Because it works


Because it works. Although there are some medications with functions nearly definite and specifically designed (such as imatanib), many of the medications used in the clinics and hospitals of the world are used because they are effective in treating disease and have tolerable side effects not because we fully understand how they work. Aspirin was used for many years in many forms before a good idea of how the medication was likely exerting an effect was worked out. Cancer chemotherapies were originally cocktails of cytotoxic drugs used in varying combinations and concentrations until a more or less effective recipe was obtained (for more on the history of cancer, Emperor of All Maladies is an excellent read). The gold standard then for determining medication is (1) Is the medication safe? (2) Does the medication treat the disease as well or better than the current standard of care? While researchers elucidate the details of how the medication is working, a well understood or worked out mechanism is not required for use in patients. Success through clinical trials requires a demonstration that the medication is safe in small and large groups of patients and demonstrates a therapeutic effect greater than the therapies which are currently available.

In a similar manner we make decisions in our life based on these two questions: (1) is it safe?  and (2) is it effective, does it work? We select anything from over the counter medications, to grocery stores, to restaurants, to friends, to cars, to occupations, to schools, to hobbies based on these two questions. Often we don’t require an in depth mechanistic knowledge of how these things work (how good of a car mechanic, pharmacist, or chef are most of us?) The strange thing is, that if you ask most people they will assume that we have an in depth knowledge of these things. This assumption makes it easier to function in a system where the real answer is very likely because it’s safe and because it works.

Real vs. Imagined: Competition


Competition is a great motivator of productivity and new discoveries. However, differentiation of competitors from comrades can often be more difficult than it appears at first blush.

One important aspect to elucidate to determine whether or not the goal you are pursuing is part of a zero sum game or if room for growth all around exists. Does you making a dollar mean another person losing a dollar? Or vice versa, does their success cost you an equal amount of success?

It often appears that as human beings we envision competition where there is none and assume a zero sum game when in reality the playing field can be widened allowing for success all around. One reason this seems to be the case is that it is easy to see those with whom we interact the most as the greatest problem. Researchers at the same institution see one another as competition instead of collaborators. Medical students, residents, or physicians see one another as challengers instead of fellow team members. Employees working on the same project see the success of fellow employees as detrimental to their own success instead of recognizing the success of the team. In everyday activities it is often helpful to carefully consider and identify the competition and recognize the collaborators. Often we limit ourselves by confusing collaborators with competition and lose out on valuable opportunities for mutual gain. From intellectual, industrial, technological, and economic standpoints our societies rely on expansion of what is not competition within. Therefore far more opportunities for collaboration exist than competition. Taking a moment to recognize and appreciate our collaborators can be instrumental in propelling our progress personally and societally. There are enough real competitors out there that we need not create imagined competition in our minds. 

The best we have


Often we think about what could be, the perfect way to solve a problem, the most ideal way to solve a problem. This sort of speculation can lead to new solutions to problems or can serve as an excuse to avoid hard work and making a difference in the ways that we are able at that point in time. I was recently talking with a researcher who was bemoaning some of the limitations associated with recent gene editing technologies such as CRISPR-Cas9. There are three different paths that this thinking can proceed. The first is to motivate one to discover and invent something new, something better, something that will address the deficiencies which one has identified. The second is to refuse to use what is available focusing on the downside instead of the potential. The third is to use what is available at that point in time to make as great of a difference as one can.

These three different paths define who  we are, how we live, and whether or not we will make a difference. Most of the time we must choose between the second and third choice. Use what is available to do what we can or relegate ourselves to the sidelines citing how less than optimal conditions for progress are. Perhaps the best option is to do what we can now while pressing forward to something better. That is the best of medicine and biomedical research. Using the tools we have now to treat the disease confronting patients in the present while also seeking new therapies and treatments for the patients who will present to us in the future. Pushing for better should no limit us to doing our best now with what we have. Let us make it our goal to do what we can with what we have while relentlessly pursuing better together. 

Finite or infinite? the present choice

20170303_203711One of the desires of the human heart is for the promise of eternity. We hate watching one chapter of life end so much so that often we are dreading the end even while still in the beginning. Our hope is to achieve some form of eternal security, something that cannot be taken away from us. A state in which striving is unnecessary and our status is guaranteed. Yet while this is the goal for many, the actual realization of that goal is enough to drive many mad. Take retirement for example, phase of life which is as close to the striving free existence as one can get. For many, the sudden absence of a reason to get moving in the morning can be disconcerting. Often alternative objects and goals to strive after are sought. Few things about the human condition are as agreed upon by writers and thinkers across cultures as constant striving as a definition of the human condition.


However, while we are striving for more, bemoaning our finitude and pursuing the infinite, it rapidly becomes apparent how unfit we are for the infinite as well. Our minds and bodies make enjoyment of the infinite an impossibility. Life desensitizes us to the things around us, both pleasant and unpleasant. Bad odors which initially gag us upon entering a room no longer bother us after a few minutes. Exciting roller coasters or delicious treats which initially enthralled us become nauseating. Part of the human condition is the pursuit of new experiences. We want to hear new music, see new places, meet new people, eat new food. Expand this to the infinite. We are so bound to living in a finite place and time that we cannot think of an eternity with any form of accuracy, however let us make a few points. However one could think of an infinite life in this universe as a form of groundhog day. One may be able to change some things, go visit a new place here or there, learn a new skill, but over billion, or trillion, or more years, nothing new would exist. No new ideas, nothing new to experience. One would become inured to everything.


We seem to be neither made for the finite or the infinite. Rather our hopes and desires are caught up in the infinite which propels our behaviors and actions in the finite. It is living in this tension that we continue. As C.S. Lewis writes “For the present is the point at which time touches eternity.” The only way to make a lasting impact is to live in the present. Spending time bemoaning our past and our finite nature, or conversely, only looking forward to a brighter future someday denies our humanity and robs us of our chance to make a difference with the time that we have been given.


Adept Adaptors

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Adept Adaptors

One incredible feature of human beings that I am always surprised with is the ability of the human body to adapt to gradual changes. The body does not adapt well to rapid changes but can often find a way to change in response to a slow stress. A good example of this is running. The pounding of limbs on the pavement, the increased energetic cost, the need to conserve water, and strain on soft tissue and supporting elements of the musculoskeletal system are all put under some amount of stress throughout the duration of a long run. When preparing for a long distance run, the runner generally does not increase distance more than 10% each week as a general rule. The systems of the body are generally able to adapt to this amount of incremental change. However abrupt changes shock the body and can lead to debilitating injury instead to remodeling. If a non-runner goes out and runs 20-30 miles serious injury is likely, whereas most people, if they decided to, could slowly build up to run a marathon with no serious injury.

There are many other examples both good and bad. The body can adapt to harmful eating habits if these habits are gradual. This is not to say that the eating habit becomes non-damaging, but simply that the body is able to mitigate the damage that should be done to an amazing degree. The body is able to adjust to changes in oxygen levels in the atmosphere, availability of water and nutrients, heat, and a plethora of other stressors. Once again, this is not to say that these stresses are beneficial for one’s body, but merely that the body can often compensate for the stress to some degree.

Choose your stress wisely

In modern society we have some amount of control over the stress which we put our bodies through. Whether through exercise and diet, occupation and recreation, drugs and alcohol, we maintain some control over what stress we put on our body. Chronic drug users will often have to use more of the substance they crave to obtain the desired effects or will need to switch to a different drug of choice as their bodies have compensated for the toxin being taken in. People drinking large amounts of coffee may find that it has lost the desired stimulating effect. When starting anything that could be habit, consider how your body will change in response to that stress and decide if that change is something that you desire.

Pleasure is no different
Millionaire celebrity Dan Bilzerian, by self admission not the picture of virtue, made an interesting observation about pleasure, particular that brought about by money, on a recent interview. Pleasure, in very real terms, comes down to brain chemistry. Without getting into neurobiology, pleasure is the result of the release of particular substances from specific parts of the brain in response to a stimuli. As with any neurotransmitter-stimuli relationship then, this effect can be maxed out. If you or I (or any contestant on a game show) were given a brand new BMW we would be ecstatic. On a pleasure scale of 1 to 10, most of us would be at a 9 or 10 shortly after winning that car. However, for a millionaire like Bilzerian, a brand new BMW means nothing. It would take a car worth 10-20 times as much as the BMW to move Bilzerian’s pleasure scale at all. Pleasure, just other stresses, can be something your body adapts to. One could logically argue from this that the best pleasure then is the pleasure that moves your scale, but yet does not desensitize you to future pleasure. While there are a few examples of this form of pleasure, love within family and between friends is perhaps the best. So when we pick stresses, when we select pleasures, let us choose not based on what we hope to feel, but who we hope to be. Let our stresses make us stronger, our pleasures more closely knit. As the characters of the Narnians in C.S. Lewis’s Last Battle shout, “further up and further in” may our pleasures, may our stresses propel us farther, drive us deeper, and move us beyond where we now stand.

To live forever

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If you were given the option would you choose to live forever?
In the life that you now know?

Or would you choose mortality?
Believing that a story with no end is no story at all.

I think that if offered immortality on this earth many people would take it.
But they would take it out of fear instead of with joy.

It would be the fear of death, of the possibilities of what comes next that would drive them to say yes.
Instead of enthusiasm and vigor it is with hands shaking with fear that one grasps that life.

So my hope is that if I were ever given the choice, I would shake my head. To choose not fear but meaning, and live the years left with gratitude.


A review of history


Our perception of historical figures, whether great or terrible, is precisely that, a perception. We picture events in the past as being a certain way, often painting a rosier picture of people and events than is accurate. Reflecting on the current political climate is significantly above my pay grade, however one thing as been made more and more apparent to me as I watch events happen around the world- we often redefine historical figures and historical people to better match how we want the world to be. Allow me an example. Alexander Hamilton is currently a role model to many especially since the Broadway musical launched. Certainly there are many aspects of Alexander Hamilton’s life that are laudable. His work ethic in drafting our current economic system. His willingness to state his opinion no matter the cost. His enthusiasm for creating a better country. The thing that people love about the musical in today’s political climate is the fact that a young immigrant who began with nothing, invented and defined the financial system in America. However to get to place Alexander Hamilton on the pedestal of virtue and greatness much has been glanced over. For approximately year Hamilton had an affair with a woman 11 years younger. Throughout his life he was impatient and tirelessly self promoting to the point at which his relationship with George Washington was damaged. Although Aaron Burr is painted as the villain (which is certainly deserved) it was the constant battles for honor and reputation which lead them to that point- a point where verbal arguments were escalated to the level of deadly duals. Taken together, Hamilton did incredible things yet was a broken human being like the rest of us. And that is how is has always been and will always be. Humans rising to incredible heights to take on great challenges while at the same time often falling short of our own expectations and ideals. So let us not become disillusioned believing that we are worse today than the great people of old. Rather let us take hope in the fact that we too can do great things even as we stumble along the way.

A career or a calling


Often the words career and calling are used together. ‘Find your career and calling’ was a familiar catch phrase during my time in college; however, as ideal as this seems, the truth seems to be more complicated.

My reflection on the topic, albeit brief, has made the phrase ‘career or calling’ perhaps more accurate. Before determining what one’s career and calling is, it seems that one should first decide whether they want a career OR a calling. The difference, as slight as it may seem, is of the utmost important. If one wants a career, they can hope for a job where they are gainfully employed, being a productive member of society for 40 hours a week. They count on a paycheck at regular intervals, and given the choice between working or recreation, they are bound to select recreation as long as their 40 hour a week obligation has been met. However, if one wants a calling they are asking for an obsession. Something that occupies them not merely during the hours they are at work, but something on which they think, dwell, scheme, and pontificate at all hours of the day and night. This doesn’t mean that nothing else exists for them outside of that, but it does mean that they are working for the love of what they do. If one asks for a career they can complain about long hours, low pay, and few vacation days; however if one asks for a career the hours, pay, and vacation mean little, whereas the resources to make progress, the dedication of the team, and the creativity of those around them are key. Career and calling are different.

Neither career nor calling is superior to the other. Rather one must simply decide which version of life they choose. Many will choose career because it is safe, secure, and there are firm limits to what can be asked of you. However some will choose calling because they are curious, even troubled, by all they see around and can’t help but act.

Consistent and persistent

“We are what we repeatedly do. Greatness then, is not an act, but a habit” – Aristotle


In multiple aspects of my life in the last year the importance of consistency over intermittent hard work has become apparent. Recently, while reading Alexander Hamilton by Ron Chernow, Undaunted Courage by Stephen Ambrose,  Unbroken by Laura Hillenbrand, and Amazing Grace and Bonhoeffer by Eric Metaxas, it became clear that the people who leave great legacies do so through consistency, not merely a punctuated moment or two of valiant effort. Even Oskar Schindler, who early in his life was largely motivated by profit and hedonism, was changed such that he spent years of his life, and eventually his death, saving Jewish workers from Nazi camps. Each of these people made an impact not for singular actions, but for consistent and energetic work towards changing their world for the better.

It can be difficult to understand our actions in the light of their lives so an example may be helpful. Often when students or co-workers can be heard boasting about the number of hours they have worked. Pulling an all-nighter, working 80+ hours the past week, or coming in on the weekend are all examples of this. However when looking at the activity of most of the people over the course of six months, a year, even five years, one of two troubling patterns often emerges. Either the person works this hard only on isolated occasions, or the goal of their work is to put in many hours but not necessarily accomplish the most. (Some people certainly do work long hours, towards great goals, for years at a time but these people are seldom the one’s boasting the number of hours they have put in). More people working with greater consistency would yield greater results than more people working hard on intermittently although the the later often is more impressive to boast about. Hamilton, when he was working to build the financial system, worked for many months from morning until late at night designing, writing, and campaigning for a sound financial system for the new country. Wilberforce spent decades of his life working towards abolition and the end of the slave trade in Britain. A few all-nighters or several 80 hour work weeks would not have accomplished either of these feats. Instead years of consistent, persistent work was required.

As we move into the new year with renewed hopes and goals, may we pursue greatness through consistently working towards better, through persistently reaching towards perfect, and through resiliently moving from setbacks to work towards those goals. 

Myself, the problem


G.K. Chesterton is said to have responded to the inquiry “What’s wrong with the world today?” with two simple words. “I am.”

This must be where we both start and end. I am what is wrong with the world. My faults contribute to the brokenness we see. My actions, outright or inadvertent, cause pain and confusion on a daily basis. The inner dialogue of my mind is often not filled with grace and love but pride and selfishness.

As much brokenness as we see in the world, we must first address the problem of ourselves, for that and that alone is our responsibility.