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.

S2.8 Hero Of Your Own Story

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Reading a storyline, both stories that actually happened and those that have been imagined, we track with the narrative of the main character or characters. Readers of J.K. Rowling’s Harry Potter series are enchanted with the magical world that intersects with the seemingly mundane world of the non-magical. They are caught up in the plight of Harry and his group of loyal friends as they fight the often overwhelming forces of evil. With the popularity of the franchise one can now travel to the theme park, buy all manner of merchandise, and go on your own adventure through the medium of a video game. The secret wish of most Harry Potter fans, or fans of any series is that this fiction were a reality and they were able to play the main character, the hero. Looking only at the numbers, it is much more likely that one would be one of the bystanders, possibly even collateral damage in the narrative of Harry Potter. This is all well and good, but that is fiction, surely storylines in real life are different. 

The key to keeping a captive reading audience is a storyline which must be maintained. Even in actual events, such a battles during the Civil War, genocides in unstable countries, and even stories in the Bible, a limited narrative focusing on very few characters is required. We are drawn to the story of one person, identifying with their struggles and rising with elation at their successes. However we cannot track or identify with the multitudes. As Joseph Stalin supposedly said, “A single death is a tragedy; a million deaths is a statistic”. A book listing all the dead from a world war would be incomprehensible and boring, not because we are heartless and unfeeling but because it is a recitation not a story. In the Bible we read stories of old battles and feuds, kingdoms that rise and fall, people being taken into captivity and walking through prison doors. Mixed in with the story of the main character often it is mentioned that thousands of people perished or a whole nation fell. These offhand mentions make us wonder “what about everyone else?”. Does the world not care about the masses? Does God not care about the masses? 

The answer is, of course, no. Of course we care. Of course God cares. A series with many volumes could be written about the storyline of each person’s life, detailing the battles they won, the people they affected, and how their decisions changed the course of history. The main character in one storyline is just a member of the mass in another storyline; likewise a member of the mass in one narrative is the hero in the next narrative. Each of us is writing our own story. Perhaps our stories will never be put down in writing or made into a full-length feature film, but rest assured, each story, each life has enough drama, action, suspense, and redemption to make many movies. You are the hero of your own story and in a critical supporting role in a multitude of other stories.

Therefore live, act, and dream accordingly.

S2.7 The Ants Go Marching On

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The narrative we are being sold on climate change holds the wrong emphasis. The earth has never been a static place, rather it has been a dynamic place of rapid change, and rapid correction of momentary imbalance. Populations have grown too large, shrunk too small, and species have gone extinct. Species change their form to adapt to the environment. Certainly humans have demonstrated an unprecedented ability to alter their environment and affect other species. However in our current narrative Mother Nature is cowering in the background waiting to see if these selfish bipeds wipe the globe or not. In reality Mother Nature sees very little that is unique about this species and has a multitude of checks on an unbalanced system. Humans have the ability to wreck havoc on the rest of the ecosystem and push species- including ourselves- to extinction. However if the oceans rise and the temperature escalates mother nature will correct with replacement of humans. Human extinction is certainly a possible result, the complete annihilation of life is not.

The picture that mother nature is cowering in fear of the these rampaging, wasteful bipeds is wholly inaccurate. She has dealt with populations that have threatened to overcrowd the world before. New predators, infectious diseases, rapid changes in environment, and starvation have all been used to limit these populations. This is the basis of evolution within a global ecosystem. Every organism from the smallest and simplest to the largest and most complex is trying to expand, jockeying for position. There is nothing more natural. While the human species can, and has, caused damage to other plants, animals, and organisms this is also part of the game. If our population overreaches the correction will be swift and a new balance established. Even if the ozone is depleted or water levels rise or the temperature increases life will continue. Species will evolve to adapt to this new environment no matter how harsh the conditions and new species better equipped to these new conditions will emerge. 

Humans are important, but not THAT important. We have more significance than we fear but much less than we hope. We have the power to change our own lives and outcomes but not life and the processes that propelled us to this place in the first place. Just because we understand the rudiments of evolution does not mean we have escaped the box. Indeed we have merely seen a shadow on the wall of the cell that encases us. Certainly we have a moral and ethical responsibility to be good stewards of what we have. But the threat is more to our species itself than life on this planet. If civilizations crumble other creatures will quickly take over and fill in our crumbling cities and dominate the void we leave behind. The ants go marching on.

S2.6 Medicine And Movement

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When I was younger I had several misconceptions about health and the human body. The first was an overzealous faith in the state of medical knowledge and the abilities of physicians, the second a belief that taking shelter from the environment was the best way to prevent declines in health. 

Death, I initially thought, was simply another name for when people couldn’t get to the doctor in time. Maybe they were stuck somewhere far away or were hurt so badly by an accident that they never made it to the hospital. The hospital was a mystical place where, on the several occasions we visited, people seemed to run around with purpose, always knowing what to do. Every time I went there they seemed to know what to do. While medicine is a fascinating, constantly evolving, and highly dynamic field, the amount that we know is dwarfed by what we do not know. In fact the things that medicine knows with the most certainty is when an intervention is unlikely to work and what is bad for you. For example there is still disagreement of what you should eat in an ideal diet, however we are sure that chips and soda pop are not good for you. We are sure that if someone is found without a pulse or electrical activity in the community, resuscitation efforts are unlikely to be successful. Incredible advances in interventional procedure related to heart attacks, strokes, and bleeds coupled with fantastic therapies for treating formerly life ending infectious diseases like HIV and hepatitis C make medicine a fantastic field, but there is much to learn and explore. Often it can feel like you are watching people slowly die in the hospital as one organ after another slowly shuts down. Medicine still has a long way to go and much of what can be known has yet to be discovered. 

My initial notion was that the toxins from the environment including radiation from the sun, smoke from cigarettes, smog from cars, lead from paint and water, chemicals in your food, and dust in the air accumulated causing the overall decline in health as people aged. I then imagined that the one could live for a much longer time by being put into a coma and laying in a box with filtered air and water and sterile food fed through a tube. While the notion is partially true as smoking, radiation, and chemicals can all limit your health and longevity, health requires much more than that. Beyond genetics and environmental factors, movement is absolutely key. After surgery, or even in people who are bed bound for significant amounts of time, significant complications including blood clots in the legs and lungs, backing up of the gastrointestinal tract, sores from microvascular compression and skin breakdown, not to mention mental decline from not engaging with an interactive environment can all cause problems. Movement and motion is critical to being human and maintaining both the physical and mental person (see Barbara Tversky’s Mind in Motion for more). In reality, my idea of a sterile tube is probably one of the easiest ways to guarantee both a short and an unfulfilling life. You and I were made to move.

So learn from my foolishness. Recognize that medicine is incredible though has limitations. Make movement and activity, in whatever way makes you happy, a part of your life. 

S2.5 Things I Wish I Knew Before Medical School

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  1. Life keeps going while you are training. Medical training takes a long time; doing a PhD in the middle certainly does not shorten things. Making time for things outside of medicine including family, friends, exercise, and hobbies are critical to success in training, longevity in the medical field, and overall happiness.
  2. Degrees do not define you. There is a reason that you need to get a medical degree from an accredited institution and pass a litany of examinations in order to practice medicine in the United States. You certainly do not want someone with a half baked education and understanding of the human body taking charge of your care. However the degree does not define the person. It does not define their worth or value. It does not tell you whether they can sleep at night. Whether they feel satisfied with their job or whether they truly care for their patients or are just in it for the money. It doesn’t tell you if they are a good person, whether they love their spouse and family, whether they are constantly striving for better. All it tells you is they went to school for a long time and can take standardized tests. Do not be lured into thinking that the degree will be your defining feature. Rather define yourself by what you do, how you treat people, what you strive for, and what you stand for. Allowing your degree to define you settles for too little and sell you far too short.
  3. Your view on faith, religion, or spirituality will significantly change how your patient interactions will affect you.  First note that I did not say that your view on faith, religion, or spirituality will affect your ability to practice good medicine. Rather this view will change how your care of patients will affect you. In medicine you see people endure and sometimes succumb to terrible illnesses. You hear their stories and the circumstances that led up to that place. You often spend weeks or even months sometimes seeing patients year over year. Their family gets to know you and seeing them everyday becomes a ritual. Many people die despite your best efforts. Your beliefs on a soul, an afterlife, a deity, the nature of that deity, and overarching plan for the world will directly affect how these experiences affect and change you. Your beliefs in this area will determine whether you into harden into something unbreakable and unfeeling, crumple under the weight of having to know everything, take every loss personally, or are able to rest in your own mortality, in your own efforts, and in the belief that a greater plan is afoot.
  4. People, not problems are the object of medicine. Going through the first years of medical school it feels like the goal of medicine is to accumulate the most knowledge that you can so that you have the right answer to give the patient to solve their problem. Of course some knowledge is necessary, but the knowledge necessary to become a good physician is less than some might suspect. Frank Abagnale Jr., the inspiration for the movie Catch Me If You Can, once worked in a hospital posing as a physician. He was able to get away with it for some time without any problems simply by managing his junior residents and utilizing his skills as a con man and people person. Being a good physician is about the people. Medical and nursing staff, other support staff, and of course the patients and their families are the focus. The way in which you manage these relationships will be of far greater import than how much you know.
  5. It is worth it. There is always a lot of complaining no matter where you go. The discontented are often the loudest. As the saying goes, the days are long and the years are short, but it is worth it. The failures and successes, the struggles and the achievements are all worth it. Not only because of the end result, but because the process was refining, enlightening, purifying, and clarify. Despite the flaws and failing of the system and the people, there is no better field to be in, no more interesting problems to solve, and no more humbling occupation.