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.

S2.4 Physician… Don’t Kill Thyself

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“Physician heal thyself” has changed to a plea “Physician don’t kill thyself”. Every year it is estimated that 300-400 physicians commit suicide. To put this in perspective, my graduating medical school class is approximately 200. So every year up to twice the number of my classmates who are entering the workforce, exit the workforce in an untimely manner at their own hand. This has been rightfully recognized as a problem; the response? Something called “Wellness initiatives”. 

Wellness is one of the buzzwords that medical schools, residency programs, and academic hospital systems are all touting. Visiting large academic centers around the country “wellness initiative” were defined with some variation of visits from therapy dogs, ice cream, wine and painting, or cookies. Akin to rearranging the deck chairs on the Titanic, these measures are laughable. Just as worrying about what to serve at dinner is a moot point as the ship slips beneath the waters, so junk food and running around with a four legged fur ball is a moot point as the crew drowns in 80 hour work weeks often watching the people they take care of slowly deteriorate and die. 

A small handful of programs are taking meaningful measures including scheduling preventative health appointments and faculty members who could be reached 24/7 to provide support. There are no easy answers to this problem, and no easy solution. Certainly medicine may attract people who are already at increased risk of taking their own life. Or the decade or more of training may play a role. Or the bad outcomes, difficult decisions, and limited time outside of the hospital to attend to ones own affairs may play a role. 

The hours in the hospital are entirely necessary for good training. You must see a lot of cases and work a lot of hours to be a good physician. One of the problems with the hours and the stresses is that you are not given freedom to self regulate. Running long distances you can feel yourself start to overexert, a feeling of panic and uncertainty creep in. At that time you can slow down until you regain control so that you are better off in the long run. In medical training you hop on the treadmill and the system increases the speed. Will Smith is quoted as saying about his work ethic “I’m not afraid to die on a treadmill”. Most physicians would probably agree. Unfortunately on the treadmill of the medical system, many have and many more will. 

80 hour work weeks are fine. Often they are enjoyable because you are doing interesting things with interesting people. However when you are working 80 hours a week, as soon as anything becomes off kilter there is little room to correct before large consequences are realized; the margins are already so thin. Often it is not just the number of hours in a day or week, but the number of weeks and months in a row. One time I accidentally referred to having a weekend completely off as “vacation” because that was how it felt. 

As our current system works, it is a fragile system. The hope is to maintain without any catastrophic mistakes and outcomes. The status quo is intermittently interrupted with major losses, and we return to the status quo waiting for the next catastrophe. Moving toward the antifragile, as Taleb puts it, should be the goal. Where struggles, perturbations, make both the person and the system stronger. Where the goal is an upward trajectory from the difficulties and shattering events instead of simply plodding away where we were before. Wellness initiatives and discussions of physician suicide must be replaced with focusing on strong social connections, honest reflections and the opportunity to rebuild and regroup, and the time to live, sleep, eat, and exercise in a healthy manner. 

The goal is true wellness and longevity for both the patients and the providers. 

S2.3 Relatively Defining

 

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We define ourselves in many ways. People select titles such a “fighter”, “contrarian”, and “creator” and use these terms to define themselves. Dependent identities such as these have the concerning feature of being highly laudable, unspeakably evil, or anywhere in between depending on external factors. In many contexts to be a fighter is a good thing. To fight for other people, to fight for new knowledge, to fight against disease, are all commendable. However to fight for selfish gains, out of spite, or to marginalize a specific people group would be despicable. Using this term to describe oneself is similar to using the term “non-profit” to describe an organization; it provides incredibly little information about the person or organization themself and only provides a passing reference to a relative characteristic. 

Christopher Hitchens, reknown author, speaker, intellectual, and atheist was often well known for his independent thinking and contrarian views prior to his untimely death. He wrote a book titled Letters to a Young Contrarian in which he discusses, as the title would suggest, contrarian thinking, that is holding and articulating positions that go against the prevalent tide of thoughts. The issue with identifying as contrarian is that contrarian is a relative term, it relies upon prevalent thought in order to take a position. To further clarify, it would be better, more descriptive, and more reliable to describe oneself as an independent thinking, that is someone who is willing to put in the difficult work of gathering and analyzing data for oneself and coming to their own conclusion independent of the persuasive powers of the masses. If I am contrarian and you decide that apples are tasty I am obligated to disagree and label them as unpalatable. If I am an independent thinker I am free to try the apple and decide for myself if I believe the apple to be agreeable or disagreeable. In an information and choice rich environment, one of the key underpinnings of societal improvement and uptrending will be a large population of independent thinkers who search out information and do their own analyses. A large population of contrarians will get relatively little done. 

Thinking independently is difficult. Gather information, think critically, and be willing to defend your conclusions. Being either ‘yes’ men (or women) or contrarians both hand all of the power to others as our stance is relative to theirs and not an absolute based on a well reasoned articulation of our analyses. 

One of the key aspects to maturing is defining oneself. This is a good and natural progression. As we are taking on labels and crafting our own definitions of ourselves, we must define ourselves as absolutes, things that are irrespective of the whims of the mob. We must define ourselves by what we are for, what we actually stand for and believe in, not a reactionary definition reliant upon what we are against.

S2.2 Welcoming the Sceptic, Inviting the Questions

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Science is a system, a methodology, that is used to approach empiric truth. It is a construct by which we ask questions, search for answers, and attempt to construct working theories of the world and universe around us. Nothing more, nothing less. Perhaps the most important part of being a scientist is curiosity, having an inquisitive mind that wonders at the world around oneself. Of course there is more to it than just asking questions. Doing science then entails figuring out a way to answer that question, collecting the necessary data, performing the proper analyses, and then drawing the proper conclusion to answer the question that one set forth to answer in the first place. But the question always comes first. 

We should never be afraid to ask scientific questions in good faith. Nothing should be out of bounds as long as curiosity and a search for truth is the driver of the question. As soon as one begins to engage in science, it becomes painfully, and excitingly obvious how little we know about the world around us. Even well founded theories can be questioned and tested. For example at CERN at the beginning of the decade scientists thought particles had exceeded the speed of light, something that challenged the theory of relativity, one of the most foundational physics theories in existence. Although a faulty wire was subsequently found and relativity was upheld as a theory, the fact that something so cherished and foundational could be openly questioned is one of the beautiful aspects of science. In medicine things that we have thought for many years, such as the transfusion goals for blood products, proper ways to prevent infections or do procedures, and even the composition of an “ideal” healthy diet are constantly being challenged and redefined. 

Concerningly there are topics that people are often discouraged from questioning or challenging. When one is unable to challenge or question a particular theory or teaching this is dogma and not science. Three notable examples are evolution by natural selection as the driver of organismal progression to advanced life forms, global warming induced by human actions, and the safety of specific vaccines. First let me clarify that there is great evidence for all three of these points (although for natural selection the specific mechanisms and probability of such a feat occurring is still debated freely and the safety of the common vaccines on the schedule has been well validated although there have definitely been harmful vaccines given in the past). The point is not whether any of these three theories are right. The point is that practitioners of science should ALWAYS be allowed the latitude to question and experiment in order to get closer to the truth. Any time science attempts to limit questions this is simply not science. Skeptics and questions are always welcome to science as long as they want to do science- that is ask questions and address those questions with the proper methods, data, analyses, and conclusions. To limit questions in science is to limit the beauty of the discipline and hamper the search for truth

S2.Intro: Welcome to Season II

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Welcome to Season 2 of the Blog! After the first season we took a break to recalibrate, reimagine, and reorganize. Now we are back and enthusiastic for the start of Season II. Over the next 50 weeks we look forward to exploring medicine, leadership, motivation, and struggle as well as a handful of other topics.

As always the goal is to think on, explore, question, and celebrate the many adventures and challenges of life. We are excited to have you here with us as we start Season II!