions on evidence that really isn't junk science at all, including evidence for climate change and evolution.  So, for anyone who thinks I am applying this label to the study of which I am about to tell you because I'm a right-wing social conservative, that's not so.  It's just that I know real junk science when I see it.

I became aware of this study when a friend posted on Facebook a link to an article from a blog called "Smell the Truth," whose subtitle says it covers "medical marijuana news."  So, when I read the article from that blog, which put a very positive spin on the findings of the study it described, I thought I should read the original paper to see for myself.  And then I saw the title of the journal in which the study was published, Clinical Gastroenterology and Hepatology.  Hmmm.  Not a journal I routinely read, but the last time I read a paper published there, the study was so badly designed as to be laughable.  But let me keep an open mind. Surely the authors of the paper, and the editors of the journal, deserve that.  And no doubt the lead author's mother thought it was an excellent paper.

The study investigators wanted to know whether smoking marijuana might help patients with Crohn's disease.  This is an inflammatory disease of the bowel that tends to be a chronic, progressive disease that causes much misery.  It is challenging to control with medical therapy and not infrequently requires surgery to treat complications.

The study, conducted in Israel, took a group of patients with Crohn's Disease and randomized them to marijuana or placebo.  The patients were then followed over the next ten weeks, and their symptoms were quantified by the Crohn's Disease Activity Index (CDAI), a standardized research tool used to assess the effect of approaches to treatment.

The authors defined a CDAI score <150 as "complete remission." Without getting into the details of the scoring system, I should just point out that the term "complete remission" is misleading, as much of the score depends on symptoms that can wax and wane over a short period of time, while other elements of the score (4 of the 8 elements) relate to complications that occur over a longer time.
So it is possible to achieve substantial reductions in the CDAI through short-term symptomatic relief without any real change in underlying disease activity.  To call such an effect "complete remission," then, may give us the wrong impression of what is happening.
It would be more accurate to describe the effect as what it is, namely short-term symptomatic relief.

Of course the "Smell the Truth" blog trumpeted the phrase "complete remission" and said the treatment "performed like a champ."

But let us move on to the design of the study, so I can skewer that before I tell you about the results.

The number of patients was a mere 21.  This is very small - in fact, inexplicably so.  This is because the smaller the study, the less likely it is to find significant differences between the treatment and control groups (the "control group" consisting of patients who did not receive the treatment, typically receiving a placebo, or "sham" treatment, instead).  I will repeat my favorite example of this. Everyone understands that, when you flip a coin, it has an equal chance of coming up heads or tails.  If you flip it twice, however, it could easily come up heads twice or tails twice, and if you didn't understand the effect of sample size, you could easily be misled about the probabilities.  If you flip it 1,000 times, you will get pretty close to 500 each heads and tails - and learn the truth.

Anyone who engages in scientific research should understand the effect of sample size on the value of the results and can do something biostatisticians call a "power calculation" to figure out how big the study has to be to yield meaningful results.  Assuming these researchers were not clueless, and assuming they had access to someone who knew enough stats to do a power calculation, the only explanation for doing such a small study is that they intended it to be a very preliminary pilot study, a sort of "proof of concept" trial.  But that isn't how it was reported in the journal.

So the small sample size is major flaw #1.  Often a single major flaw is enough to render a study useless in telling us anything worth knowing.  But there's more.

When one does a study to test the effects of a treatment, the best design is what's called a randomized, controlled trial (or RCT), and an RCT is best done in a way that is "placebo-controlled" and "blinded."  Ideally it should be "double-blind," which means that neither the subjects (patients) nor investigators know which subjects got active treatment and which got placebo.  Often, from the subjects' perspective, placebo control and blinding are closely intertwined.  It is easy to see the challenge of placebo control and blinding in this study.

Subjects randomly assigned to the active treatment group smoked marijuana cigarettes containing a standardized amount of tetrahydrocannabinol (THC, the important active ingredient).  The control subjects smoked "sham" cigarettes made from cannabis flowers from which the THC had been extracted.

Now, remember, in order for the desired effects of blinding and placebo control to operate, the subjects in each group must not be able to tell whether they are receiving active drug or placebo.  Imagine you are taking a medicine to treat depression, an illness with mostly subjective symptoms.  If you are in a study, and you don't know whether you are taking active drug or placebo, you could easily be taking placebo yet experience improvement because you think maybe it's the active drug: the "placebo effect," which is very real and often surprisingly powerful.

So how could blinding and the placebo effect work in this trial?  Let us assume, giving the authors maximum benefit of the doubt, that they recruited only subjects who had never smoked marijuana and who would therefore be unfamiliar, at least from personal experience, with its effects.  (The paper didn't say that, and so it probably isn't true, but I'm trying to help them out here.)  Even then, subjects probably all had at least some idea what marijuana is supposed to do and could very easily tell when they smoked their cigarettes, real or sham, which they were. So there could not possibly have been any real placebo control or blinding effect. And that is major flaw #2.

The remaining major flaw, which is also related to sample size, is the importance of randomization.  The value of randomization is that it helps to minimize the chance that the subjects who've been enrolled are sufficiently different, between the two groups - in some way that the investigators may not even have realized could matter - as to affect the results.  For example, let's go back to testing the new medicine for depression.  Suppose we look at the two groups and find that the active treatment group did better than the placebo group.  But then suppose we go back and ask all the subjects whether, during the study, they happened to acquire a new boyfriend or girlfriend, and it just so happens that far more in the active treatment group than in the control group say yes.  We would then have no idea whether they felt better because of the new relationship or the treatment, or whether the treatment helped them get into a new relationship.  This is what researchers call a "confounder."  The effect of randomization is to minimize the role of confounders, and the larger the sample size, the more effective randomization is in accomplishing this.

So now that you know the three major flaws, let's look at the results.  Of the 11 subjects in the cannabis group, 5 achieved "complete remission," meaning short-term symptomatic improvement, while this was achieved for only 1 of 10 in the control group.  Looks like a big difference, right?  Well, because the sample size is so small, statistical calculations tell us there is a 43% likelihood this difference was due purely to random chance!  Thus, for the primary outcome measure, the main thing investigators were testing for, they found no difference with active treatment.  The most positive spin you can put on this, while maintaining scientific objectivity, is that there was a "trend" toward improvement that might turn out to be real in a larger study.  To their credit, part of their conclusion says a larger study should be done, and a "non-inhaled" form of the drug should be tested.  But that did not deter them from spinning the results as positive: cannabis "produced significant clinical benefits ... without side effects."

That last phrase didn't quite get me to laugh out loud, but I did find it quite amusing.  "Without side effects?"  That is nothing short of hilarious.  Any effect of a drug that is not the intended effect is, by definition, a side effect.  And so all of the effects of smoking marijuana that were not related to ameliorating the symptoms of Crohn's Disease were side effects.  Anyone who knows even a little about marijuana knows that users experience several completely unrelated effects.  These may not have been side effects that caused subjects distress or made them decide to drop out of the study.  But they were most definitely side effects.

So what does this study actually tell us?  We now know that researchers in Israel have studied medical marijuana for Crohn's Disease, and some patients experienced short-term symptomatic improvement.  This was only a trend, and the sample size was so small that the difference could have been due purely to random chance and must be tested in a much larger study before we will know anything with any confidence.  Finally, this study cannot tell us anything about longer-term effects of marijuana on Crohn's patients, either positive or negative. There is no known medical reason to suspect it has any effect on the pathophysiology of the disease, and so it would not be expected to have any effect on the frequency of exacerbations or development of complications.

This study will be touted by advocates for medical marijuana and by those who support decriminalization or complete legalization.  And now you know just what the study tells us - and what it doesn't.

 

Walk for the Homeless, Part 2

Geese and Goslings participating in the Walk

It was a cool, gray pearl of a day.  Nothing shy of perfection for this event.

I don't care for hot weather. Not even warm weather.  And I don't like to drive in snow and ice.  So if I picked a city to move to just for weather, it would be San Francisco.  No snow, no ice, mild winters.  And the summers are not hot.  The warmest month is September, when the average daily high is 71.  On average there are fewer than 30 days a year on which the high temperature exceeds 75.

Mark Twain famously said, "The coldest winter I ever spent was a summer in San Francisco."  I shall now pause to allow you to do a bit of Web research to discover that the general consensus is that Twain never actually said (or wrote) that, and no one seems to know who did.  Even more vexing, I could not find out who first called my favorite city the "cool, gray pearl."

The forecast was for showers.  And indeed there was an intermittent, light drizzle as I was driving into the city.  When I got out of my car at Heinz Field, though, it was chilly but not raining.  I had worn shorts and a T-shirt, and the temperature was barely 60.

Inside the stadium were far more people than I had expected.  I had registered online for this event, and I had done all of my fundraising online, too.  The total number of people who had done this was less than 60.  But when I got in line to sign in, it was clear this was a much bigger deal.  Apparently many people do things the old fashioned way, using paper forms and asking people at work and in their neighborhoods and social circles to give.  Then they show up and register on the day of the Walk.  The turnout was about a thousand: roughly 900 walkers and about 100 volunteers who were not walking but helping with everything else.

There was coffee (for which I was grateful), and fruit and cookies for breakfast. Before the Walk began we were addressed by the former Steelers whose names are on the Walk, Tunch Ilkin and Craig Wolfley, and we were introduced to various local dignitaries who came to lend their support, including members of City Council, and the Steelers organization, and the local news media.  Former Steelers running back Rocky Bleier looked healthy and fit.  And WTAE's Sally Wiggin was there.

[I don't watch local news much, which is a whole 'nother subject I may write about some day, so I decided to read up on Sally Wiggin, who has been a news anchor in Pittsburgh for over 30 years.  "Not just another pretty face" is an understatement.  Phi Beta Kappa.  Studied Japanese and has degrees in East Asian History and Chinese History.  A string of journalism awards.  Wow.]

Tunch and Wolf told us about how, when this annual event began more than a decade ago there were a dozen people walking.  It was really heartening to see that so many people had turned out this year.

And so we got underway.  It's still pretty chilly, I thought, as we left the stadium. But I knew that feeling wouldn't last.  Sure enough, by the time I had walked a kilometer or so of the 10K, I thought the temperature was ideal.

Many of my friends seem to spend most of their waking hours taking pictures and posting them on Facebook.  I've never been much of a photographer, although the fact that I am now never without a camera (aka smartphone) makes it easy. So I decided I should have at least one picture to accompany this essay, and there it was at the top of the page.

A brisk walking pace doesn't inhibit conversation, and there was plenty of that. Some people I talked to had been doing the walk for years.  Others had known about it but only this year had signed up to join the effort.  Still others, like me, had never heard of it until last month.  A few were people who'd volunteered at the shelter, and one was an employee of the Light of Life Ministries.  Some had interesting questions.  I think there were more questions than answers.

One lady wanted to know how many homeless there were in Pittsburgh.  She realized as soon as she finished the question that there was surely no definitive answer.  After all, the very fact of homelessness means you won't get a survey from the Census Bureau.  Doing a Web search, I found figures in the 1300-1500 range for recent years in Pittsburgh.  But part of the challenge is getting started: you have to define the problem.

Everyone would agree that if you're living on the street, sleeping under a bridge, or staying in a shelter, you're homeless.  But in some studies of social problems, the term "homeless" is defined much more broadly.  You are living in an apartment that you can barely afford, the landlord decides to convert to condos, you don't qualify for a mortgage, and you can't find another place to live before you're evicted.  A cousin has a spare bedroom and takes you in.  You're homeless.  No, not like the person living in a big cardboard box positioned over a subway grate on the street in a big city, but categorized that way in some studies of homelessness as a social problem.  That isn't helpful, because it makes people who have charitable impulses or who are inclined toward spending public dollars to ameliorate the plight of the homeless think maybe the problem is being overstated.

I've spent time in a lot of medium-sized and larger cities in the United States. Take my word for it, if you are willing: the problem is big enough without anyone overstating it.

The folks at Light of Life do not, I think, devote a great deal of effort to quantifying the problem.  They're too busy trying to solve it, one homeless person or family at a time.  Food, shelter, clothing.  Counseling for personal problems.  Treatment for mental illness and addiction.  Help with education and training. They teach people what they need to know to obtain a GED (the credential in General Educational Development that is widely accepted as equivalent to a high school diploma). They've helped homeless people enroll in Community College of Allegheny County and obtain degrees from CCAC.  One worker told me proudly about a fellow who had transferred his CCAC credits and was in a degree program at the University of Pittsburgh.

At the end of the walk there was a very nice lunch.  And some more conversation.  There were T-shirts for everyone who had raised at least a certain amount of money for the walk or paid a nominal sum.  Most of us had picked them up before the Walk, and many wore them.  I did, although I really didn't need the extra layer.

I have a confession to make.  (This is for those who don't know me well.  Those who do will nod in immediate recognition.)  I have a very mischievous sense of humor.  So I thought about saying, in a stage whisper, if I ever got the chance, "I don't give a damn about the homeless.  I'm just here for the T-shirt and the exercise."  But everyone was so sincere, and enthusiastic, and upbeat about what they were doing that morning.  I couldn't bring myself to say it, because I wouldn't want anyone to think I actually meant that, even for an instant.  I was happy to be a part of it.  Happy to be doing something to help people who, I sometimes think in moments of gloom, are beyond help.  The folks at Light of Life know that's not true.  They don't believe anyone is beyond help.

Walk for the Homeless

I've been thinking about this every day for the last month.

One day in April a little graphic on Facebook caught my eye.  There was going to be a Walk for the Homeless on a Saturday in May.  Two former players for the Pittsburgh Steelers, Tunch Ilkin and Craig Wolfley, have lent their names to this annual fundraiser for the Rescue Mission run by the Light of Life Ministries on Pittsburgh's Northside.

The names of these two former NFL players were somewhat familiar to me, both because I've been following the Steelers for 35 years and because they have a radio show in Pittsburgh.  But I had never heard of this fundraiser.  Until two years ago I had never heard of Light of Life, either.  But then I took a position as faculty for the emergency medicine residency training program at Allegheny General Hospital.  The Ministry's shelter for the homeless is just a few blocks away.

Over the years I have written many checks to make charitable contributions.  I have much more limited experience as a fundraiser.  For the last six years I've served on the Board of Trustees of the Emergency Medicine Foundation, which raises money to fund grants for scientific medical research in my specialty.  This experience has shown me that I'm not very good at asking people for money, although I'm working on it and have gotten a little better than I used to be.

One cannot spend any time in medium-sized or larger cities in the United States without encountering homeless people.  This is a tragic fact of life in our country.  The reasons for homelessness are numerous, varied, and complex, and I wil not try in this essay to offer any sort of discourse on the nature of this deeply saddening social problem. But on the streets of our cities it is there, every day, facing us.  And we mostly turn away.

I know I look away when I see a homeless person on the street holding a sign. There are only so many variations on "Homeless - Please Help."  I feel as though I've read them all.  I've also read many articles telling me money given to these people will go to buy booze and cigarettes.  One could argue that we should not make value judgments.  If that's what they want to spend their money on, why does it matter?  Well, aside from the Puritanical wish to avoid funding vices, I think it is not helpful to support addictions or to give people money in hopes they will use it for food only to have them spend it on things that will damage their health and make their lives worse instead of better.

In a search of the blogosphere I found several essays by people who had explored urban homelessness and found an abundance of sources of food and shelter, and even discovered that some of these folks have access, through the social support services, to day labor they can do to earn a bit of money.

Surely this guy could be helped to find work!

Aside from poor choices in what to do with the money, it might seem to be a good idea economically.  After all, money given to the homeless will be spent right away, and any economist will tell you that is a good thing in a consumer-driven economy.

But the immediacy of the spending has a downside.  It is not invested in making life better.  What the homeless need to get their lives moving in the right direction is a roof over their heads and a job.  A charitable organization that provides food, clothing, shelter, counseling, and
training is focused on changing lives.

The Light of Life Ministries is incorporated, and I spent some time on their Website reading about them.  This is a capsule of what they try to do:

The Corporation operates a long-term (12 months or more) recovery program for men, women, and children, in addition to outreach services that provide for the direct care of the needy and homeless populations. These include: a comprehensive recovery program consisting of transitional housing, counseling, education, work training, individual case management, and health care referrals; and Samaritan ministries providing meals, emergency shelter, chapel services, and community outreach. The goal of these programs is to equip people to transform their lives and function as productive employees, competent parents, and healthy, self-sufficient citizens to the greatest extent possible. 

This language is, of course, written to appeal to those who might be inclined to donate money, but any charitable organization is "mission-driven": everything they do is planned and executed against the backdrop of their Mission Statement, with the question repetitively asked, "Is this consistent with, and in the service of, our mission?"

I read a bit more about the fundraiser.  It's a 10K walk.  I popped that into the section of my brain that does arithmetic, and it translated into two hours of walking at a moderately brisk pace. Walking is not an activity I enjoy.  I injured my knee playing basketball in college. (Intramural, not varsity - I'm not anybody's idea of a competitive athlete.)  There are two C-shaped pieces of cartilage in the knee joint that have a cushioning function.  These were both badly torn and had to be removed.  I also tore ligaments, which were never repaired, so the joint is inherently unstable.  So walking, which pounds the knee joint with every step even if your body weight is not too much more than it should be, is not pleasant for me.  But hey, there are people who have walked across America.  (Really. You could look it up.  A Google search will even yield a link with a list of people who've done that, so it's not just one crazy guy.)  So surely I can manage two hours without whining about it.

I thought I could handle that part.  But what about the asking-people-for-money part?

Now that I've been blogging for two years, it should be obvious that I like to write.  So there is e-mail and there are social media. The only social media stuff I do is Facebook. But this could work.  Post messages, send messages, trying to reach hundreds of people who are, at least nominally, my friends, and try to convince them this is a good cause and that they should pony up some bucks.  It shouldn't be so hard to pester people when I know that they do not have to read what I write if they don't want to, and if they do read it, they will do so at their own convenience.  I'm not showing up at their door like an evangelist or calling them in the middle of dinner.  Yeah, I can do this.

Here's part of what I wrote in the last of my series of e-mails:

Practicing emergency medicine at Allegheny General Hospital, just a few blocks from Light of Life, has shown me what an important community resource this ministry is.  I do not have to discharge homeless patients to go find a place to sleep under one of Pittsburgh's many bridges.  Helping those who benefit from the services available through Light of Life means helping the least fortunate of the unfortunate.  I cannot think of a more worthy cause.

I know, I know, it's not Thoreau (no rhyme intended).  But I think it gets the point across.  And I'm hoping it will generate enough of a response to push me well past the 110% mark for my original personal fundraising goal.  If you're reading this, and you aren't one of the friends who have already helped, I hope you'll consider it.  All you have to do is go to this link, click on the big orange "Donate" button, and follow the instructions.  I plan to come back with Part II of this essay after the walk.

http://www.crowdrise.com/tunchandwolf/fundraiser/bobsolomon