On outcomes


You cannot always guarantee a positive result but you can certainly guarantee a negative outcome.

As the saying goes, “nothing is certain but death and taxes”

You can make certain outcomes- good health, responsible children, financial security, successful marriage- likely, but no one can guarantee any of these, even with vast amounts of effort. As important as a healthy diet and exercise are to health, taking care of your body does not ensure a healthy and long life. Cancer, underlying genetic predispositions, accidents, or other diseases can strike even the people with the healthiest of lifestyles. However, by drinking large amounts of alcohol, smoking, and neglecting essential nutrients, you can certainly guarantee a negative outcome and an early death. Even the most successful person cannot guarantee financial security. MC Hammer for instance… wait, nevermind that’s a bad example, but you get the point. Money now does not guarantee money later even when stewarded well. Fluctuations in an economy and a financial system that even the smartest of us do not understand, health problems, bad business partners, or criminal acts can all result in loss of financial security. However, by stewarding money poorly, spending lavishly, running up debts, and living outside your means, you can certainly guarantee that a future that is financially destitute. Even the best parents with the best techniques cannot guarantee that their children will grow up to be responsible. The wrong friend crowd or an innumerable number of other tangible and intangible things can wreak havoc on even the best upbringing. However, through neglect, abuse, unfair criticism, and a poor example, you can certainly set up children for failure. It is extremely difficult to rebound from a poor upbringing during the early years (see A Path Appears by Nicholas Kristof and Sheryl WuDunn). A successful marriage, like any partnership, is never fully under your control. You can work towards a great marriage through picking the right partner, developing solid methods of communication, being attentive to one another, and learning to accept and compensate for the strengths and weaknesses of the other person. However, people change, and like any partnership, nothing is ever fully in your control. On the other hand, you can certainly guarantee an unsuccessful marriage by not attending to the other person or being abusive and neglectful.

All this is very cheery and I’m sure I’ve brightened your day through sharing all the ways you can tank important aspects of your life. Importantly, this highlights the fact that the negative outcomes are the default, not the positive. Healthy living is an choice and a constant one at that. The couch is the default, the treadmill is the choice. Fast food is the baseline, a balanced diet must be selected and prepared. Squandering money is the default with plenty of credit cards, lending services, and advertisers to help. Financial planning and building wealth requires meticulous planning. Lazy, irresponsible children are the default, respect and character must be actively taught over many years. A crumbling marriage with poor communication is the default. A successful marriage must be fought for and intentionally built.

So that’s the encouragement. Although nothing in life is guaranteed, with meticulous planning and intentional actions we can make some of the most valuable things in life highly probable instead of impossible.

Live with intention  

The good and the bad


We have a wealth (also known as a glut) of information around us and in the news. There will always be something terrible happening that we can read about. Horrible people do horrible things. Nature does horrible things. Horrible things randomly happen. In generally things are improving despite what the news cycle tells us. People’s behavior is improving (see Angels of Our Better Nature by Steven Pinker) and fewer people are dying around the world from preventable or treatable diseases (see Bill Gates and the Gates Foundation). In general, things are improving yet we can still overwhelm ourselves with all the stories of evil.

Balance in this area seems to be difficult. One one hand we do not want to be in an isolationist bubble. We want to be aware of what is going on around us. However we also should keep ourselves focused on the good, those things that might not be news but are encouraging. As Philippians says “whatever is true, whatever is noble, whatever is right, whatever is pure, whatever is lovely, whatever is admirable, if anything is excellent or praiseworthy, think about such things.”

Any idiot can be a downcast “realist” by thinking about all the bad things that are going on and all the bad things that could happen to them. It takes far more work and discipline to engage in the important struggles of the day while maintaining an attitude of gratefulness and an optimistic outlook. In general, if it is something you can directly change, engage with it. Otherwise move on to the causes that you can directly change. The idea that feeling sad or indignant or angry or dwelling on bad things in the world is, by itself, a virtue is poorly formed. Dwelling on these things without action means nothing. Be intentional about being grateful for the good and actively work to improve the bad.

Towards being intentional

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Let’s talk for a moment about social media, in particular Twitter. Social media is not inherently bad, but it is probably not as innocuous as it appears on first pass. And, as we’ve seen in the past several years, a simple 140 characters is enough to end careers and uproot lives. The larger problem of social media witch hunts aside, the fact that a quick tweet can drastically change things, is an important consideration. One of the reasons that guns or cars can be so dangerous and must be handled carefully is for that exact reason. A small squeeze of the trigger can have irreparable consequences. Losing focus on the road can have dire consequences. In the same way, small tweets have been used to destroy careers, announce major policy decisions from the government, and spark debates that waste everyone’s time and energy. It would be nice if there was a safety on Twitter, something like grammerly but for insensitive and alienating comments. Not something that censors (We are big fans of the first amendment after all), but something that says “this is racist/sexist/mean, are you SURE you want to post this for everyone to see?”. Perhaps a voluntary breathalyzer or drug test before you could post would also be beneficial. The things that take years to build can often be destroyed in seconds.

The big push in using social media must be being intentional about it to relate to one another in positive ways. Thoughtless scrolling and mindless posting is dangerous, and the drastic downside far outweighs any potential upside. Live intentionally.


Jack of all trades, Master of none


It is surprising to me how often I hear this used as a compliment still. Although it is intended as a compliment, it is most assuredly a criticism not an aspiration. At most we should hone a handful of crafts, a handful of things, because the opportunity cost of trying to learn a little bit about everything is knowing everything (or at least, a lot) about a single thing. An inch deep and a mile wide.

Consider how we got to where we are today. Specialization plays a huge role in that. Look at the things around you. Few, if any of them could you have made by yourself without the help of many experts or professionals. Most of us could not build a computer from the ground up, and even if we could we certainly could not manufacture the necessary parts alone. Most of us could not build a car even if we had all the rights parts and a detailed instruction manual. Most of us are probably not doing ourselves (or our doctors) a favor by surfing Web MD or watching Dr. Oz to try to self diagnose what seems to be ailing us. Most of us cannot act well, sing well, or write well. Most people cannot grow enough food or gather enough provisions to keep themselves fed. If we each tried to make our own clothes the result would almost assuredly be extremely time consuming and uncomfortable.

I was listening to the Director of the National Center for Advancing Translational Sciences at the NIH. He commented on the fact that there are over 7,000 diseases. SEVEN THOUSAND, with more being discovered every year. As a medical student with books and books just summarizing the most common of these diseases this can be discouraging. The reason there are so many advocacy groups for less common diseases is that physicians cannot keep the signs and guidelines for every disease in their head all at once. The key is knowing when and who to ask for help.

The reason we have specialists is because they can have in depth knowledge about a specific area without concern for everything else. In the Emergency Department or with the primary care physician, the task is to know the most common diseases, recognize when someone is acutely ill, and then know who to call (or page) in each instance. A primary care physician memorizing large lists of genetic loci and rare neurologic conditions is not benefiting his or her patients through this impressive, but futile efforts. Stabilize, recognize, and treat or refer. The emergency physicians and primary care physicians are experts in that task! Even the more “general” medical disciplines are still specialists as it pertains to their job.

The physician however should NOT be working to be the best accountant, or computer programmer, or car mechanic. Physicians fixing their own cars could probably cause enough accidents to generate a whole new medical speciality.

Find what you want to be an expert in. Develop your craft. Hone your skills. And, be content with being ignorant in many areas of life. That is the cost of specialization and contributing to society as a whole. That is the cost of progress.

A student and a patient


Often when I was first talking to and working with patients I felt bad for them. As a student there is always someone there who could do a better job than you whether that be the resident, fellow, or attending, and instead the patient is stuck with you. Sometimes your stethoscope (or hand) is cold or your questions annoy them (how dare you, of course, they have never smoked, drank or done drugs). Naturally, most patients are sick, and many sick people want to be left alone. All of these made me feel slightly bad for the patients I saw.

Several things changed how I view my interactions with patients. First, they are not receiving lower quality care by any means. If anything, they have another set of eyes and someone who is attentive to their problems. The expertise of the attendings and the appropriate care will all be provided regardless of whether the student is present. The one thing that the patient is giving the student is time. In very few cases have patients ever seemed to mind that my questions and exam take longer than someone more experienced, or that I might have to pop back in at a later time to obtain a piece of information I missed initially. In fact many patients appreciate the extra time and the extra efforts you go to. Second, the thing that most sick patients want more than to be left alone is for someone to care. Listening to someone’s story, to how long the disease has caused them pain, or to how many doctors they have seen can be its own form of therapy. As the saying goes the job of a physician is to cure rarely, to treat often, and to comfort always. Students and patients often have time in the hospital during which they are not busy and listening to the story can be a key aspect of comforting. Third, you are doing this for the patients you will see in the future. When it takes a little longer to hear a murmur in a patient’s heart or the patient has to take a couple of extra deep breaths so you can hear the wheeze, it is for the patients who will be seen and treated by you in 10 years.

So instead of feeling bad for patients, I appreciate the extra time I have with them and the experience they provide me for treating patients in the future. And I am thankful for their patience with me and their gift to the patients I will treat in the future.