Guarding fire

Guard carefully the fire that burns inside you. Remember how feeble the flame was at first, how it quivered in the frigid air, how the slightest breeze threatened to extinguish it. Remember how you nursed it along, with bits of the choice fuel, using your body to protect it from the winds. Remember the feeling when it sprang to life and grew of its own accord, when the flame multiplied into a robust fire.

Do not take for granted the comfort of the flames, the warmth it provides for it can always be taken away at any time. Left untended, even for a short while, the flame, once robust and seemingly invincible, may slowly fade and die. Without fuel, without air, the flame will go out, returning your world to darkness and cold. 

Guard your fire with your life, for it gives your days meaning and your movements purpose. Guard your fire for it is your life, for without it your days are meaningless and your movements void. There are those all around who’s fire has gone out. Empty shells who continue on an uncontemplated trajectory simply because they know not what else to do, who trudge on because a body in motion will stay in motion and there is no force, no will, no fire to direct them in a different path. 

Guard your fire well, tend it with all your might and you will be kept warm on the coldest days and your vision clear through the darkest nights. Stoke your fire and fuel it well and it will light the fires of those around you. The fire that burns within you will provide the spark, the energy to activate a fire in your neighbor. 

Guard your fire well. 

Tend your fire with care.

Again

Repetition is the basis of excellence. Do it until you get it right. Keep doing it until you cannot do it wrong.

Repetition is where learning starts. As toddlers and children, repetition is how memory is built, muscles are developed into functional units, and how language is learned. The importance of repetition extends all the way to the masters and experts within a field. Malcolm Gladwell emphasizes this in the book “Outliers” where the 10,000 rule is noted; the idea that at least 10,000 hours is required to master a field or discipline. In many cases, the hours are likely significantly more. How much time is 10,000 hours? How many repetitions is that? How many iterations, are held within those 10,000+ hours? Striving towards mastery one assumes that extra effort, beyond the 9-to-5 is being exerted, with time in the evenings or on the weekends devoted to ones craft. At 60 hours a week, for 48 weeks a year, the 10,000 mark is reached in just under 4 years. Incidentally this is approximately the amount of time for an undergraduate or graduate degree. 

There are disparate reactions to this. The first is surprise at how long this is, the second surprise at how brief. If mastery is accomplished in significantly less than 10,000 it is likely a field in which mastery is not highly valuable. The emphasis here is that this is MASTERY, not merely competence. Whether medicine, computer programming, law, or any number of other tasks, basic competency can be achieved at or below 10,000 hours. Yet to be a true master, to be exploring the fringe of the known and the unknown, requires enormous repetition. 

Many attending physicians have incredible stories. Many have lived through many eras of medicine- some before HIV drugs were discovered, others when cancer therapies were still in their infancy. Even decades after a particular patient, they can envision specific patients, specific disease manifestations, or other interesting aspects in the case. Often they even remember the family of the patient. These repetitions, achieved over decades, not hours or years, are where true mastery is developed. 

Often repetition feels monotonous, like the background drone of an airplane. When it goes on for long enough there may even be a sense of futility, a sense of repetition without improvement or purpose. Perhaps there is a sense of numbness, perhaps even a loss of purpose for brief periods along the way. Yet it is in these repetitions that true mastery, expertise, is developed. Anyone can do something once. A blind squirrel will eventually find a nut. Only a master performs Every. Single. Time. 

Do it until you get it right. Keep doing it until you cannot do it wrong.

This is the basis of excellence.

Sleep on it

Waiting is the hardest part. Waiting 24 hours can feel like an eternity. In a fast paced world where responses via email, text, or social media are expected around the clock, pausing, contemplating, and allowing the situation to settle is one of the most difficult things to do. There is a pressure, a tension nagging in the back of the mind, a compression within the chest compelling a response- any kind of response. 

Alarms for one patient in the intensive care unit were going off. The patient was incredibly ill and had many drips and machines supporting multiple organ systems together attempting to correct  the radical imbalances which he had developed. With multiple alarms sounding and staff members nervously moving around the room, the temptation was to go into the room, become overwhelmed by how ill the patient was, panic, and make a large number of changes to the drips, ventilator settings, and other machines in hopes that something would change. After making one change to the ventilator, with alarms still going off, the attending simply said, “Let the patient settle”. The team walked out of the room and allowed the patient to settle, while intermittently checking back in throughout the day to ensure that the changes were ameliorating, not exacerbating his overall condition. An important change was made and the patient required time to equilibrate to this new adjustment. Valuable information could be obtained from observing the patient’s response to the change. That said, no information would be gained if many changes were made simultaneously as it would remain entirely unclear what changes resulted in improvement and which changes resulted in decline. 

There is often the feeling that something must be done, more often that multiple things must be done all at once. There is a pressure to act. Whether it is an email, a phone call, something we read in the news, or an in person meeting, there is a pressure to generate a prompt response. There are many times when this first response is not the correct response, and can do much to worsen a situation, even more than doing nothing at all. Instead of the reflexual flail making a deliberate change and then allowing time to settle is often the only way to make meaningful forward progress.

In basketball there is the principle of letting the game come to you. The default is often to feel the tension and importance of the game and then to begin to attempt to push. This results in forced plays, turnovers, poor shot selection, and a frenetic sense of anxiety amongst teammates- the opposite of a flow state. Letting the game come to you means waiting for the open shots, practicing the fundamentals while looking for opportunities, slips by your opponent. Letting the game come to you means biding your time, observing the court, and then acting deliberately when the time is right. 

Constant reaction is replaced with deliberate action. 
Variable emotion is replaced by intentional motion.
Haphazard flailing is replaced by purposeful work. Let it settle. 

Sleep on it. 
Wait. 
Your time will come. 

Breadth and depth

Jack of all trades, master of none is the unfortunate default state. The beauty of specialization is that one can get better products and services for less time invested. Complete ignorance is discouraged as a cursory knowledge of what exists is required for productivity and establishing oneself within a relevant context. Furthermore, knowing the place or the people to whom one would go for help, to learn more on any given topic,  is of course hugely beneficial. It is difficult to collaborate on a project or to seek help with a particular problem or question if one is unsure what technology exists and is available. One pitfall after realizing that something exists is the perceived need to become competent in a particular piece of technology or a particular skill. Exerting excess time and energy to gain unnecessary competence unfortunately negates the benefits of specialization and either decreases the quality of the product or service or increases the time and price at which the result is achieved. One may have a working knowledge of computer programming which may aid in communication, project design, and the selection of the team with which one works, however one would be foolish to spend one’s time attempting to learn, then perfect and implement the coding themselves. 

Success in the near future depends on the ability to identify opportunities and then work well with other team members from different backgrounds in order to achieve the goal. Being able to communicate well with members of other fields in order to harness the unique expertise and perspective from each individual field is vital. The list of hospital tasks in which a physician does not have expertise far outstretches the list of tasks for which a physician does have competency. For example, swallow evaluations, starting parenteral nutrition, determining the range of mobility and assist devices which would most benefit a patient, and compounding specific medications for administration are all outside the physician’s wheelhouse. And that is okay. Recently on rounds in the ICU the team outnumbered the patients by a significant margin. The rounding team was about 15 strong- enough to start a couple of basketball teams. The goal of any member of the team is not to become proficient in all the tasks and all the aspects of patient care, but rather to have expertise within their one area with enough knowledge and appreciation of the other aspects that they are able to work amicably and synergistically with all other members. Dietitians are not asked to interpret EKGs, start central lines, or declare patient’s deceased. Physician’s are not asked to perform swallow evaluations or conduct strengthening exercises although are certainly expected to recognize the general theory and importance of each discipline and identify patients who would benefit from such interventions. The goal is not to do the every job- that is simply wasteful redundancy. The goal then is to be able to understand the overarching principles of each job to enable teamwork and enhance productivity. Ultimately, the competency goal must be “Works with all trades, Master of one”. 

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.