When Alan Braverman, MD, FACC, was given his first stethoscope in medical school he took it home and immediately began listening to his family members’ heartbeats. What he found would alter his life forever.

“There are six kids in our family,” explains Braverman, now a medical professor in the cardiovascular division at the 

Washington University School of Medicine in St. Louis

. “I discovered a heart murmur in my older brother, David. When an echocardiogram showed an enlarged aorta and mitral valve prolapse, we recognized that David had Marfan syndrome.”

Braverman also realized that his late father, who died in 1977 from an acute aortic dissection, had also been afflicted with Marfan syndrome, unaware that he had the condition. Perhaps more importantly, those events put Braverman on a career path to not only learn as much as he could about the genetic disorder, but to positively impact the way Marfan is diagnosed and treated.

And Braverman is not the only physician to combat a disease that has touched them personally. Mark Lewis, MD, a hematology/oncology fellow at the 

; Douglas Dieterich, MD, a professor of medicine in the 

Liver Diseases Division at Mount Sinai Medical Center in New York City

; and Stanley Nelson, MD, a professor in the 

Department of Human Genetics at the UCLA Jonsson Comprehensive Cancer Center

, are all waging a personal vendetta against diseases that have hit too close to home.

Marfan syndrome is a genetic disorder affecting one in 5,000 people, meaning that it is rare enough that physicians often misdiagnose it. That’s problematic because Marfan can also be fatal if unrecognized and untreated. The symptoms include disproportionately long arms and legs, elongated fingers or loose fingers, and a tall and lanky frame. Braverman’s brother David was 6-foot-4, considerably taller than the rest of the family. David underwent life-saving aortic surgery in 1985, and has done very well since. But David’s son (Braverman’s nephew) also has Marfan syndrome, and is monitored regularly.

When Braverman came to St. Louis as a general cardiologist he learned of a local chapter for the 

. He attended a meeting, immediately became involved with the local chapter, and later on became active on a national level. Today, he’s not only director of the 

Marfan Syndrome Clinic at Washington University Medical Center

, he is also chair of NMF’s Professional Advisory Board. “So much of what has happened regarding Marfan syndrome is because of interested researchers and the incredible passion of the National Marfan Foundation,” Braverman says. “What the foundation tries to do is educate physicians, medical students, residents, physical educators, parents, teachers, and patients. It’s a wide net to try to cast to continue to have awareness in education. It’s an ongoing challenge, but there’s no question that in the last 20 years people have become more aware.”

To help address that challenge, Braverman and his colleagues created a scoring system to help physicians diagnose Marfan syndrome. The system, which is based primarily on a multi-system clinical examination, also provides patients with a more accurate diagnosis and better medical management.

“There are many conditions with features which overlap with Marfan syndrome,” Braverman explains. “The new diagnostic criteria assist clinicians with the approach to the diagnosis and evaluation of these conditions.”

Braverman also praises the work being done by researchers on the gene that affects Marfan syndrome and other related disorders. He himself is currently involved with a major study funded by the 

National Heart, Lung, and Blood Institute

 on a potential treatment for aortic enlargement in Marfan syndrome that is opening doors to potential treatments for the life-threatening problems associated with the condition.

“The work being done has led to translational research on medications which prevent Marfan syndrome in the animal model,” Braverman says. “And that has led very quickly to human studies. There are simple compounds that are blood pressure medicines that might change the natural history of Marfan syndrome. So, we are part of ongoing trials that are looking at these medications, and hoping they will make a difference.”

When attorneys have a personal relationship with individuals in a legal matter, they are required to recuse themselves from the proceedings. Braverman, however, says that having a family connection with Marfan syndrome has been one of the most positive things about his career. Often, patients are initially unaware of that connection.

“I’ll tell patients that my brother has Marfan syndrome, and all of a sudden there’s a total change in the way the person I’m speaking with interacts with me and thinks about me,” Braverman explains. “Because they now know I’m not just a doctor. I have a very personal interest in this, and in their well-being. And when they hear that my brother’s first surgery was 25 years ago and he’s still doing fine, that gives them a new appreciation for what they can expect; that they can live a long and fruitful life with this condition. That’s been a source of tremendous gratification.”

Immediately after Mount Sinai Medical Center’s Douglas Dieterich, MD, accidentally stuck himself with a needle that had been used on a patient who was a drug user, the 4th year medical student knew he was in trouble. But with an upcoming funeral for his grandmother, he pushed the incident to the back of his mind. Six weeks later Dieterich became very ill and was completely exhausted. He was tested, then told that he had non-A, non-B hepatitis, and that there was nothing the doctor could do for him.

“I guess it was frustrating, but I was so sick at the time when I first got it that it never even occurred to me that there might be something to do,” Dieterich says. It was only later when his condition became chronic and he had to take time off from his residency that the frustration came to the surface. Dieterich clearly recalls the turning point.

“I remember walking with my dog, because I was home from residency, and thinking, damn it, well, if I can’t do anything for myself, the least I can do is maybe work on doing something for somebody else,” Dieterich explains.

He switched his specialty from ophthalmology to GI, and began learning about immunology and virology. Woefully, he says, there was little research being done in hepatitis. Compounding the problem was that his liver was getting worse. He was treated with interferon in 1991, and again in 1997 before he was finally cured.

“I took the medicine every day for 18 months,” Dieterich recalls. “That was before they had the once-a-week stuff, so it was pretty brutal. But I continued to work; that was my answer. I wanted to be doing something constructive.”

Dieterich admits that he takes the battle with hepatitis C “too personally” sometimes, but is not concerned about its impact on his approach to treating patients—many of whom are as determined as he was to get cured, no matter what it takes.

“We have pretty concrete stopping rules, so we follow those,” Dieterich explains. “So as much as we hate to give up, sometimes we have to because we’re kind of torturing the patients unnecessarily, and I know how much they suffer when they take this medicine. So, if it’s not working, it’s not working, and we stop.”

He and his colleagues are heartened, however, by the fact that there are many new medications in the pipeline. “If what we’re doing right now doesn’t work, there are 30 or 40 other medications that are under clinical investigation now for hepatitis C. So it’s sort of okay; it’s not like it’s the last resort.”

Going forward, Dieterich says it’s important for work to continue on two fronts: education and awareness, and research and clinical trials. In particular, he says, education is critical.

“In the US, 75 percent of the patients who have hepatitis C don’t know they have it,” Dieterich says. “And even if we were to identify those people through screening, we still have to get the boots on the ground and treat them. And that’s a daunting task.” Nevertheless, his message to patients is one of hope, not despair. “I tell patients that it’s a really good time to have hepatitis C, compared to when I had it. And it’s a good time to be treating hepatitis C too, because there are so many wonderful things we can do.”

It was clear something was wrong. UCLA’s Stanley Nelson, MD, and Carrie Miceli, PhD, noticed that their 2-year-old son Dylan was having both language difficulties and motor movement problems. What followed was a diagnosis of Duchenne muscular dystrophy, a rare and fatal neurodegenerative disease that affects approximately 1 in 3,500 boys. The ensuing nine years have changed their lives.

“Once we recovered from the shock of the diagnosis, which was pretty substantial, it was a major change in our expectations for Dylan’s life and future that fundamentally changed our career paths,” Nelson says. “We were going to be invested in learning as much as we could about Duchenne and what ways we might be able to alter the disease course, and how to optimize his care.”

Miceli, who is a professor in the department of microbiology immunology and molecular genetics, says that Dylan’s diagnosis completely changed the focus of her research lab. “I never worked on muscle, I never worked on Duchenne, and now the bulk of my lab works on those two things.” In addition, Miceli believes that as both parents and scientists, she and Nelson are able to offer a unique perspective.

“Things that may not occur to other people just in terms of study design or even just the logistics of certain things, you have a very different perspective because you know [the disease] in a different way,” Miceli explains. “And I find that our colleagues are very thankful for that, and it’s inspiring to everybody.”

Dylan, now age 11, is “engaged in life” says Nelson, noting that there have been a lot of positive changes since the youngest of their two sons was first diagnosed. “The disease is not a fatalistic diagnosis,” Nelson says. “More so, it’s a diagnosis that requires a very well organized team—collaborating neurologists, cardiologists, pulmonary specialists, along with steroid treatments. And I think that was just starting to get organized when Dylan was diagnosed. I think that’s become fairly routine and accepted, and the clinicians themselves are doing it much better than they were nine years ago.”

Nelson and Miceli have been active writing grants and gaining funding for new research projects. One of their major efforts led to the opening of a 

Duchenne muscular dystrophy clinic at UCLA

 in 2010. The clinic, which serves approximately 350 boys, has grown substantially in two short years, and is now one of the largest clinics in California. Perhaps the most significant accomplishment of late is that the clinic has been given status as a California Children’s Services Special Care Center for pediatric neuromuscular diseases.

“The work’s not done yet by any stretch of the imagination,” Nelson cautions, “but the accomplishments so far are really quite impressive.”

Miceli adds that the biggest change in the field of DMD since Dylan was first diagnosed is that the multidisciplinary approach has become the standard mode of care. “It’s a mind change. And you can gather data from the literature that says multidisciplinary care extends life 10 years. That’s pretty powerful in terms of progress.”

Many public figures, from Albert Einstein to Michael Jordan, have commented on the ability to turn a negative situation into a positive one. For Mayo Clinic hematology/oncology fellow Mark Lewis, MD, living those words has been the story of his young life.

Lewis’s father, a lifelong non-smoker, died of lung cancer at an early age. Watching his father undergo treatment drew Lewis to oncology, but initially not in a positive way.

“When I was young all I could see was the negative, and I was quite angry at whatever force was responsible,” Lewis recalls. “But out of that came what I would call a personal vendetta against cancer.”

Lewis pursued that vendetta, but when he began his fellowship at the Mayo Clinic, he was diagnosed with multiple endocrine neoplasia type 1 (MEN 1), a rare and familial tumor syndrome that forecasts a predisposition to tumors in the endocrine organs, specifically the pituitary gland, the parathyroid glands, and the pancreas. The discovery that he had a high calcium level, similar to what his father experienced, sealed the relationship link. But out of that negative, too, came a positive.

“It seemed like a dark time, but I think it really deepened my relationships with my patients, and I hope it makes me a more effective communicator with them,” Lewis says. “I think it gives me a lot of meaning and drive, but it can be a Pandora’s Box when you look at it more thoroughly.”

Lewis, who says the tumors that currently reside in his pancreas are stable for the moment, further explored Pandora’s Box recently when he had his two children tested. The inheritance pattern, he says, is a flip of a coin, 50-50, and those odds played out exactly where his children are concerned. His 4-year-old daughter does not have the syndrome, which is brought about by a defect in a protein called menin, but his 1-year-old son does.

“I think what has troubled me more than anything is the knowledge that I’ve given him an inherited disease,” Lewis says. “But sometimes not knowing is worse. I may not be able to do anything right now with that information, but I think forewarned is forearmed.”

Lewis admits that he is the “farthest thing from a basic scientist,” but is excited about the prospects of strides that can be made to better understand MEN 1—specifically through establishing a national or international database.

“Rather than facilities just looking at the patients they’ve seen within their walls, it would be nice to share that experience across the globe,” Lewis says. “And that way it might be easier to see certain trends.”

For now, Lewis is focused on patient advocacy. “I always hope to be involved with patients.” And because MEN 1 has implications for families, he believes it’s particularly important that people understand genetic illnesses; that they’re not a death sentence for their children. The more they know, the less scary it seems. “If nothing else, what I’ve tried to do by sharing my own story is I want awareness of this condition to be raised. That’s my own personal mission.”

Articles

Cover Story

When disease hit close to home, these clinicians tackled the problem head on.

Family Medicine

Technophile or technophobe, your online presence is becoming increasingly important. Four out of five Internet users now look online when they need health care information, and searches for specific providers make up a sizable portion of their requests, according to recent data from the 

. You’ve likely heard a fair amount about the threats this can pose, yet what’s important to keep in mind is that it’s also a powerful opportunity. Below are six key ideas you can use on your own.

Prevention is more effective than treatment:

 From both a financial and time-saving perspective, preventive reputation building is much more efficient than reacting after a problem appears. 

 public profiles can be a good start—you control what information you share, from practice address to published works. You can also set up an 

 page or a www.YourNameMD.com site, listing any professional information you want to emphasize. In addition, update your practice information on physician review sites. Search engines prioritize websites that have been up for a long time, so there’s no time like the present to get started.

 If you fail to publish some of your own information, your online reputation will consist entirely of what other people have written about you. Patients often search by condition or procedure, so even if you don’t have any negative reviews, you might, for example, find yourself with a lot of content that—while positive–doesn’t represent the full scope of your practice or interests.

 Once you start putting information online, try to hit as many bases as possible. Search engines penalize duplicate content, and they give priority to different types of results: websites, blogs, new articles, journal publications, photos, videos, social media and so on. Make sure you have a presence on several types of sites.

 If someone attacks you online, avoid the temptation to post a rebuke in the comments. Your feedback tells search engines that this is an important website that people will want to see—the opposite of the message you want to send. For this reason, your best approach is almost always to keep your cool and just move on.

Remember there are positives to patient reviews:

 For many consumers these days, reviews are almost as trusted as word-of-mouth endorsements. And there are plenty of positives to this. Don’t be shy, for example, about encouraging satisfied patients to leave their opinions on review sites. Also, consider linking to positive reviews on your website; they’re an added reminder to potential patients of just what you’re capable of. Lastly, be sure to establish a patient wrap-up protocol with your staff that encourages unhappy patients to vent in your office instead of online [

Online Physician Reviews: 6 Essential Actions

With social media, it’s okay to stick to your comfort zone:

 You need a basic presence in social media to prevent “brandjacking” (antagonistic impersonations of yourself), so go ahead and set up a 

 for your practice. If you enjoy social media, use those accounts, taking care to respect 

 and other ethical considerations. However, if you don’t or feel you have too much on your plate, that’s fine. Social media is a good way to build your online reputation, but there are plenty of other paths you can take.

 The more types of material you publish, the more you yourself can own your online presence.

, the world’s leading provider of online privacy and reputation management services. 

Feature Article

Technophile or technophobe, your online presence is becoming increasingly important. Four out of five Internet users now look online when they need health care information, and searches for specific providers make up a sizable portion of their requests.

Online Reputation: 6 Tips from Reputation.com's Michael Fertik

Can’t fall asleep because you’re too distracted by your noisy environment? Use the White Noise app for your iPad to “create the perfect ambient sound environment for relaxation or sleep.” Comes with 40 pre-programmed ambient sound patterns and includes customizable shutdown timers and alarms. Users can also import additional sounds and mixes.

This app, which claims to have the best color blending capability available in the App Store, creates “the simulation of wet oil paint on canvas, allowing amazing blending effects with five real kinds of brushes.”

Use this app “to view the beautiful images and movies of NASA’s Astronomy Picture of the Day Website (APOD) in all their majesty on your iPad.” Each day, the app loads a new astronomical image along with a description written by a professional astronomer.

With StarSeek, you can “see a detailed, colorful map of the night sky from any location on Earth up to 100 years in the past or future. Double tap on any celestial object to pull up intriguing information about it. Animate the night sky by compressing up to years of time into seconds!” How does it work? Just hold it up to any portion of the sky and StarSeek automatically displays a matching star map that moves as you move your iPad.

Machinarium is an adventure game in which “players take on the role of a robot who has been exiled to the scrap heap. Players must use logic, collect important items, and solve environmental puzzles to get the robot back into the city of Machinarium so he can rescue his robot-girlfriend, save the head of the city, and defeat the bad guys from the Black Cap Brotherhood.”

This app “presents William Shakespeare’s immortal collection of love poems in an interactive digital edition that allows you to explore, appreciate and understand this great work of literature as never before.” In addition to video renditions of all 154 sonnets by an all-star cast, the app also features “the complete Notes and Introduction from the Arden Shakespeare, offering unsurpassed scholarly commentary and insight.”

This playful app “dissolves the images of yourself into countless dots. Your camera image is translated into virtual confetti that follow your movements and delight you with an ever changing reflection of yourself.”

Luminos “brings the universe to you” by rendering “textured 3D planets and moons, constellations, and deep space catalogs and imagery” that are positioned and scaled to their actual position in the sky.

This amazing video, produced by the University of Virginia’s Rome Reborn Project, offers a fly-through animated tour of the Eternal City circa 320 AD.

The Check Up

Cool, Fun, and Useful Apps for Docs

Twin Cities physician is team doctor for several big league franchises and runs a patient-centered practice.

Question: What do the Minnesota Twins, Vikings, and Wild have in common? Answer: Aside from hailing from the Twin Cities — Minneapolis and St. Paul &mdash; they all share the same team physician: Charles Crutchfield III, MD.

The principal of Crutchfield Dermatology, considered the premier medical and cosmetic dermatology clinic in the Twin Cities, is a sports enthusiast with a particular love for baseball, which is the source of some of Crutchfield’s most vivid childhood memories.

“When I was a small child, this was back in 1965, my grandfather was diagnosed with multiple sclerosis,” Crutchfield recalls. “And the Minnesota Twins went to the World Series that year, but because of [my grandfather’s] MS, he was not very mobile. At the time color TVs were a big deal. I remember my father went out and bought a color TV so our family could watch the World Series with my grandfather. Unfortunately, the Twins lost, but it was still fun. And in fact, some of the players who were on the team in ’65 are now my patients, which is really fun.”

And “fun” is the best word to describe Crutchfield’s affinity for life and medicine.

Crutchfield began his medical career early — very early, he says. His parents were physicians; his father still is. And his mother became pregnant with him during her first year in medical school.

“She likes to joke around with people and tell them that I’ve been through medical school twice,” Crutchfield laughs. “So it has been medicine ever since I was a little kid.”

As for dermatology, Crutchfield — who is also a clinical professor of dermatology at the University of Minnesota Medical School, as well as a mentor in the University of Minnesota’s Future Doctors of America Program &mdash; calls himself a visual person with a photographic memory for images, not for words.

“I can read something and two paragraphs later forget what I’ve read,” he says. “But for images, I’m good at that. I think that’s what kind of got me into dermatology. I still do surgical procedures, laser procedures. I still use the microscope every day to look at different specimens. And I see children, I see geriatrics, I see a broad spectrum of patients. I think all those things combined made dermatology the field for me.”

Crutchfield opened his own practice in 2002. He knew that he wanted to have a support staff that really supported him, and he’s been true to his word. His practice features one nurse per physician, not one nurse per exam room.

He hit the ground running a decade ago, seeing 48 patients the day he opened his practice doors, and has built Crutchfield Dermatology into a 45,000-patient practice that has logged more than a quarter of a million patient visits in its first 10 years.

“The secret is to design a system to practice medicine the way that it really should be practiced, where you have the physician as the leader of the team, not an administrator telling the physician what to do,” Crutchfield explains. “And then you surround the physician with superb support staff. And I’ve got fantastic staff.”

Crutchfield usually runs anywhere from eight to 10 exam rooms, with 16 nursing staff who are either in the rooms, working on notes, doing triage, or working in the lab. When he walks from room to room to see patients, his staff gives him a presentation very similar to a resident’s presentation.

“I do all the examinations, I do the diagnosing,” Crutchfield says. “If I can’t diagnose, I come up with a plan to get the right diagnosis. And I come up with the treatment plan. And once I develop that, then my staff takes that and they help me implement it. They write prescriptions as I’ve instructed, they act as scribes for me for charting. They also review all the materials with the patients and do a great job of educating the patient. I believe this is the way medicine should be practiced.”

Away from his practice, Crutchfield serves as a Hero Benefactor for a local reading center, stepping up to the plate to assist when available scholarship funds are insufficient to cover the number of hopeful students.

“That’s because I’m dyslexic,” Crutchfield acknowledges. “They helped me when I was in college. I had a teacher who told me, ‘Dyslexia is not going to hold you back.’ And I realized that if I were ever in a position to help other people, I would do so. It’s so important to give back.”

And the giving continues. For more than a dozen years now Crutchfield has been working with a program called Play it Safe When It Comes to the Sun, which is run through the American Academy of Dermatology in Major League Baseball. One day a year, a dermatologist goes into major league locker rooms to screen players and their families.

“It’s a really big campaign to let kids know to play it safe in the sun,” he says.

That activity has borne fruit. Crutchfield was approached about co-authoring a children’s book on being sun-smart. Titled 

, the book is named after his son, and the home run aspect refers to getting smarter about sun protection. The book, which was recently released in prototype, is currently in large-scale production.

“I can’t even say how nice it is [to be a published author], because it was something that came out of nowhere,” Crutchfield says. “One of life’s little unexpected gems.”

Crutchfield says that he truly looks forward to going to work every day, and reminds himself daily how fortunate he is to be in a position where he has the knowledge and ability to help people.

“I know that dermatology is not cardiology or oncology, but when you have a skin problem, you’re itching, you can’t sleep, or you’re embarrassed about the way you look — it’s a problem,” Crutchfield says. “I’ve had great teachers and training in the past. I’m just fortunate that I can really make a difference for people.”

Dermatologist Makes the Most of Life's Unexpected Gems

Many physicians are feeling the earnings squeeze amidst the tectonic shifts in the health care system and changing US demographics.

In a 2009 study of physician compensation, The Lewin Group estimated that medical practice incomes would decline 15% to 20% if greater numbers of Americans were allowed to participate in government health care plans modeled on Medicare payment rates.

Even if physician incomes do not fall, they may not experience the high growth rates of past eras. Recent experience supports this trend, with many physicians reporting little increase in overall compensation levels in the past five years. Some practitioners have sustained their income only by operating more efficiently, working longer hours or both.

All of this is occurring at a time when Medicare’s financial sustainability is in serious doubt and the US population is experiencing negative real wage growth. These and other forces are obscuring the economic future for doctors of all ages and specialties.

Traditionally, young doctors have entered their practice years with a heavy load of educational debt, meager savings and the prospect of initially working long hours for relatively low pay during residency and training. But the hardship seemed worth the pain, as doctors understood that, over time, they could reliably convert their knowledge and training into a reliable, growing stream of lifetime earnings.

Their future earnings potential provided the motivation and security to buy into their medical practice, take business risks, spend on lifestyle, and hold speculative investments while also saving enough for retirement. But this growing income potential is no longer a sure thing for doctors in today’s market. In fact, many are feeling the earnings squeeze amidst the tectonic shifts in the health care system and changing US demographics.

Investment decisions: more important than ever

The changing earnings landscape for physicians means that investment decisions are more important than ever. As a result, doctors need to have a keen understanding of the following factors:

Slower earnings growth should make many physicians more risk averse in their investment decisions. In the event of a major loss, they will not have enough surplus income to quickly replenish their portfolio. To make up for lost time, some investors may be forced to take excessive risks, thus increasing the odds of an unfavorable outcome.

Consequently, physicians should consider strategies that eliminate or at least reduce the possibility of experiencing unrecoverable investment losses, while also positioning their portfolio to pursue expected returns above the rate of inflation. In general, they should avoid:

		Owning highly speculative investments — for example, those relying on high debt to generate returns (often related to real estate, commercial or residential properties)

		Taking large, concentrated positions in start-up companies, individual stocks or asset groups

		Chasing new or unconventional investment ideas offering high returns with low risk, which is a sure sign of a false hope

		Holding unproven, illiquid investments whose outcome will be unknown for many years

An immutable law of investing is that risk and return are related, and investments touted with having high returns bear the highest risk of failure or significant loss. Modern financial theory and academic research indicate that it is possible to minimize the likelihood of certain types of investment losses by choosing to accept only those risks that have shown a consistent long-term reward — then diversifying broadly to reduce the impact of a single negative performer on your portfolio.

In the traditional income model for doctors, high earners could spend a larger portion of current earnings on lifestyle and push their saving efforts to their later years. Today, a large loss from speculation, professional liability or another unfortunate event can ruin these plans.

Physicians should consider moderating lifestyle spending until they have established a sufficient retirement portfolio that can begin working for them early in their career. This early investing bias reinforces good spending habits and allows a more balanced, long-term investment approach. You can still invest in an aggressive, diversified portfolio of stocks and bonds, but in a way that avoids the unnecessary risks of market timing, forecasting, overconcentration and other speculative methods.

Doctors can build a portfolio that has an academic basis for earning higher expected returns relative to the market. The portfolio may hold asset classes with a documented history of performance in different economic and market environments. Other strategic actions may include:

		Overweighting the portfolio to small company stocks inside and outside the United States, and to high "book-to-market" (value) stocks in every asset class

		Avoiding concentrated stock portfolios in favor of highly diversified global asset class portfolios that hold thousands of securities

		Investing the majority of the portfolio in readily marketable and transparently priced investments that you can monitor in real time

		Further dampening overall portfolio volatility through high quality, shorter-term bonds

The lifetime earnings equation for a doctor is under pressure and will likely change dramatically over the next decade. The ultimate financial impact is uncertain due to the dubious state of federal health care policy, the increasing costs and risks associated with practicing medicine, shifting US demographics, and the unknown number of individuals who are unprepared to fund their own medical care in the future.

This uncertainty should lead physicians to take early steps to prepare for and protect their financial future. Their actions may include adopting practice risk management strategies, protecting themselves from large losses and investing in academically proven, non-speculative vehicles offering a relative high probability of long-term success.

Kent Kramer, CFP, is a partner of Foster Group, a wealth management group based in West Des Moines, Iowa. Kent works alongside clients to help them identify and achieve their most meaningful financial and related goals. Drawing on his varied experiences as a communicator, elected official, financial adviser and portfolio manager, Kent uses his unique abilities to describe and connect clients’ financial goals with strategies that will lead toward success.

Money and Finance

Physicians' Investment Decisions Magnified Due to Earnings Potential Uncertainty

, the second largest city in the Czech Republic, may be an enigma to American tourists. Strangely, it hardly does any marketing of itself. Book stores in the United States seldom carry enough information about the one-time capital of Moravia to make Americans think it’s where they might want to go on vacation. More is the pity because it’s really a fascinating town: it’s less expensive than Prague and less busy, less touristy. And you can walk through its very heart in a single day.

“The trouble with Prague is that 90% of the tourists in Prague are in 5% of the city!” says a Brno friend who loves both cities. “I believe famous cities are either extrovert or introvert. Paris, for example, is extrovert. London is introvert.”

“Well, there’s a saying, ‘Prague and Brno are both provincial cities, but only Brno knows it.’”

Well, maybe that’s been said, but we are captivated as we walk through the city along the cobblestones with our guide 

. When we ask about the city’s history, he warns us that Brno doesn’t have many buildings from the Middle Ages. He says that the reason for this is that, “Where you find lovely, intact old cities in Europe, it means one of two things, or both: that at some point in the past the city was lucky enough to escape the wars that swept back and forth across the continent for centuries or it became a backwater, bypassed by progress.”

Brno, like the whole of the Czech Republic, was spared virtually every war after the Thirty Years' War in the first half of the 17th century.

Don says, “But in the nineteenth century — unlike, for example, Prague &mdash; Brno, as one of the richest and most progressive cities in the Austrian Empire, had its focus on development.”

It still does. We walk past a new building going up next to St. Anne’s University Hospital. It is the International Clinical Research Center (

), and it will be the largest medical research collaboration Mayo Clinic has outside the United States. (Location shown as 1 on our map)

Such a health facility will surely contrast with Brno’s most popular tourist attraction, 

, which was built as a royal palace in the 13th century then converted centures later into the Baroque fortress “that was the most feared prison in the Habsburg monarchy.”

The Gestapo found it ideal during World War II when history cruelly repeated itself. An ancient apothecary store has been maintained as a tourist attraction in the castle.

The Czechs supposedly have a reputation of being a bit paranoid, but Don disputes that. “This is a small country with a population of only 10 million that has spent centuries under oppression,” he says.

Vaclav Klaus once said, on the subject of identity and the fighting to maintain it, the Czech Republic could “dissolve in the EU like a sugar cube in a cup of coffee” if care isn’t taken. The current Czech president was once called “the Margaret Thatcher of Central Europe,” and his Euroscepticism surely now is seen as prescient!

Ten minutes after walking past the cannons at the castle we pass a downtown wall of photographs (situated someplace around 3 on map). The photos show young people who were detained by the communists and executed on trumped-up charges. It makes you realize the Hungarian Marxist Georg Lukacs and the famous Czech writer Milan Kundera might have both had a point when they said: “Kafka was a realist!”

Maybe, but we see a lot of tongue-in-cheek humor as we walk Brno’s streets with Don, who was educated at the University of Toronto and Oxford, England, and was the former director of International Studies at Masaryk University, Brno.

We walk past the massive St. James Church and our attention is directed to a carved figure mooning the passersby. Anton Pilgrim created it around 1520, a Late Gothic joke, possibly because the church took its time to pay its builder.

A more modern example of Czech humor lying beyond is the Town Clock (5) in Freedom Square — in a city of antiquity it’s a complicated digital time piece put up in 2010 and shaped like an immense bullet.

There are, for sure, many statues in town but the tendency of the Czechs not to take themselves too seriously is seen in their statue of Mozart in front of the Reduta Theater. (6) Mozart performed here in 1767 at the age of 11. He is portrayed with a young body but an old face and the wings of an angel.

The New Town Hall is misnamed. Sure it’s more recent than the 1240 Old Town Hall, but only by about 10 years! It’s a former Dominican monastery and within its courtyard the fountain with allegorical figures represents the 12 months of the year. Sculptors designed the fountain in 1928 to celebrate the 10th anniversary of the Czechoslovak Republic.

town hall’s cellar had the medieval workshop where coins were minted. The cellar connects with the labyrinth 

 under the Vegetable Market — the new tourist attraction in town.

A pharmacy called The Sign of the Red Cray Fish was built in 1620 on the street now called Masarykova. It’s still there.

Another place perhaps as interesting to physicians — perhaps not &mdash; is the Baroque Capuchin crypt (8) built by the architect Grimm. He was not related to the Brothers Grimm, who wrote the scary children’s fairy tales, but the crypt might be creepy enough for a lot of people. Until 1780 the Capuchin order members were laid out here and the bodies became mummified due to the soil composition and air circulation in the church pillars. They still lie here at peace with our world.

As we walk back to the Grand Hotel, (a great location right beside both the bus and the train station) we pass again through Freedom Square with its tall digital clock, the oldest and biggest square in town. The Brno Council decided to grace the square with memorials to the four “platonic virtues” which are Foresight, Temperance, Justice and Courage. (9)

The first is portrayed by a metal map of the city in 1645 when a general had the foresight to remove the roofs of houses that could be set on fire in an approaching siege. The second virtue is seen in a long tank of cascading water. The third shows a figure in front of the Court House wrestling with its obvious burden.

“Where is Number Four?” we ask our guide, “Where is Courage?”

He coughs and looks at the ground. “The council was given several controversial designs to decide on,” he finally says. “They couldn’t agree. They couldn’t choose. They didn’t have the…,” he hesitates then says “…the courage!”

Our walk is almost over but there is still time to see the Neo-Renaissance Mahen Theater built in 1881-82 — the first theater building in all Europe lit entirely by electric light. (10)

Thomas Edison himself came to supervise the work, and a memorial of electrified wire commemorates the event. Inside, looking at the rich velvet drapes and the gilded cherubs it’s easy to be transported back into the Victorian era and the mystique and magnificence of Moravia’s capital.

Despite the name, Old Brno has hardly any old buildings. With the establishment of the city of Brno by royal charter in 1243, Old Brno became of secondary importance. By the early twentieth century much of it was pretty dilapidated and so being torn down and rebuilt, and this continued between the wars and afterwards, when war damage led to further demolition. The monastery and its church are the main historical buildings in Old Brno.

So around the turn of the twentieth century the vast majority of Renaissance and Baroque buildings in the city were demolished to make way for modern buildings with all the latest modern conveniences. And then in the twentieth century, between the wars, it became the centre of the modern, Functionalist movement in architecture not only for this country but for the whole region. As a result, visually the city has its own distinct ethos, but it's not one that can easily be conveyed in individual photos, since it has more to do with the feel of the place than the quality of any specific buildings.

One other thing about Brno is that it is also a very convenient home base for making day trips in the region. The site of the Battle of Austerlitz is only about twenty kilometers away, with a superb Art Nouveau memorial and the splendid Baroque chateau in the town the battle is named after, where Napoleon stayed following his victory. (He also stayed in Brno both before and after the battle.) The extraordinary Valtice-Lednice complex is about 60 kilometers to the south - the seat of the Lichtenstein family for almost 600 years, and now a UNESCO World heritage site (in fact one of six such sites that can be reached easily from Brno, something of a rarity).

And as the day ends, we pass the school on Janska Street where Mendel gave his first lecture on genetics in 1865 — but that’s another story.

The Andersons, who live in San Diego, are the resident travel & cruise columnists for Physician's Money Digest. Nancy is a former nursing educator, Eric a retired MD. The one-time president of the NH Academy of Family Practice, Eric is the only physician in the Society of American Travel Writers. He has also written five books, the last called

The Man Who Cried Orange: Stories from a Doctor's Life

Travel and Leisure

Brno, the second largest city in the Czech Republic, is a fascinating town: it's less expensive than Prague and less busy, less touristy. 

A Great Walk Through Brno

Looking for a tablet computer but want to know a bit more about the iPad alternatives on the market? We’ve compiled information on 10 tablets for all budgets and performance needs — from high-end, high-powered 10-inch devices, to lower-priced 7-inch models that combine affordability with capability. 

Billed as a “crossover between a tablet and a mobile phone,” the Asus Eee Pad MeMO 171 features a 7-inch, Gorilla® Glass-protected screen with 1280x800 resolution. The device comes with 1GB of RAM and 16GB of memory storage, and is powered by a 1.2Ghz dual-core CPU. It runs Google’s Android™ 3.2 Honeycomb OS, but can be upgraded to the Ice Cream Sandwich 4.0 OS. It comes bundled with a Bluetooth headset that “provides an integrated experience with the MeMO” and is “super convenient for placing calls, sending texts, and listening to music.” It features a 5MP rear-facing camera and a 1.2MP front-facing camera. It has a listed battery life of 10 hours (or roughly 8 hours of video playback). Other features include “Supreme SRS” 3D stereo sound, HD video, GPS, E-compass, pre-loaded productivity apps, and more. The MeMO 171 has a Micro USB port, Micro HDMI, audio jack, card reader, and one SIM card slot. The device weighs in at a light 14.1oz (about 400g) and is 7.8”x4.6”x0.5”. Note: as of this writing, the MeMO 171 has not been made available for the US market.

Sporting a unique, ergonomically designed wedge shape, the Sony Tablet S features a 9.4-inch display, a 1GHz processor, and 1GB of RAM, and comes with either 16GB or 32GB of memory. It runs Android 3.1 (aka Honeycomb), but as of April 2012 is upgradeable to the Ice Cream Sandwich 4.0 OS. The Tablet S is Bluetooth enabled and features a micro USB port and a full-size SD card reader. It has a 0.3MP front-facing camera and a 5MP rear-facing camera. Battery life is approximately eight hours. The Tablet S also enables users to access several Sony media services, such as Video Unlimited and Music Unlimited, which allows you to stream or download movies and music.

The Galaxy Tab 2 runs on a dual-core 1GHz processor with 1GB or RAM and comes installed with Android 4.0. It has a 10.1-inch, 1280x800 display, with a VGA front-facing camera and a 3MP rear-facing camera. The Tab 2 has 16GB of internal memory, and a micro SD card slot that can support up to 32GB more. It’s Bluetooth, USB, and WiFi compatible, and boasts 6-8 hours of battery life. Thanks to the IR “blaster” on this device, you can use one of the installed apps to turn the Tab 2 into a universal remote for your TV (though you’ll have to buy an HDMI adapter if you want to connect the device to your TV).

This powerful device features a 1920x1200 resolution, full HD screen, SonicMaster audio technology, and a 1.6GHz quad-core CPU with 1GB of RAM. It runs the Android 4.0 OS and has a 2MP front-facing camera and a 8MP rear-facing camera with auto-focus and LED flash. This device has a micro-SD card slot and micro HDMI port. When attached to the optional keyboard dock, it has an additional SD card reader and USB port. Battery life as a standalone tablet is roughly 9.5 hours; when docked this can increase to as much as 14 hours. The device also comes installed with a suite of Asus media, entertainment, and productivity apps.

The initial version of the Microsoft Surface tablet that will debut in the fall will run on Windows RT (which has been described as a “light” version of Windows 8) and will be powered by an ARM processor. It will feature a 10.6-inch high-def display, and a “pressure-sensitive cover that doubles as a fully functioning keyboard.” The Surface has 32GB of internal Flash memory, with micro-SD support for up to 32GB more. Other features include a USB port, front- and rear-facing cameras (though they appear to be of lower resolution than those found on competitors’ devices), dual microphones, and more.

This low-priced ($199!) tablet features 7-inch 1280x800 display, scratch-resistant glass, a quad-core processor with 1GB of RAM, runs on Android 4.1 (aka “Jellybean), and has a battery that supports up to nine hours of video playback. The Nexus 7 also has a 1.2MP front-facing camera, micro USB port, Bluetooth compatibility, and 8GB or 16GB of memory. It weighs less than a pound and is less than five inches wide and about a half-inch thick (it’s a bit thicker at the top and bottom to make it easier to hold).

This is one of the few devices on the market that supports both Windows 

Google Android. However, it uses an older version of Android (2.2) that doesn’t support Android Market. The ViewPad features a 10-inch, 1024x600 LCD screen; a 1.66Ghz processor with 1GB of RAM; integrated 2GB SDRAM and up to 32GB SSD storage capacity; a 1.3MP front-facing camera, two USB ports, micro SD reader, mini VGA port, and Bluetooth. It weighs about two pounds.

This lightweight, affordable tablet has a 7-inch 1024x600 screen, 0.3MP front-facing camera, 3.0MP rear-facing camera, Bluetooth, micro USB and micro SD card reader, integrated GPS, and a battery that supports about seven hours of use. It has 2GB of internal Flash memory, an ARM Cortex processor with 512MB of RAM, and weighs less than one pound.

The PlayBook offers a 7-inch, multi-touch, 1024x600 LCD screen; is powered by a 1GHz dual-core processor with 1GB of RAM; includes a 3MP-front-facing camera and a 5MP rear-facing camera with HD video recording; Bluetooth and WiFi connectivity; and a micro USB and micro HDMI ports. It supports both Flash and HTML5. The PlayBook is 7.6”x5.1”x0.4” and weighs just under one pound. Note: Research In Motion recently announced it would cease production of the 16GB model of the playbook, but would continue to manufacture the 32GB and 64GB models.

The Carbon has a 1024x768 pixel, 9.7-inch, multi-touch IPS screen; runs on a 1GHz ARM processor with 1GB of RAM that powers the Android 4.0 OS; has a 0.3MP front-facing camera and 3.0MP rear-facing camera with HD video capability; includes micro and regular USB ports, a micro SD slot, and HDMI output; sports a battery that supports up to eight hours of video playback (20 hours of music); and offers 16GB of internal memory.

Gadgets and Technology

Looking for a tablet computer but want to know a bit more about the iPad alternatives on the market? We've compiled information on 10 tablets for all budgets and performance needs â€“ from high-end, high-powered 10-inch devices, to lower-priced 7-inch models that combine affordability with capability. 