S2.14 Choosing to stay

A common refrain heard in medicine is “I should have done ________” or “I should quit practicing medicine and do _________.” The sentiment is well taken. The hours are long, the years of training are substantial, and often the job description and responsibilities have grown while the benefits and perks have decreased or stayed the same. However in many ways this sentiment also rings hollow. There is always the opportunity to change jobs, to move to consulting, to work in research, or to just do something else altogether. If one truly believes that they should have done something else or truly wants to quit medicine to do something else, they can easily walk away and into a myriad of other opportunities, different fields where a 9-to-5 schedule and weekends off are standard and where one does not encounter people dying on a daily basis.

Yet overwhelmingly, physicians choose to stay. They choose to stay because it is a calling, not a career. They stay because there is a camaraderie among healthcare workers not found in the 9-to-5. They stay because medicine is unique amongst the other careers in the diversity of encounters, in the interesting problems, and the even more interesting individuals you meet along the way. The frustrations with the job and the healthcare system are because physicians care, because constantly correcting the imperfections in the system matters, because for all of the flaws, there is no better career or calling in the world.

S2.13 What If There Was Silence

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What if on the last car ride before the end, the last moments at the bedside, the last roll down the hallway there was only silence. What if there was no scramble to get things in order, no panicked attempt to remember everything that must be done. What if there was no hurried goodbyes compressing everything that should have been said over decades into a handful of minutes. What if there were no desperate attempts at reconciliation, no last minute need for apology or the appreciation that should have been voiced long before. What if there was silence. 

Silence because everything that should be said, that wanted to be said, that needed to be said had already been said. Silence because every expression of gratitude had been made, every appreciation made known. Silence because every implicit  affection had been made explicitly known. Silence because every grudge had been released, any anger extinguished. Silence because every question had been asked, every concern given voice. Silence because every future plan had been made every detail worked out. Silence because every “one more thing” had been taken care of. 

What if instead of the frantic phone calls, the hustle to get things ready, to cram everything into the final few minutes, there was peace. Instead of doing there was only being. Instead of words there was only presence. What if there was silence, and the silence was enough. What if there was silence, and the silence was perfect. What if there was silence.

S2.12 Be Like The Firefighter

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The critical, title job of a firefighter is to fight fires. Thanks to many improvements in building codes, preventative measures, technology, and awareness, the number of fires has dramatically decreased. Thus the role of the firefighter in the community has expanded to become that of a first-responder to a variety of situations including motor vehicle accidents, paramedic response, and other rescue operations. While not performing these duties or training to perform these duties, there is often a significant amount of downtime at the fire station during which they must be on the premises but are otherwise free to engage in the activity of their choice. Cooking, cleaning, working out, playing games, and watching movies are often among the options. However chatting around the dining area is also one of the preferred past times. 

Sitting around the fire station table talking with a number of firefighters I was pleased to find a high diversity of opinions and world views as well as a genuine curiosity and desire to learn more. The extra down time at the station meant that many were well read or studied on many subjects from science to religion to sports. One Sunday I talked with a firefighter who was an atheist who was interested in many topics in science from origins to gene editing to the impact of diet on health. Later that day I spent several hours talking about conspiracy theories with another firefighter, a friend of the first, who believed the earth was flat. Each of these “debates” were friendly, curious, genuine, and colloquial. As the firefighters live in close quarters for extended periods of time in a sometimes stressful environment, they have learned the art of pleasant discourse and courteous disagreement without any of the acrimony and vitriol that has seemed to permeate our culture otherwise. 

While stating your point and making an argument it was completely acceptable to disagree but personal jabs were discouraged and the zingers that would normally make the highlight reels on YouTube were out of place. Everyone was attentive to the interpersonal drama as well as the sparring of knowledge. Importantly, no one cut off the discussion or stormed out (unless there was an emergency of course… then you went to the call and picked up wherever you left off several hours later). This is the type of discussion, and disagreement, that we should all be building towards. The type where you can disagree but will not walk out. Where you care more deeply about the relationship than the win. Where your understanding of truth is important; as is being able to clearly understand the other person’s understanding as well. Consider how your arguments would be different if you knew you were going to be fighting fires, cutting apart cars, eating, sleeping, and laughing with that person across from you for days at a time. Be like the fireman. Discuss and dispute like the fireman. Be relational like the firefighter.

S2.11 Sunset Rides

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Timing is everything. More specifically the timing of the end is everything. The place that the director calls cut, the moment that the movie cameras stop rolling, the place that we leave our characters in the last chapter of the book define how the story ends for the viewer, but not so for the characters on the journey. Fairy tale endings, the ride into the sunset has been criticized and rightfully so. However it is not the ride into the sunset that should be criticized but rather our sustained notion that they continued this blissful ride with the sun held perpetually at a romantic angle above the horizon ad infinitum. That if we were to revisit our favorite characters they would remain as happily on their journey decades or centuries into the future as they were at the moment that they first set out. Unfortunately for the characters in our fantasies, they must continue their journey even after the documentary crew has wrapped and retired to their trailers for the night. 

Let us mention the fact that sunset is a terrible time to begin a journey. If the sun is beginning to kiss the horizon you have less than an hour before things slide into the cold and darkness. Travel, especially on poor roads and without electric lighting is slow and dangerous with a high likelihood of injury. Once you arrive, if you arrive, at your chosen destination setting up camp in the dark is a miserable experience. Much of it is stumbling around in the dark, trying by feel to identify the necessary piece of equipment and a semi-flat surface to lay upon. Starting a fire is out of the question since gathering wood and kindling will take more time than you have, and the prince seems to have forgotten to pack any of the presto logs and matches that were on the list. Instead of warm cocoa and biscuits while trading stories around the fire while your well groomed steads graze nearby, you fold yourself into the canvas tent that remains half set-up and dream about being back in your soft bed… in the castle in the tower… owned by the evil queen… who maybe was not as evil as you thought… after all she gave you a soft bed. You may awake in the morning to discover that you have bedded down in a healthy bundle of poison ivy or within the main drainage pathway to the nearest stream when it rains. You may awake to find a cliff nearby or evidence that your tent obscures a game trail frequented by predator and prey alike. 

If you set out at sunset and hope to stay at an inn you have no idea if they will have room. At least one King has ended up in the stable due to lack of quarters and you should expect no different. At the late hour of your arrival the innkeeper may have gone to bed; did we really expect him or her to stay up all night, every night just in case someone came traipsing in at any hour of the night? So merely several hours after their ride into the sunset our fairy tale heroes would be cold, hungry, without good shelter, stumbling around in the dark, likely trying to remember where exactly they were trying to get to in the first place. How was your wedding night? 

Waking the next day, stiff from their ride, sweaty from trying to set up camp the night before, tired from getting in so late, and hungry since horses laden down with saddlebags filled with the necessary provisions aren’t romantic enough for the final shot of the film, our now hapless heroes have to have their first discussion of where exactly they are going and what exactly they are hoping to accomplish in the next 50 or so years of their lives. Perhaps we better take an intermission and rejoin them in a couple of decades after they have sorted this out and thought through their actions a bit better.

The Corona Diaries Episode IV: Expert

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Everything has an expert. There are experts in sports, in arts, in sciences, in law, in medicine, in culture, in language, in engineering, in entertainment, in business, and in countless other venues. It is incredible what you can now get a masters degree or doctorate in. Whenever there is uncertainty or a question people run to experts. There is a certain comfort from hearing from an expert, a soothing quality in knowing that someone else must have a plan. 

However many experts from many fields are dispensable. They may have a degree from a nice university, a sparkly diploma that they can hang on the wall, but unless the expert can demonstrate value by reproducibly obtaining better results than a non-expert, the title is disposable and the diploma meaningless. 

There are some tasks or problems where it is perfectly alright to let a non-expert take a crack at it. If you are unsure if the person who is washing your car knows what they are doing you are unlikely to make a big deal about it. At the worse you may be out a few bucks and have to wash the car yourself. Likewise, you can have a non-expert give you an opinion on French politics, the quality of baked goods, or the weather with the downside rather limited to a waste of time and having to do the work or research yourself. 

On the other hand, there are some tasks where an expert dramatically raises the probability of success in a field where failure is irreversible and catastrophic such that few would even think of trying something ad hoc. No one would look for a neurosurgeon on craigslist or let someone cut you who had not been to medical school. It is not to say that they might not get extremely lucky and do the operation correctly, it is that the likelihood of them doing it correctly significantly increases with the degree and the experience. Likewise anyone could get extremely lucky and fly a commercial airplane, perfectly nailing the takeoff and the landing, but no one is going to get on that plane. In both these cases having an expert is critical because the expert title ensures a level of previous experience and skill in a setting where the consequences are devastating and irreversible. 

Now that we have established that the appeal to the expert is applicable in some, but not all situations, we also must highlight the fact that the appeal to an expert is not the same as the appeal to the expert. During Covid-19 there have been many posts on social media giving advice and information with the tag or implication (by attire, scrubs, white coat, etc) that they should be listened to because they are a physician, nurse, podiatrist, medic, or PhD in science. In general most of these “experts” are not experts in public health and infectious disease. This does not mean that they should not be listened to, but rather that the evidence that they provide should be weighed, considered, and if it is good, then accepted. Public health and infectious disease are only as good as the evidence they utilize. In this case, saying “listen to me I am a physician, nurse, medic, podiatrist, PhD etc.” without any evidence is unacceptable and akin to claiming to be an expert in economics because you have a piggy bank. Evidence trumps “expert” opinion in this, and every pandemic.

The Corona Diaries Episode III: False Assurances

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Everyone wants the guarantee, the knowledge that it will be alright in the end. During uncertain times, when health or livelihoods are at stake, we want to have the promise that we will make it out the other side. When this cannot be genuinely assured, we may often settle for false assurance, the opinion of an “expert”, the actions of the government, or pithy statements of everything being alright in the end. The selection bias guarantees that for those who are around in the end, it went okay to some extent, less so those that are no longer around to poll. 

One of the more common questions that I heard in the Emergency Room from the families of patients echoed this desire for assurance.

“Are they going to be alright?” 

Oftentimes this was a question that could be easily answer. Yes, their injuries are limited to a sprain or a strain. Other times the question was more complex. They will likely survive but they may have some deficits. Yet other times the best answer was that we did not know but would do everything we could. In medical practice it is critical that we do not provide false assurances even when that is the easiest and  most temporarily satisfying solution. 

Outside of medicine, there is less taboo against false assurances. Financial institutions attempt to convince you that your investments with them are safe from market volatility or losses. They often demonstrate this by pointing to impressive statistics extending back to the market trends of the early-to-mid 1900’s. Interestingly, they don’t extend farther back than 2 or 3 generations at the most. Car sales men and women highlight the safety ratings of the vehicle. Car seats for children emphasize increased safety even if that comes at increased cost. Universities show rates of employment following graduation, test preparation companies will “guarantee” a particular score, many products will “guarantee” your satisfaction with their product. 

In the end assurances or guarantees are almost always empty. At best they may promise or provide an exchange for a lesser entity than what they were guaranteeing. They cannot guarantee that you will like the product, instead they can only assure you that they will take it back if you do not like it. They cannot guarantee a job or a score, but perhaps can assure you that part of your tuition will be refunded if you do not achieve one of these important milestone. There are probabilities, possible outcomes, and preparations. Anything more than that is empty assurance for things that cannot be known. Life insurance does not guarantee life, disability insurance does not ensure healing, health insurance does not ensure health. There are no guarantees in life; anyone who tells you otherwise is selling something. 

As much as everyone wants guarantees and assurances during uncertain times, we must recognize these guarantees and assurances for what they are: the hopes and attempts to sooth the panic mob by an equally uncertain leadership or expert. 

Living with this uncertainty is a critical part of life. Recognizing that risks and rewards define life and that some risk is certainly acceptable, and in fact required, in order to live a robust life. Life in a bunker may be safe, but it comes at the cost of opportunities to help others, to be helped, to learn, to love, and to grow. Instead of settling for false assurances, joyfully take calculated risks to embrace living instead of huddling down in the twilight zone of safety.

S2.10 Epic

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Our greatest fears are not pain, discomfort, or difficulty. What man and woman dread most is not the agony of torn flesh or broken bones. These will heal. What man and woman find intolerable above all else and dread before any other is the agony of a broken spirit and a lost soul. Losing their purpose in life to pointlessly wander, not dead but not fully alive. For to be fully alive requires a purpose, whether big or small, material or immaterial. It is this fear that is realized when one is born to the lap of luxury, when one is handed privilege at any point in life; when the human purpose, the noble pursuit, of striving for existence is stripped away by cold hands in the form of a shiny gift. Man and woman find their meaning in the righteous struggle to define and distinguish themselves, to scrape and claw to bring about a better existence for themselves and those around them.

Wounds to the flesh will harden into scars; not so the wounds of the psyche. The worst physical pain can be brushed off, even relished if the result is found worthy. Whether the pain of labor or the pain of battle. Whether the pain of chemotherapy or healing after surgery. Whether the pain of withdrawal or the pain of rebuilding. These will pass, subservient to the higher objective of wholeness. We are resilient, able to endure anything for the right cause. However the anguish comes when we lose the cause, when we forget that for which we are fighting. When we lose our mark, the compass directing us north, every movement, becomes agony. The slightest struggle becomes insurmountable, and we flounder at the first sign of difficulty. We all define for ourselves our own epic, the overarching narrative and adventure of our lives. Within these epics are individual journeys, partitioned travels, struggles of every shape and form. And within the context of the epic, all of these meld to become joyous and surmountable tribulations. Thus the struggle of men and women, then, is not the struggles themselves but to find their epic and keep a keen eye upon it always. 

The Corona Diaries Episode II: The Promise Of Tomorrow, The Curse Of Eternity

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The famous lines in the musical Annie come as Annie dreams of the promise that better days are ahead. 

“Tomorrow, Tomorrow!
I love you tomorrow
You’re always a day
Away” 

Hope of a better tomorrow, an improved future is the why that drives and overrides the what for many people. Most of our routine actions, things that we do automatically without hesitating or thinking, are done for tomorrow. Education, cleaning, shopping, saving money, and working out all are done for the promise of better days ahead. Everyone has things that they are looking forward to whether that be a nice dinner, the night off, a weekend free, or a dream vacation. Our lives are defined in periods and have a cyclical rhythm to them. Segments of our lives may be defined by our grade, our position in a company, the home we live in, a particular project on which we work, or a special relationship. Days are broken by nights, weeks by the weekends, and years by the seasons. 

As alluring as tomorrow may be, a tomorrow incorporating an endless horizon, an eternal blank canvas, is a debilitating curse. There is not enough variety in the world, enough hobbies or occupations, enough people or places to keep one engaged for an eternity. Sooner or later, even with the best of intentions and limitless resources, the world becomes mundane. An unending vacation begins to feel like work, a retirement without anything to occupy the time like a waiting room for death. We begin to resonate with the uplifting and encouraging words of Solomon in Ecclesiastes “Meaningless, meaningless…utterly meaningless! Everything is meaningless.” (NIV). 

Tomorrow is a blessing. The future gives us hope. Immortality, as enticing as it sounds, would be itself the poison and end of a meaningful and purposeful life. Time is the commodity often wasted in yearning for a future time. The blessing of tomorrow is, in reality, a blessing of today, meant to be valued and treasured as a rare and fleeting opportunity. 

Redeem the time, look to tomorrow while living in today.

The Corona Diaries I: Essential

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When times are good, it is often difficult to remember what is essential and what is a luxury. Periods in which things are more difficult, either by choice or by unfortunate circumstance are revealing, humbling, and grounding. 

Time is one of the commodities we feel that we are constantly on the brink of running out. We rush from here to there, have long lists of things that we feel that we need to accomplish, and collapse at the end of the day or the week exhausted. Illness disrupts this routine and forces us to decide what is essential and what is a luxury. Even mild illness such as the flu or cold forces us to cut back and reevaluate our priorities. Things that we may value but are not essential, such as trips to the mall, book clubs, and social activities can be deferred or canceled to make room for the essentials including sleep, groceries, the work we are still able to perform. 

Material possessions are another of the commodities that we often take for granted. Similar to a squirrel we have supplies stashed in different places whether that be work, school, the car, or at home. We often buy more than we need and simply keep the rest for use at a later, undefined, time. Travel, especially backpacking, forces us to evaluate what material possession we actually need. It forces us to consider how much food we will eat, how much water we need at one time, and how many articles of clothing are necessary. Reading about ancient cultures, it is clear that more than one or two changes of clothing was, for many of these cultures, an incredible luxury out of reach for all but the most wealthy. Most of us, even the homeless and poor, have more than one or two changes of clothing. 

Travel is a luxury. After traveling around the country interviewing this past winter and fall, travel certainly felt more like a job, an unenviable one in fact, instead of a luxury. However, the opportunity to go new places for education, pursue new business opportunities in far-off locations, and amazingly enough, travel just for fun is an incredible luxury of time, money, and technology. Now it is standard. On one side of the spectrum travel on the bus from city to city costs several dollars whereas a first-seat ticket to the other side of the continent may cost thousands, but they are both luxuries. 

This is certainly not to say that non-essential, or luxury items are bad. Rather, the exercise and awareness of identifying what is essential and what is luxury is important. There are many things during the good time that feel essential that are in reality luxuries. Washing the car, attending boutique fitness classes, eating out, traveling on a whim, are all fantastic luxury items and should be treated as such. It is easy to make a checklist including non-essential items such as recreational activities, self-betterment classes, or shopping and then become stressed as the check next to each lines makes them appear as essential and not a luxury. As the world slows down to try to stop the virus, instead of reminiscing on the good ‘ole days and being dragged down looking around, the delineation between essential and luxury should be freeing instead! In typical glass half-full thinking, we have been relieved of the non-essential to focus on the essential. 

S2.9 Walk, Don’t Run

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There are good reasons to run. Exercise and fun are probably the best and most common. Rarely if you are in immediate danger such as are going to be hit by a car, trapped in a burning building, or escaping from a flash flood. Running could also be necessary to help someone else, perhaps a child or senior citizen, escape from the above as well. To be fair, I have never had to run for any reason besides exercise. 

Not only is running not necessary, but could even be problematic in critical situations. The one time in the hospital when running is often expected is during a code, that is when someone has lost their pulse and is not breathing. In most hospitals this is a Code Blue and everyone is expected to respond as fast as possible. I am against running even in this life or death situation for several reasons.

First, nearly everyone in the hospital is Basic Life Support certified, that is, they are able to do chest compressions and begin the critical steps in resuscitation efforts. In fact, the most important prognostic factor for a patient in the hospital who has a code is the quick initiation of good, high quality CPR. Nearly anyone, including the person or people who called the code will start this critical intervention. (As a side note, CPR is incredibly physically demanding. In my view, these are the only people who should be out of breath at a code.) 

Second,  running to a code can be dangerous to the team running as well as other patients or visitors. The mentality is that “we have to run to save a life” which is an entirely false notion. Narrowly avoiding collisions with other healthcare workers and other people in the hospital is not uncommon in these situations. 

Third, the responding medical professionals show up with their heart racing and adrenaline pumping. Similar to the reason that high speed chases can lead to judgment errors by law enforcement, so running to a code does not lead to clear headed thinking. As the famous quote in the House of God by Samuel Shem goes, “ At a cardiac arrest, the first procedure is to take your own pulse.” Instead of promoting good, clear headed, evidence based medicine at this critical time, sprinting to a code pushes you back to fast, reflexive thinking based on heuristics, without taking the time to fully assess the scenario. Ronald Epstein writes more about the importance of mindfulness and being able to step back while practicing medicine in his book Attending: Medicine, Mindfulness, and Humanity. Codes on the general hospital ward where people have to run and where teams are often less familiar with one another and the equipment available on a given floor contrast with resuscitation efforts in the Intensive Care Units and the Emergency Department where everyone is familiar with one another and the equipment, and no one has to run. In good Emergency Departments seasoned attending  physicians will often take a back seat, occasionally asking a questions or giving orders for a medication or test. There is an element of relaxation, almost of boredom that allows clarity of thinking and a 30,000 foot approach to make sure all aspects of medical care are being managed. The same principles go for many of the things in daily life that we want to run to and stress about. We often want to release some of our nervous energy through some sort of activity which counterproductively serves to accomplish little and clouds our mind. 

In general, save running for exercise and escapes. Instead walk with the purpose of maintaining a clear mind.