With the de facto focus on the things of life and the pursuits therein, whether trivial or meaningful, remembering death has been an important facet to life for centuries. The concept of memento mori, the reminder of death, has evolved over the years from actual skulls to pictures, to other tokens and reminders that death is always merely a heartbeat away. Even more than the proximity of death, the idea of memento mori also functioned as a reminder of the assurance of death, that whether now or later, death visits everyone.
The reason that the reminder of death required a token and an intentional awareness, is that often death is removed from the trappings involved in daily life. This removal has increased over the course of human history with life isolated from death. This has occurred with fewer and fewer people dying at home, with more people dying in the hospital, and the rituals of death and preparation discreetly hidden away from the common eye. In this setting, the memento mori makes sense and takes on an important role in recognizing the importance of life and the framing of human endeavors, accomplishments, and undertakings in light of death.
In the hospital, the reverse is found. There is no need for a memento mori as there is a reminder every hour of every day that one is mortal, that death visits everyone, often at the most unexpected times and in the most unexpected ways. Whenever someone becomes ill there is a search for a reason why, something that someone could have done to prevent the illness. Yet even with the most preventable of diseases there can often be little certainty that the specific disease in the specific individual could have been prevented. Each encounter is a token, a reminder of the concept of memento mori, that illness and then death are the lot of humans, and that there is no escaping this end. The interactions with patients and their family members whether in person or in review of past cases, serve as a perpetual reminder that everyone dies; even more than this, that YOU will die.
The purpose of a memento mori is to clarify and refine life, to push one to forgo things that are meaningless and to pursue the things that matter in the setting of a finite life, with finite time and resources. The memento mori is specifically a reminder not a constant and overbearing focus. The call is not to obsess about death such that one is unable to live, but to remind oneself that death is the end and encouraging one to vigorously re-engage in life. When one’s primary endeavor, the occupation in which one spends most of their waking hours is, in and of itself, a memento mori, the struggle is remembering and valuing life, not remembering that one will die. Whereas, for the vast majority of society remembering death is the counter-cultural phenomenon, when one is surrounded by disease and death, remembering life becomes the counter-cultural phenomenon. The practice of memento mori is not the isolated drive towards death, but rather the opposite. It is to hold both life and death in balance, to allow the understanding and reminder of death to permeate and enrich life. Remembering death is the road to a richer life. Both death and life must be remembered together as life is defined in its finitude by death, and death only is made possible when there is life.
Training, and the repetitions that are inherent in training, are essential not simply for establishing the ability to perform a particular action or procedure but even more, in learning how to troubleshoot the complications and inherent variations within a procedure.
The first step in overcoming a complication is recognizing that a complication has occurred. The ability to recognize that something is off, that there is something wrong in the first place, is dependent on knowing and being able to recognize normal. The ability to recognize genuine currency, gems, works of art, or designer products is established by constant and vigilant examination of the real thing. There are a near-infinite number of ways for a forgery to be made, and yet only one way to be the genuine product. Likewise, particular skills require repetition in the proper manner to establish the correct baseline from which everything else is built. Normal is the baseline for encountering and managing all variations and complications. Understanding the abnormal begins with understanding the normal.
From this base, variations and complications from that perfect base are recognized, mitigated, and managed. Experience is largely a function of having put in the time and repetitions to have seen many variations, many complications, and many outcomes, both good and bad. Experience means having seen times when people pushed on and went too far, times when people turned back too early, and times when people simply lost their way completely. The pictures of the human body that appear in medical textbooks rarely represent the actual patient. The position, origins, and shapes of vessels often vary significantly from person to person. This requires significant experience to be able to recognize these variations, adapt to the new anatomy, and understand whether the variation that one sees in front of them is responsible for the symptoms or pathology that is being observed by the patient. A structural abnormality may represent inconsequential variation, pathologic variation that impairs function, or physiologic adaptation to a particular stress or pressure from the environment. In the latter case, attempts to correct that adaptation will likely cause greater harm as the initial stress is now left uncompensated.
Experience is required not for the times that go well, but for the times when one hits resistance, when something is not going according to the textbook. Placement of central or arterial lines are good examples. During the ideal procedure, everything is smooth, with little resistance during every step from the advancing of the needle to the passing of the wire to the dilation to the placement of the catheter. When this happens everyone feels good and anyone could place the line. It is the variations of this ideal scenario that requires training. Perhaps the patient is moving around, perhaps CPR is being done on the patients such that the whole field is moving. Perhaps resistance is encountered at one or all of the steps. Is the resistance normal and one should continue advancing? Or is the resistance problematic requiring the procedure be aborted and another site chosen. How does one troubleshoot the resistance to minimize the risks of complication and improve the odds of success? Experience, seeing repetitions from all forms of variation provides the tactile background for feeling the resistance as well as the intellectual understanding of how normal, physiologic, and pathologic may present.
The need for long hours and many years of training is not for the good times, rather it is for the bad times, the times when one is unsure whether to proceed or how to proceed. There is no textbook to turn to that accurately represents the actual individual patient. Instead experience, putting in the repetitions over many years is the requirement for understanding and managing these variations and complications. Experience addresses complications, yet complications also build experience in a momentous cycle of building proficiency and expertise.
There are no passive bystanders, no actual flies on the wall. Every single person within a group changes the dynamics and direction of the group regardless of the size. Each individual changes the energy and changes the conversation. There is no option of simply being fluff, the innocent bystander, a passive observer. Whether as a witness, an audience member, a main character in the unfolding drama, every single person matters. More than matters, every individual changes the playing field and the manner in which the game is played.
Often the role of the passive bystander is assumed as a shelter from responsibility, a liberation from the need to take on an active role. The posture of the passive bystander may be taken in an attempt to shelter oneself from physical or emotional involvement in what may appear to be a difficult, complex, or unfavorable situation. The role of the passive bystander is often perceived as less risky as it is an attempt to blend in with the crowd, to be lost in a sea of faces, amongst the other bystanders. Whether this is as a physical bystander, such as in a crowded subway or along a busy street, or whether this is as a metaphorical bystander, in drama within the workplace, in relationships within a friend group, in monetary or investment decisions, or in working with a new organization, the role of the passive bystander is often perceived as safe.
Yet in reality, there is no bystander role. For better or for worse, every individual recalibrates the room, changes the energy, momentum, and conversation that is occurring within the room. If there is no safe bystander role, then there is a responsibility incumbent upon each individual to consider how they are actively changing the environment in which they find themselves. On multiple occasions, Microsoft CEO Satya Nadella has addressed what he looks for in current employees or prospective hires. There is a common theme to what he looks for- do they bring energy and do they bring clarity. In isolation, these characteristics are rather unremarkable, yet finding them in combination is rare. Often those that bring the greatest amount of energy, bring confusion as an unintended side effect. Conversely, those that bring clarity, often do so at the cost of energy. Consider a pop music concert. The excitement that draws enormous crowds is the energy, the electric hum of being surrounded by thousands of people, singing together in a collective experience. Yet the lyrics and message to even the most thoughtful song are difficult to understand and even more difficult to implement into action. There is high energy and yet little clarity. On the opposite side of the spectrum, meditative practice often brings a high degree of calm and clarity but does so at the cost of energy. It is a rare combination to find both clarity and energy in combination. Even more rare yet valuable is finding energy and clarity in combination consistently. To be able to bring clarity and energy to any environment is a unique, carefully cultivated ability that must constantly be monitored, maintained, and reassessed lest one stray to one side or there other as noted above.
If there are no bystanders, every individual in every group must be constantly considering how they are changing the dynamics of that group, whether that be at work, with friends, in the midst of family gatherings, or even in one-on-one meetings. There is no such thing as being along for the ride. Whether intentionally or unintentionally, everyone is always bringing something to the group. How does one’s presence change the dynamics and conversation of the group? How does the energy change when one enters the room? Does clarity increase or decrease. Is one bringing to the group the elements that one is intending to bring, or are there other attributes to which one aspires? If there are no passive bystanders, everyone is an active player.
“Tell me with whom you consort and I will tell you who you are; if I know how you spend your time, then I know what might become of you. “
The company one keeps is a critical determinant of the person that one is becoming. Those with whom one associates with change both the outward behavior as well as create an inner transformation though it may be in the most subtle of ways at first.
As summed up in 1 Corinthians 15:33,
“… Bad company ruins good morals.” (ESV)
The moral of the story, the truth pointed out by these proverbs appears to simply stress the importance of the manner in which one selects their friends. Yet the lesson of the importance of the company that one keeps extends far beyond how one selects their friends. Indeed, for most, though friends play an important role in social life, they are often not the people with whom one spends the predominance of their time. Instead, co-workers, collaborators, clients, and family members often make up the elite groups that dominates one’s waking hours.
When one is selecting a job, the environment in which one works should be a key consideration as, in all likelihood, one will find themselves elevating or degenerating to the level of one’s coworkers. As noble as one’s intentions may be, the amount of time and subtle pressure within the environment will definitely change any individual given enough time.
As the saying goes, “You can choose your friends, but not your family.” Unlike jobs or even good friends, family is not something that can be selected, exchanged, or rapidly altered. However family has a critical influence upon who one is and who one is becoming. Taking rather trivial examples, everyone in the family unit is affected when one member of the family smokes as the smoke permeates both the air as well as clothes and furniture even when careful precautions are taken. Secondhand smoke is hard to avoid. Less obvious, the amount that one eats is influenced by those around them. Eat with those who tend to overeat and that become normative and one will find themselves overeating as well. However the news is as good as it is bad. Healthy habits are social as well. Eating well, exercising, and avoiding excessive alcohol intake are all affected by the environment in which one finds themselves.
This leads to the responsibility aspect. Perhaps the moral corollary of Newton’s Third Law of Motion (for every force there is an equal and opposite reaction), is that as one finds themselves changed by the company in which they find themselves, they are, at the same time changing the company which they keep. Not only must one use great care in selecting the company which one keeps, but one must also be careful to observe what type of company they themselves are becoming. Are they becoming someone who elevates others to their level? Are they bringing energy, enthusiasm, yet also calm and thoughtfulness to every situation. Do they notice their good habits being adapted by those around them? The concept of rising together is critical. As social creatures, everyone in the group is affected by the actions of every other individual in the group. Thus, beyond simply the individual improvement, is the group as a whole rising, becoming better, or is there a slow slide toward mediocrity and complacency.
The decision about the company which one keeps is not limited to looking at others at one point in time before one determines whether or not to be involved with a certain group of people. Rather, the decision is both introspective- requiring examination of oneself, dynamic- requiring constant vigilance and reassessment, and collective- requiring monitoring of not only the individuals but also the movement and trajectory of the collective group.
Neil Gaiman, the author of many notable books including American Gods, Sandman, Stardust, and Neverwhere was interviewed on the Tim Ferris show about many aspects of his personal as well as professional career. Writing is one of the interesting careers where one must balance a degree of creativity and inspiration with the raw grit and sweat of putting in draft after draft, refining ideas, and developing a style that is truly unique. Gaiman has developed a technique, almost a whole genre, unique to himself. One of the keys to being good at anything, but especially at being a professional writer, is the ability to generate a habit of productive work patterns. Whether this pattern is writing in the early morning or late at night, whether this means writing at home or writing in a dedicated location, whether this means writing consistently for a couple hours every day for months or for all hours of the day for a small handful of weeks, it is up to the individual writer to formulate a productive pattern for themselves.
One of the interesting techniques that Gaiman mentions is the mental game, or rather technique, wherein when he sits down to write he gives himself permission to write or do nothing at all, without the possibility of doing anything else. This technique recognizes the incredible value of the wandering mind, how creativity and new ideas often come from a mind freed from many of the burdens of daily life. More than that it hints at the origins of storytelling as a means to communicate truths and history as well as pass time around the fire at night or during long journeys and through monotonous tasks. Writing never arose as forced creativity from 9 to 5, sitting in a cramped room agonizingly attempting to put pen to paper.
Further, in a world of constant distraction, this technique emphasizes the importance of solitude and the elimination of distraction. One of the methods of punishment within the prison population, solitary confinement, has been found by many to be unbearable. Even Nelson Mandela commented on solitary confinement as one of the worst punishments in prison, an experience he details in his autobiography, Long Walk to Freedom. The human mind is constantly looking for new objects upon which to focus. With the two options of sitting alone with nothing or writing, there is often but a short lull before writing becomes by far the favorable alternative. In allowing for only these two activities, Gaiman’s technique turns writing from something that one MUST do, to something that one CHOOSES to do. In one study by Wilson et al. published in the journal Science, they found that individuals preferred to administer electrical shocks to themselves instead of simply sitting with their own thoughts. These were not extended periods of time of many hours or days, but rather for time spans of as little as 6 to 15 minutes. Of course, the mind would prefer to write, to run wild with new stories, characters, and plots over sitting in perpetual boredom. Blaise Pascal noted in Pensees that “All of humanity’s problems stem from man’s inability to sit quietly in a room alone.” In this setting, writing becomes a joy, the task that the writer gets to do instead of a task of drudgery. There is nothing else to distract, no scrolling through social media, no videos to watch, no games to play. In this context, writing becomes a joyful, guided meditation seeking both clarity and creativity.
The ability to do something on demand, whenever it is needed or desired is the ability to actually perform the task in a useful and practical manner. The ability to produce excellent results on command is the difference between performance during practice and performance during the real thing.
There is a difference between being able to deliver a speech in front of a bathroom mirror and speaking in front of hundreds or thousands of people. There is a difference between being able to make basketball shots in practice without an opponent and being able to score with the clock winding down and a defender charging at you. There is a difference between being able to perform a procedure in a simulation center and being able to do it on an unstable patient while the rest of the room watches. There is a difference between being able to be kind to others when everything is good, when a full night’s sleep, a warm environment, and plenty of food are present, and being able to be kind no matter what the environment and no matter how tired or cold or hungry one may be.
Being reliable, someone upon whom others are able to count on, requires the ability to perform on-demand. Being someone who can be trusted to make good decisions requires that one be able to make these decisions both under the best of circumstances, as well as the worst conditions, for it is under the worst conditions that these decisions matter the most.
Performing on-demand is the skill that is amassed during training. Performing an action again, and again, and again in practice provides the basis for being able to produce a result on demand. Repeating three-point shots is critical to being able to make the basket when the game is on the line. However, shots in practice must be taken with both the mental and physical pretense of preparing for the critical moment. That is, both mentally and physically one should be constantly playing iterations of real game scenarios during practice. From the presence of a defender to the feel of the court, even to the noise of the crowd, the more realistic the practice, the better the preparation for the game. Most practice facilities have basketball hoops which are framed against a wall whereas nearly every large arena has free-standing hoops, that is, there is no wall behind the hoop. This optical illusion can often cause good shooters to underestimate the distance to the basket resulting in missed shots. Thus practice shots must be taken in game-like conditions whenever possible and recalibrated in the real venue or as close to it as possible.
There is a difference between being able to tie sutures at a desk and being able to tie them with gloves on, working with a patient who may or may not be cooperative or sober. There is a difference between being able to answer kindly to another seated in one’s optimal environment and in the pressure cooker of a high-stress environment. Having the muscle memory for a kind and calm response is the same as having the muscle memory to throw a stitch as both are learned, and when learned, the muscle memory becomes natural and frees one up to focus on the larger picture.
With practice, there is gained a joy, a freedom in the performance. With muscle memory and practice, one is allowed the luxury of freeing up the mental space and bandwidth to perform higher-order tasks, to begin thinking several moves ahead.
As the saying goes,
“An amateur practices until they can do it right, professionals practice until they can’t get it wrong.”
Performance under pressure is performance on demand.
During the medical school admissions process, the last step before signing on the dotted line and committing to a specific school for medical training is an event called Second Look. This is an opportunity for prospective medical students to revisit the campus, meet with faculty and current students, ask any questions, and look at the surrounding area for extracurricular opportunities including recreation and housing. Medical school applications are now a decade in the past, and I certainly do not remember much of the Second Look experience at the respective schools, however, one line from one professor was notable a decade ago, changed where I decided to go to medical school, and has stuck with me since.
As we were sitting around a table, prospective students nodding and smiling as faculty members shared about the benefits and future plans of this particular medical school, one of the older professors who had trained several generations of physicians in the past began talking about the hospital and the system in which the medical school was situated. To the best of my memory, his statement went as follows:
“If you take a good physician and place them in a bad system you get bad results. If you take a bad physician and place them in a good system you get good results.”
Surely this could not be true. With curricula that stressed individual achievement and excellence, surely a good physician could do everything to create good outcomes despite the system. Right? And then I began to reflect on this statement more.
Inherent in this statement was the belief that a good physician in a good system would yield good results and a bad physician in a bad system would yield bad results. The determining factor, therefore, was not the physician, but the system in which they were operating. A decade ago I took that lesson to heart. As I was considering this statement I realized in that moment that this particular medical school where I was enjoying Second Look and was planning on attending, was a bad system and that by staying in that system I was likely to yield worse results than if I were in a better system. Certainly, I still would have ended up with the degrees as well as the experience necessary to practice medicine as a physician-scientist, but the system itself was not engineered to be frictionless towards attaining favorable outcomes. Notably, that program has significantly turned around in the past decade, and is now a better system which has been reflected in the renewal of NIH grants that had previously been lost primarily related to systemic problems at the institution. As the professor noted the importance of systems in success, I realized that the other medical school that I was considering boasted a significantly better overall system, especially for training physician-scientists, and had been doing so for longer than any other program in the country. This school which was previously my first choice dropped out of contention, and the medical school which had at first appeared to be an unlikely choice became the place where I would train for the next seven years.
Beyond altering where I attended medical school, this lesson has continued to stick with me to this day. The validity of this lesson has been, and continues to be, repeatedly demonstrated over the years. Making good medical care easy, the default, makes achieving good medical care more likely. When patients are admitted to the hospital there is a general order set that must be filled out which differs between hospitals and institutions. Things like monitoring parameters, laboratory studies, medications to avoid blood clots, and code status discussion are common aspects of such an order set. There are also many combined order sets. For example, for the order set for high potassium in the blood, many common medications for high potassium may be brought up at their likely doses such as furosemide, insulin, bicarbonate, calcium, and albuterol, as well as relevant additional testing including an EKG, orders for continuous telemetry, and repeat blood work. The order set does not force or automatically order everything but prompts the physician with orders and dosages that may be appropriate. In these cases, the order set functions as a schema to organize possible approaches to diagnosis and management as well as reduces the friction, or the barriers, to implementing appropriate medical care. Within the order set may be clinical guideline or recommendation statements with citations of relevant studies, or parameters or cautions to be aware of for a particular condition or medication. Without such order sets, the door is opened for wider variability in practice patterns between practitioners, some of which may be evidence-based while others are less evidence-based. As well it relies on significantly more thoughtfulness and prepared schemas by each practitioner in order to deliver excellent care. Making good medical easy leads to good medical care.
During a given shift a physician makes decisions and clicks through orders hundreds to thousands of times. These clicks often are a critical component to delivering medical care for individual patients. The first step to making good medical care easy is reducing or eliminating unnecessary clicks, that is redundant or pointless prompts and making the electronic system easy to navigate. However, the system extends far beyond the electronic medical record. Making good communication possible is essential. Having a way for nurses, physicians, medical assistants, respiratory therapists, and other providers to communicate is essential for patient care. Doing so in a way that does not interfere with medical care but enhances care is the point of many studies. For example ease of reaching someone at any time is likely not the solution. For example during a code I have been called regarding non-essential aspects of care for other patients such as routine labs, nutrition orders, or clarification on an imaging order. This can be dangerous as there is no mechanism to filter out essential calls from nonessential calls without redirecting one’s attention from a critical situation to whatever phone call or page is ringing. In these cases, there should be a mechanism to have text messages or pages that can be read later and addressed at a better time to enhance clinical care. Beyond communication, the system is also defined by the ability to accomplish what may seem like mundane tasks but which are critically important including restocking supplies, providing patients palatable food, ensuring that medications are delivered on time, and working out the details of transitioning care back home. The best physician, no matter how well trained and well-intentioned, cannot touch on many of these critical aspects of the system on a daily basis, instead, the system in which they find themselves often beget their own results whether good or bad.
Yet this principle is not limited to medicine alone. Making it easy for people to make the “good” decision whether that be exercising, eating healthy, going to the physician for regular checkups, or taking care of their car, makes it more likely that the right behavior will be performed ending in a better result. In addition to working to improve oneself, the choice of the system is critical to achieving good results. The people, organization, and parts are critical to success. Picking the right system and then working to improve that system is essential for forward progress and achieving excellent results.
Throughout the course of the Covid-19 pandemic there has been the constant question of the risk of infecting other individuals after coming down with Covid-19. Is it a specific amount of time? There have been varying times used from >20 days to 14 days to 10 days to 5 days, and in some cases, requests that specific workers in healthcare return immediately even while actively infected with additional precautions including masks. Or perhaps there is a test that can be used? However the sensitivity of many of the popular antigen tests range is approximately 65-75% with a large margin for false-negative results. Conversely, PCR testing has very high sensitivity making it well equipped to detect the presence of viral RNA, yet can remain persistently positive in those who have been infected for weeks to months, far longer than the infectious period. Perhaps it is symptoms then? However, the symptoms of Covid vary to such a degree that many infectious individuals have no symptoms whereas others have severe symptoms requiring intubation even as they near the end of the infectious period. The approach that has been taken has been rational, generally well-conceived, even though many of the guidelines and regulations have been fairly criticized as a moving target throughout the course of the 2+ years of the pandemic.
The underlying principle to using any combination of the methods noted above is that some cutoff must be used whether it is the number of days, the often subjective sense of symptoms, or the sensitivity and negative predictive value of a specific test. And in choosing that cutoff a decision to allow for a certain tail, that is a certain number of outlying cases, must be made. In the distribution of cases, whether this is the cases fall within a normal distribution or another pattern, some distinction, a line in the sand, must be drawn separating the two groups. Although the actual status of infectivity is marked by varying shades of gray spanning the spectrum of white to black, practicality dictates a cutoff by which some amount of contrived yet agreed upon certainty is derived from amidst the uncertainty. By none of the above mechanisms or tests is there a way to guarantee with 100% certainly across a large population that a patient that has been diagnosed with Covid-19 is no longer infectious. In a small number of cases, often in patients with underlying diagnoses or complicating conditions, the infection may linger far longer than in the general host individual or may even reactivate in extremely rare cases at a later time if there is a significant immunocompromising factors or altered host anatomy or physiology. The only way to ensure that no infectious individual spreads Covid-19 is indefinite quarantine. Of course, this is untenable, unthinkable, and unpracticed for both the individuals as well as society at large. Instead a cutoff must be decided upon where the remaining infected tail of the population being studied is small enough to lead to an overall decline in infected cases while protecting the majority of the population and allowing society to continue to function with most individuals free to go about their lives after a brief hiatus for isolation and quarantine.
The current protocols in most areas of the country have sought to thread this fine line sometimes with outstanding results, in other cases with lax restrictions allowing rapid spread and overwhelming of the local medical establishment, and yet others strict enforcement causing undue quarantine and isolation with economic and social repercussions. No matter where this line is drawn, there will be a tail of people who are still infectious as well as people who quarantined for an extended time beyond their personal infectious period. There is no single right or wrong answer, rather there is a likely a range which individuals and society find generally acceptable. Critically, as the virus changes, as population density, vaccine and natural immunity rates vary, and as new data, testing, and treatment become available, this line should constantly be reevaluated. The place whether the line is drawn initially may continue to be reasonable and good, however there likely should be small, or even large, changes as this new information becomes available.
The problem of the tail is not limited to the current Covid-19 pandemic but has brought to light a problem that is faced with any disease and with any diagnostic test. Even beyond medicine, deciding where to draw the line, to designate a tail which is acceptable at the individual level, one must decide, for themselves what the acceptable level of risk is, as there is always risk. For every behavior from driving a car, to using a stove, to operating any appliance, to using money, to storing valuables, there is always a risk which is assumed as well as a benefit that is gained by interacting with the world and society at large. Specifically where to draw the line, where the acceptable tail of risk lies must be dynamically evaluated just as the situation, context, and technology dynamically change. Guidelines nor governments nor societies nor celebrity influencers can decide upon this cutoff in one’s stead. The hard work of constant consideration and reevaluation remains a personal privilege and even more, a personal responsibility. Constantly consider the tail.
Starting is the most difficult part. The first step of the journey is a step into the unknown. The first steps gives birth to all the subsequent steps.
As the proverb from Laozi goes, “A journey of a thousand miles begins with a single step.”
The first step is not a giant leap, nor a plunge into the unknown, but rather represents a move from the complacent, the act of beginning, of intentionally setting out on a long and potentially difficult road ahead. The first step is a promise to continue on the journey, a pledge to continue moving towards the final destination, a recommitment to continue on the way. The first step is the most difficult part as there is no mode or model for the first step. Standing at the start of the path staring at the journey ahead is the struggle of the writer facing the blank page, the skydiver preparing for the jump, or the student preparing for the first day of school.
Unlike subsequent steps, the first step cannot be visualized through the lens of experience. After the first step, one is able to picture in their mind the action of taking the next step, and the step after that. One is able to appreciate the movement forward and grow in confidence that, given the results of the first step, subsequent steps are less foreboding. There is a high activation energy for the first step, an input of energy required to overcome the barrier and move off of the couch and start running, or the energy required to break the invisible strings binding one to the confines of the bed in the morning. Life is a game of momentum wherein there is a buy-in of energy simply to play the game.
In the book, Zero to One, Peter Thiel, notes that the greatest gains and yet the hardest thing to do are accomplished in the space between zero and one. This is an oft-repeated phrase by the wealthy as they recount the difficulty of earning the first $100,000 or the first $1 million as being significantly more difficult than the vast sums they amassed subsequently. As Thiel emphasizes, it is the step from nothing to something that is the most profound; subsequent iterations are found to be far easier but do not change the shape of the world in the same way that the step from zero to one is capable of changing the world and inspiring the imaginations both of the inventor as well as those around them.
Once the first step is taken, the momentum favors a continuation of progression, the taking of a second step, and then a third. The act of efficient running is not indifferent from the mechanics of a slow, perpetual fall forward. In Atomic Habits, by James Clear, he notes that once good habits are established there will inadvertently be days that interrupt these habits, times when for whatever reason the momentum is lost. Perhaps an illness occurs, a family event or an important work function interrupts the ability to continue the habit of a daily workout. Perhaps the need to travel or a change in the timing of shifts makes maintaining a specific diet or sleep cycle impossible one day. As Clear writes, it is not the goal to never miss a day or stray from a habit, but that if one day is missed here or there, two days in a row are not missed, and certainly not more. As the missed days begin to stack up, a new momentum in the opposite direction builds up as a new habit, the wrong habit, is formed.
Taking and retaking the first step is not an isolated event but is itself a habit. After missing a day of working out, missing an opportunity to get a full night’s rest, or missing a goal to write 500 words per day, retaking that first step is itself a habit. In this, the unpredictability of life is predictable. Whatever else happens, there will be distractions, habits will be disrupted, and one must get used to retaking the first step.
Practicing this first step whether it means consistently returning to a diet, picking up books and completing them, restarting a workout regimen, or reinvesting and reengaging in a relationship is essential to forward progress and dealing with the twists, turns, and occasionally disasters that life hands out. Walking while running a race is not inherently bad, but there must be a time at which one returns to running, when one decides to push on, to start the exertion once again. The first step from walking to running is the most difficult but it must be done over, and over, and over again. This is especially true in the longest and most impressive races such as ultramarathons where a single pace cannot be picked and held for hours or days, but rather one must flex and adapt to the course, to the elements, and to their own body. Learning and re-learning how to get up, how to start again is the only way that one can continue to move forward through both the good and the bad times, to build a life of resilience and hopefulness for the future.
As the Japanese proverb intones, “Fall down seven times, stand up eight.” Note that this proverb assumes one started on the ground; the first required act was standing up. The starting position was not standing or in a position of strength. Starting and restarting ensures that defeat is never final, that progress can always be made. Starting and restarting establishes a precedent of continuing on, picking up where one left off, and retaking the first step.
The basic building blocks of life, the biochemistry that gives rise to cells, to tissues, to organs, to organisms, are shapes and charges. The first portion of this, shapes, are intuitive as modern life is dependent on tangible interactions with geometry on a daily basis. Whether it is arranging shelves in the refrigerator, finding clothes that fit, using a lock and key, parking in a parking lot, or loading a car, there is an intuitive sense regarding the geometry of objects and how things may or may not fit together. This three-dimensional spatial reasoning may come more naturally for some than others, however, it is also rapidly learned.
The most rudimentary iteration of the geometry exercise is the childhood game wherein wood or plastic shapes such as a star, circle, square, or triangle, must be fitted through their correspondingly shaped holes. The initial efforts at this exercise are simple trial and error, attempting to push each shape one by one through each hole and seeing which fits. Subsequently, a thought process develops, the visual identification of a shape and then the attempt to match that shape with the corresponding hole prior to the attempt to push the shape through. Once mastery of the visual identification of shapes and holes is accomplished there is yet another aspect to the game which must be mastered, that of orientation. With the exception of the circle, every shape can only be placed through the hole in a particular configuration. On an unrelated note, the interview question of the rationale behind why manhole covers round utilizes a similar logic. A round manhole cover does not need to be oriented to a particular configuration to fit in the hole, a round manhole cover cannot fall through the hole no matter what configuration in which it is placed, and the manhole cover can be rolled on its side such that a single person does not have to lift the weight of the manhole cover to maneuver it. Returning to the shape game, all other shapes must be placed in very specific configurations in order to pass through.
Yet in playing this game, one realizes that there is a linked proximity and probability problem. That is that if the shape is brought in close proximity to the hole and multiple attempts slightly differing from one another are utilized to attempt to pass the shape through, the odds of the shape finding the correct configuration go significantly up. Likewise, decrease or remove either the proximity and probability and any likelihood of success disappears. If the shape is separated from the hole by distance there is no possibility of passing. Likewise if only a single configuration is utilized, there is an extremely low likelihood of the shape passing through the corresponding hole. Both proximity and probability must be present for success.
Yet the idea of shapes as the building blocks of life becomes even more complicated as neither the shapes nor the holes are static, both are changing in small and large ways many times every second. This adds on the third aspect- both sides must be in an acceptable conformation for the interaction to occur. Imagine a key and a lock. Instead of requiring simply that the correct key be inserted into the correct lock, imagine that both the lock and the key were changing conformations continuously. One would immediately be reduced to the first step of the children’s games with rudimentary shapes as they were forced to resort to trial and error, pushing the key into the lock many times hoping that at one point the conformations were correct. In such a way interactions of shapes are one of the fundamental building blocks of biology and thus life. These random interactions of shapes occur millions of times every second in every cell of the human body. The way in which shapes interact affects subsequent interactions changing the conformation of both shape and hole such that the passage of additional shapes through their corresponding holes may become more likely to the point where a subsequent binding event is a near certainty, or less likely, such that the possibility of a subsequent binding event is vanishingly small. The sum of these interactions between shapes at the molecular level defines biological reactions which determines the phenotypes of organs and organisms.
This butterfly effect, as shapes interact and change one another, defines biology and is also the building block for how nearly every medication works from small molecule inhibitors which activate or inactivate specific enzymes or receptors, to targeted monoclonal antibodies which bind and activate or inactivate specific signaling molecular or cellular targets, to chemotherapeutic agents which intercalate, or insert themselves between DNA strands, to change cellular biology. All rely upon cascade started by the interactions of the smallest of shapes.