Author Archives: jamesmarroquin.com

The Washington Post reports on a new study that reveals the prevalence of depression around the world.  Researchers at Australia’s University of Queensland found that the Middle East and North Africa suffer the world’s highest depression rates.  Globally, depression is the second-leading cause of disability, with slightly more than 4 percent of the world’s population diagnosed with it.  The article reports that 

the most depressed country is Afghanistan, where more than one in five people suffer from the disorder. The least depressed is Japan, with a diagnosed rate of less than 2.5 percent.

What accounts for the higher rates of depression in certain countries?  Researchers theorize that military conflict is one important cause.  The article also points to a 2010 paper by the Inter-American Development Bank which found that unemployment, low incomes and high income inequality correlate with high depression rates.  Finally, there is the age factor.  Studies have shown that people between 16 and 65 tend to suffer depression at much higher rates.

That age factor, along with massive population growth, actually explains the fact that the burden of depression has grown by nearly a third since 1990.  And since both aging and population growth are likely to continue, that makes low-cost depression interventions even more of a priority for both global organizations and national governments. 

The November 6, 2013 issue of the New England Journal of Medicine has an important editorial entitled Grading a Physician’s Value: The Misapplication of Performance Measurement. It begins by acknowledging that

perhaps the only health policy issue on which Republicans and Democrats agree is the need to move from volume-based to value-based payment for health care providers. Rather than paying for activity, the aspirational goal is to pay for outcomes that take into account quality and costs.

 

But even as the authors  

agree that value-based payment is appropriate as a concept, the practical reality is that the Centers for Medicare and Medicaid Services (CMS), despite heroic efforts, cannot accurately measure any physician’s overall value, now or in the foreseeable future.

They argue that “physicians simply do not respect the (current quality) measures, and for good reason.”  Such quality measures

reflect a vanishingly small part of professional activities in most clinical specialties. A handful of such measures can provide a highly misleading snapshot of any physician’s quality. Research shows that performance on specific aspects of care does not predict performance on other components of care. Primary care physicians manage 400 different conditions in a year, and 70 conditions account for 80% of their patient load. Yet a primary care physician currently reports on as few as three (quality) measures.

They continue:

One definition of physician professional competence is “the habitual and judicious use of communication, knowledge, technical skills, clinical reasoning, emotions, values, and reflection in daily practice for the benefit of the individual and the community being served.” Patients place emphasis on physicians’ confidence, empathy, humanity, personability, forthrightness, respect, and thoroughness. A global measure of value should capture most, if not all, of these diverse elements of desired performance. Yet available measures in the Physician Quality Reporting System (PQRS) and elsewhere are relevant to few of these professional qualities.

 

More concretely, examples of important but mostly overlooked aspects of physician performance that we would want to measure include making accurate and timely diagnoses, avoiding overuse of diagnostic and therapeutic interventions, and caring for the growing number of patients with multiple chronic conditions and functional limitations.  A radiologist’s primary role is to provide accurate and complete interpretations of imaging studies. Yet because we lack measures of accuracy for radiographic diagnoses, PQRS measures include “exposure time reported for procedures using fluoroscopy” and “inappropriate use of `probably benign’ assessment category in mammography screening.” The PQRS is predicated on the dubious proposition that measuring and rewarding performance on such obscure clinical aspects of care is worthwhile. Even if such activities are beneficial, performance on these measures is not indicative of a radiologist’s quality as part of the CMS value calculation.

 

Consider quality for surgeons. We want to be able to measure performance on core competencies that affect outcomes, such as judgment about whether and when to operate and which procedure to use, as well as the surgeon’s technical skill in the operating room. Yet because these characteristics are difficult to quantify accurately and routinely, PQRS measures for surgeons instead include adherence to guidelines for antibiotic and anticoagulation prophylaxis. Again, these measures assess worthy prevention activities but do not reflect a surgeon’s contribution to producing value.

 

The bottom line is that the things in health care that are most easy to measure quite often are not what translates into healing, value, and a higher quality of life for patients.  

Another issue the authors address is judging a physician by how much money is spent in the care of his or her patients.  The government and insurance companies will be increasingly penalizing and rewarding primary care physicians on this basis.  This is problematic since

current methods for case-mix adjustment do not adequately capture variations in patients’ illness severity, complicating coexisting conditions, or relevant socioeconomic differences — differences beyond the physician’s control that affect the cost of care. 

I am very much for a health care system that rewards high quality, cost-efficient care.  But for that to become a reality, researchers must develop much better methods of accurately measuring quality and cost-efficiency.

Here is a review I wrote on a book about blood called Five Quarts.  

It is only natural to take for granted that with which we are most familiar. Just as a cell down- regulates its receptors in response to activating hormones, so humans quickly become habituated to novel experiences. The surgeon who at the beginning of her training found the operating room to be a terrifying and exciting place, years later experiences it as a zone of comfort and security. In relationships, the thrill of reciprocated affection in time gives way to the quieter love of friendship, marriage, and family. But even as we cherish our dependable routines, we sometimes feel nostalgia for a time when the familiar was new. This is why the long-married couple still takes time out for formal dates. It may also explain why many physicians strive to impart their knowledge to younger generations. Through teaching, these seasoned professionals vicariously relearn their craft. Perhaps procreation is the most obvious example of the human desire to make the familiar new. Parents know that a child brings fresh eyes to the world, making the ordinary extraordinary again.

A layman’s naiveté can likewise bring a unique sense of wonder to a complex subject like blood. This is certainly true with respect to Bill Hayes’ new book, Five Quarts: A Personal and Natural History of Blood. Incorporating mythology, history, literature, medical science, and personal experience, the freelance writer Hayes has composed a fascinating exploration of the crucial red liquid that we physicians so matter-of-factly extract and study every day.

Hayes’ discussion of the mythological figure Medusa near the beginning of Five Quarts serves as a launching point for the rest of the book. Besides having snake-hair and a face that turned all of its beholders to stone, Medusa’s blood also possessed special qualities. If drawn from the left of her body, her blood brought instant death. But if extracted from Medusa’s right side, it restored life. Hayes remarks that “this duality was an especially prescient invention of the ancient mythmakers, for we now understand in cellular detail how blood can bear both disease with deadly efficiency and save a person’s life, as with vaccinations and transfusions.” This idea of blood as both a killer and a savior, as a source of both dread and fascination, recurs throughout Five Quarts. Indeed, it flows from the deeper purpose of his book. Hayes’ long-time partner is HIV positive, and one senses that the author’s exploration of blood is a quest to understand the mysterious substance that has afflicted his beloved.

As part of this quest, Hayes recounts the history of humanity’s efforts to grasp blood’s content and meaning. Particularly interesting in this respect is the story of Paul Ehrlich’s life and work. Born in 1854 in a small German village, Ehrlich was the only son of Jewish parents who operated an inn. As a teenager, he was fascinated by his older cousin Carl Weigert’s research staining cells with synthetic dyes. Generated by the flourishing German dye industry, these dyes revealed contrast and texture in biological specimens, making them easier to view under the microscope. In his own studies, Ehrlich observed that different dyes responded uniquely to certain cells or parts of cells. To him, this suggested the existence of distinct cellular receptors (“side chains”) for the various dyes. The concept of cellular receptors ultimately led Ehrlich to his side-chain theory. It proposed that cells have receptors or side chains that bind invading toxins “like a key in a lock,” thereby neutralizing them. The theory further held that a cell under threat grows additional side chains to bind the toxin and that these additional side chains break off to become antibodies that are circulated through the body. As Hayes reports, Ehrlich’s revolutionary side-chain theory was just one of his many crucial contributions to the field of hematology.

Exploring blood’s role in literature, the author considers Bram Stoker’s Dracula. It turns out that the historical inspiration for the great novel’s vampirism may have been the hematological disorder of congenital erythropoietic porphyria. Inbreeding within the isolated and remote Eastern European communities, such as the valleys of Transylvania, may have resulted in an unusually high prevalence of this rare condition during the Middle Ages. As Hayes writes, “The corpse-like appearance and odd behavior of sufferers may have given rise to whispers of vampirism.” Folk knowledge about the disease may have gradually evolved into legend. Certain chemicals in garlic, for example, can exacerbate porphyria symptoms, thus giving rise to the idea that garlic repels vampires.

Toward the end of Five Quarts, Hayes writes about Dr. Jay Levy’s codiscovery of HIV and his remarkable contributions to understanding and fighting the disease. The medical progress made possible by Levy and other scientists profiled in the book has prolonged the life of Hayes’ HIV-positive partner. Much of the book can be read as a grateful tribute to their efforts.

For its beautiful writing, captivating stories, and eclectic approach to the subject of blood, I heartily recommend Five Quarts. It just might affect the way you look at your next blood smear.

Francis Collins is the current director of the National Institutes of Health (NIH) and oversaw completion of the Human Genome Project.  He wrote a book called the Language of God in which he shared his Christian faith and its relationship to his work as a scientist.  Here is my review of it.

Stepping into the crossfire between these two warring camps is Francis Collins, a scientist with impeccable credentials and a devout Christian. Among Collins’ accomplishments is a gene-hunting technique called positional cloning, which his laboratory used to isolate the genes responsible for cystic fibrosis, Huntington disease, and neurofibromatosis (2). In 1993, Collins was selected to succeed James Watson, the codiscoverer of DNA, as the director of the Human Genome Project. Under his leadership, a working draft of the human genome was announced ahead of schedule in June 2000. In The Language of God, Collins seeks to bring his credibility in both scientific and spiritual circles to bear in an attempt to achieve a harmonious synthesis between science and faith.

Collins begins the book by telling the story of his journey to belief. His parents were Yale graduates who did the “60s thing” in the 1940s, seeking a simple agricultural lifestyle on a farm without the use of machinery. Homeschooled in a place with no running water and few other physical amenities, Collins treasured his unique upbringing for the remarkable culture of ideas created by his parents. He writes, “Those early years conferred on me the priceless gift of the joy of learning” (p. 13). One area in which Collins did not receive instruction was religion, as his parents were relatively indifferent to faith. Collins likewise gave spiritual questions little thought growing up and described himself as a skeptical agnostic through his early adulthood. During his PhD program in physical chemistry at Yale, he read the biography of Albert Einstein. Learning that despite Einstein’s Zionist position after World War II he did not believe in Yahweh, God of the Jewish people, only reinforced Collins’ conclusion that no thinking scientist could seriously entertain the possibility of such a deity.

A turning point in Collins’ spiritual journey occurred during medical school when he encountered patients whose faith provided them with reassurance and peace during terrible suffering. This led him to question if belief could have a rational basis and to survey the world’s great religions. During his investigations, he was most influenced by C. S. Lewis’ Mere Christianity, a collection of radio talks delivered by the legendary Oxford scholar on the BBC during World War II. Lewis argued that the human conscience provides genuine insight into reality, just as our senses or mathematics do. In his view, for example, the statement that the Nazis’ treatment of Jews and slavery in America were morally wrong more closely resembled a fact than a cultural sensibility. Lewis contended that holding up morality as an objective reality rather than merely a human construct requires positing a Being that defines right and wrong. Collins was persuaded by this moral argument for God’s existence and impressed by the rest of Lewis’ case for belief. And though he continued to have doubts, Collins decided to take a leap of faith.

Collins goes on to share some of the rest of his rational basis for belief. He points out that 15 physical constants, such as the strength of weak and strong nuclear forces and the speed of light, all have values within the narrow range necessary for the existence of a stable universe capable of sustaining complex life. The odds of this happening by chance are almost infinitesimal. One theory proposed to explain this coincidence is assuming the existence of an infinite number of universes, each with their own physical constant values. Among these universes, it is postulated, ours happens to contain the physical properties permitting life and consciousness. The alternative explanation for the improbable conditions that make intelligent life possible is that rather than occurring by chance, they reflect the action of the One who created the universe. Collins finds this second account to be more elegant and compelling.

Collins’ next task is proposing a framework for reconciliation between science and religion. He first reviews what astrophysics, the geological and fossil record, and the study of genetic material across species have to say about the question of origins. He concludes that the evidence overwhelmingly reveals a universe billions of years old and that evolution through natural selection is the crucial generator of the diversity and complexity of life.

Collins then presents a case that this modern scientific account of origins is compatible with belief in God and the biblical narrative. Examining the Genesis creation story, he argues that the text intends to impart theological truths rather than provide a natural history. Here he follows a long tradition of biblical exegesis. For instance, in the fifth century, St. Augustine wrote contemptuously of a literal interpretation of the Genesis creation account: “The shame is not so much that an ignorant individual is derided but that people outside the household of faith think our sacred writers held such opinions … and are criticized and rejected as unlearned men”.

Collins also rejects intelligent design (ID) theory, which points out the explanatory shortcomings of evolution theory and on this basis postulates the involvement of an intelligent designer. He argues that ID fails to function as a viable scientific theory since it does not predict other findings or suggest approaches for further experimental verification. ID also fails to provide a mechanism by which its hypothesized supernatural interventions took place. Finally, many of the cases in nature that ID points to as examples of the inadequacies of evolution theory are now being shown to be consistent with it after all.

Collins points to theistic evolution as an explanation that reconciles faith and science. It is a view espoused by most serious scientists of all faith traditions and includes among its adherents Asa Gray, Darwin’s chief advocate in the USA, and Pope John Paul II. Theistic evolution holds that God used the elegant mechanism of evolution to create all of life, including human beings.

Francis Collins is under no illusion that his book will settle the often rancorous disputes between the religious and scientific communities. But he hopes at least to offer a model for more civil and reasonable dialogue. In this respect, I believe he has succeeded.

Vitamins are carbon-containing substances that the body relies upon to perform essential functions.  With the exception of  vitamin D, vitamins cannot be synthesized by humans.  They, therefore, need to be ingested in the diet or through supplements to prevent severe disorders.

A multivitamin usually contains the recommended daily intake of all the vitamins.  They are recommended for people at risk for vitamin deficiencies, such as those with alcoholism, malabsorption, a vegan diet, a history of gastric bypass surgery, or some inborn errors of metabolism.  For the rest of the population, the available evidence suggests taking a multivitamin does not offer any significant health benefits.  This is because we are already receiving a sufficient amount of vitamins in our diets.

It would be a grand task to comment upon all of the vitamins, so I’ll briefly discuss a vitamin that commonly comes into play in my medical practice: Vitamin B12.  

Vitamin B12 deficiency is most commonly caused by poor absorption and inadequate intake of B12-containing food sources such as liver, milk, fish, and meat.  Why might somebody not absorb Vitamin B12?  In some people, the body forms an antibody against a protein called Intrinsic Factor, that is needed to absorb Vitamin B12 in our gut.  This is called Pernicious Anemia.  Malabsorption can also occur in people taking certain medications.  For instance, Metformin is a commonly used medication for diabetes that prevents the liberation of Vitamin B12 from foods. Strong antacids for acid reflux can also decrease the gut’s ability to absorb B12.  Finally, surgeries that remove part of the stomach, such as gastric bypass weight-loss surgery, can make it difficult for the gut to absorb adequate Vitamin B12. 

Vitamin B12 deficiency can damage the central and peripheral nervous system.   Low levels can cause cognitive impairment and even dementia, as well peripheral neuropathies and difficulty with balance.  It can also cause anemia, which is a low level of the red blood cells that carry oxygen to our body’s tissues.

Before Vitamin B12 was identified, people with B12 deficiency syndromes were treated by being fed a copious amount of liver.  Upon B12’s identification, Vitamin B12 injections became the standard means of replacement.  More recently, it has been found that most people with Vitamin B12 deficiency can attain an adequate level of B12 through high-dose oral supplementation.  When I detect low B12 levels, I offer people the oral or injection route of repletion, then later check a blood test to ensure they have achieved an adequate level.

In my next post, I’ll discuss Vitamin D.

Ever since the days of William Osler, annual physical examinations with one’s doctor have been an accepted and expected part of health care.  But recently the practice has come under some criticism.  Given the dearth of studies showing that physicals lower the risk of death and hospitalization, some experts and organizations state that the annual physical should be abandoned.

I appreciate the effort here to question tradition and to consider if a commonly accepted practice truly has value.  Nonetheless, I believe that in the appropriate patient population, annual physicals serve important functions.  First, they ensure that people are up to date on their health maintenance measures.  Screening for colon, breast, and cervical cancer is proven to save lives.  In my work in hospice and otherwise, I have seen the tragedy of lives radically shortened by a failure to undergo appropriate cancer screening tests.  In my physicals, I also review patients’ immunization records to make sure they have been appropriately vaccinated against tetanus, diphtheria, pertussis, shingles, pneumonia, flu, and hepatitis A and B.  Doing so decreases their chance of suffering from these diseases and helps protect the surrounding community.  Appropriate screening for sexually transmitted infections is also tremendously important.  Through such screening, I have detected cases of HIV and syphilis, thereby enabling effective treatment and preventing the disease from spreading.  Physicals are also a chance to see if a person has high blood pressure, elevated cholesterol, or type 2 diabetes.  People with these conditions often do not present with symptoms, but left untreated they can result in debilitating outcomes such as heart attacks, strokes, blindness, and kidney failure. Finally, there is the issue of hip and vertebral compression fractures. By some estimates, nearly half of all women and 1/3 of men will have fragility fractures in their lifetimes.  Such fractures increase the risk of death and can end or limit many people’s ability to remain independent.  Effective screening and treatment for people with fragile bones can markedly lower their risk of fracturing their hips or spinal vertebrae.

Physicals are also occasions for addressing a person’s health lifestyle and habits.  Smoking, excessive alcohol intake, and drug use can be identified and appropriate counseling given.  I also assess how much a person is exercising and inquire into the state of their nutrition.  Even if people already know the value of staying physically active and eating well, there is value in encouragement and reinforcement.

Physicals also allow me to obtain or review a person’s entire health history, as well as their family’s health history.   This information is usually not addressed during other visits that focus on 1-2 specific problems.  The process of reviewing a person’s complete health history helps put the issues a patient presents at other visits into a helpful context and framework.

Beyond all this, I view physicals as a time to get to know who a person is and what makes them tick.  My task is to help people live longer and better, but what are they living for?  Accordingly, as part of my social history, I usually ask patients something like “what gives meaning and purpose to your life?” or “what do you enjoy doing these days.”  Having a stronger grasp of a person’s values allows me to be a better guide in making health decisions.  And I believe there can be healing in simply sharing and receiving important, formative stories

Reading a novel can seem like a solitary, private pleasure rather than a public-spirited act.  But a recent study published in the journal Science found that after reading literary fiction, as opposed to popular fiction or serious nonfiction, people performed better on tests measuring empathy, social perception, and emotional intelligence.

“Researchers say the reason is that literary fiction often leaves more to the imagination, encouraging readers to make inferences about characters and be sensitive to emotional nuance and complexity.”  Here is a New York Times commentary on the study.  

Dementia is a syndrome characterized by a deterioration in cognitive function that results in behavioral problems and difficulty performing the activities of daily living. Alzheimer Disease is the common form of dementia in the elderly, accounting for about 60-80% of cases.  Under the microscope, the brains of people with Alzheimer Disease have abnormal clusters of protein fragments called amyloid plaques between nerve cells. The brain cells also contain aggregations of abnormal proteins called neurofibrillary tangles.  A new imaging technique called Amyloid PET tracing can measure how much amyloid plaque is present in the brain, but is currently used only for research purposes rather than being clinically available.  Thus, doctors now diagnose Alzheimer Disease based on a person’s presentation in the clinic and by ruling out other causes of impaired cognition such as Vitamin B12 deficiency, depression, and a low thyroid level.

A new study published in Science discovered that in mice, the brain’s system for flushing out toxic waste products is especially active at night.   The study author and University of Rochester neurosurgeon Maiken Nedergaard stated that “sleep puts the brain in another state where we clean out all the byproducts of activity during the daytime.”  These byproducts include the amyloid proteins that make up the plaques found in Alzheimer Disease.  Nedergaard explained that “brain cells shrink when we sleep, allowing fluid to enter and flush out the brain.  It’s like opening and closing a faucet.”  The study found that the harmful beta-amyloid protein clears out of the brain twice as fast in a sleeping rodent than in an awake and active one.

Besides providing insight into the mystery of why we need sleep, this interesting study may be a helpful contribution in the quest to someday prevent and effectively treat Alzheimer Disease.  Here is a Washington Post article describing the study published in Science.

The chickenpox that nearly all of us experienced as children is caused by a virus called varicella.  After the pox go away, the virus lives a quiet existence in some of the neurons of our nervous system.  When the virus becomes reactivated, itchy, painful vesicles form.  Receiving an antiviral medication promptly can shorten the duration and severity of a shingles outbreak.  Overall, the vesicles usually crust over within a week to ten days, but in about 10-15% of people, a form of severe, chronic pain lasts much longer.  This condition, called postherpetic neuralgia, occurs most often in people over 60 years old and is fortunately responsive to certain pain medications.  

Shingles occurs in about 1/3 of people during their lifetime.  A vaccine for shingles is available for people 50 years and older.  It is given only once during your life.  For people, between 50-59 years old, the vaccine lowers the risk of shingles by 70%.  For people, 60 years and older, the vaccine decreases the risk of getting shingles by 51%.  The risk of post-herpetic neuralgia (chronic pain from shingles) is reduced by 67%.  

Despite its demonstrated efficacy, in my experience many people decide not to receive the shingles vaccine. The biggest barrier is cost.  Its price is around $250 and Medicare and many insurance plans do not cover it, although some persons’ Medicare prescription drug plan contributes to paying for it at a pharmacy.

I’ll also briefly address three other vaccines.  The flu shot markedly lowers the risk of being miserable with a high fever and body aches for a few days.  But it is especially for important for older folks and those with compromised immune systems to get the flu vaccine since for them, the flu could result in a hospitalization or even death.  

All of us need a tetanus vaccine booster every 10 years to prevent tetanus.  Tetanus is a severe nervous system disorder characterized by muscle spasms.  It is caused by a bacteria that lives in the soil entering a person’s body through trauma to his or her skin.   

The pneumonia vaccine decreases the risk of developing a bacterial infection of the lungs (pneumonia).  It is indicated for all people older than 65 years and in younger people with a condition that renders them at a higher risk of getting pneumonia.  In addition, it is now recommended that an additional pneumonia vaccine, called PCV13, be given to people with compromised immune systems.

I’m sometimes asked by teenagers and young adults how I decided to become a doctor.  More broadly, they wonder: how does a person determine what to do with his or her professional life?  Here are some reflections on the idea of calling from my spiritual tradition of Christianity.

The scholar William Placher writes, a calling is “the idea that there is something . . . God has called me to do and my life has meaning and purpose at least in part because I am fulfilling my calling.  (T)he God who made us has figured out something we are supposed to do—something that fits how we are made, so that doing it will enable us to glorify God, serve others, and be most richly ourselves.” A choice, in contrast, is not a response to God’s call.  It flows instead from our own agenda. 

This raises the question of how God communicates a calling to human beings.  Put another way, how do we discern God’s will for our lives?   Theologian James Gustafson sees God’s call on us manifesting itself as a moral imperative.  He writes, “The presence of poverty, social disorganization, disease, personal anguish, injustice in the distribution of human services, ignorance, and similar factors move persons to seek the education and training to relieve these impediments to human fullness.”  He does not seem to envision God necessarily communicating one particular calling to an individual.  Rather, the person will have “a sense that one’s life experiences, one’s capacities for sympathy and empathy, and one’s moral beliefs and moral sensitivities make it reasonable to choose a certain profession.”

William Placher writes that “most people figure out, usually as part of a community, how God is calling them through prayer and meditation, inward reflection on their own abilities and desires, and looking at the world around them and its needs.”  He quotes Frederick Buechner’s wise statement that God calls you to “the kind of work (a) that you need most to do, and (b) that the world most needs to have done. . . . The place God calls you to be is the place where your deep gladness and the world’s deep hunger meet.”

Placher also helpfully chronicles how the meaning of a calling has changed over time.  The early Christians viewed becoming a Christ-follower as their primary call.  Making Jesus their Lord “made them outsiders to most facets of society.”  In the Middle Ages, when “the vast majority of Christians grew up in the church, surrounded by other Christians,” whether to become a Christian was no longer a real question.  The issue of calling was whether God wanted an individual to stay part of his or her family or join the clergy.  At the time of the Reformation, “the increasing complexity of society offered many people more (professional) choices” and Martin Luther proclaimed the “priesthood of all believers.”  According to Luther, “your job was your vocation (calling), and thus everyone, not just priests, nuns, and monks, was called by God to their particular work.”  Now, in what he views as our post-Christian world, Placher argues that “simply living as Christians could be our calling” since “trying to live as a Christian pushes upstream against the dominant values around us.” Realizing that Christians have struggled over two millennia to discern God’s call on their lives helps us realize we are not alone in our quest for vocational clarity.  It also helps us appreciate that finding our calling does not need to be understood primarily as identifying the perfect fit for our aptitudes and interests.

As theologian Alister McGrath writes of Calvin’s thoughts on this matter, “It is the person working, as much as the resulting work, that is significant to God.”  For instance, Brother Lawrence saw his humble chores of cooking and cleaning as being deeply meaningful when he performed them out of love for God.  He wrote that “is it (not) needful that we should have great things to do. . . We can do little things for God; I turn the cake that is frying on the pan for love of him, and that done, if there is nothing else to call me, I prostrate myself in worship before him, who has given me grace to work; afterwards I rise happier than a king. It is enough for me to pick up but a straw from the ground for the love of God.”  Here he echoes Paul’s admonition in Colossians 3:23 that “whatever your task, put yourselves into it, as done for the Lord and not for your masters.”