Do what you are able

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The endless stream of information being fed to us is overwhelming. New entertainment, narratives, and news stories are being uploaded at a rate that outpaces any hope of ever taking it all in. Up until recently the great limitation was the availability of information. However, now not the amount of information but the interpretation and packaging of that information is what ultimately determines how people consume the media and allow it to affect them. One of the problems now is that we can pick and choose. We can pick stories that confirm what we already believe instead of being confronted by opinions that differ from our own. We can pick content that entertains rather than informs. We can decide what we would like to know and can remain ignorant of inconvenient facts. With all of the information available to us today we absolutely should struggle with the issues facing our culture, mourn the loss experienced by those around the world, and plan wisely with how the earth is changing around us. However the opposite of this is also true. We have an endless supply of terrifying stories to choose from. There are continuous natural disasters, a constant threat of new wars, and uncertainty in the environment and the economy. One could easily sit at home, surf the web and repeat “this is bad” until one of those bad things hit close to home. Our responsibility is to engage with the serious issues of the day while maintaining our balance and perspective. Those who keep their critical minds and comical spirits through even the most troubling times are a benefit to themselves as well as to those around them. So while we do have a dictator gaining nuclear power, social unrest and discrimination at home, an endless salvo of hurricanes on our southern coast, famine in other continents, problems of addiction in our communities, on top of our own personal travails, nonetheless we must limit our stress to only those things in which we can affect change and allow the others to pass. This is not a call to ignorance or push away from unhappiness, rather a push toward change in a select number of instances instead of despair at the ocean of misfortune in the world. Start where you are, to do what you are able.

For the patient

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One problem confronting the American healthcare system today is the projected shortage of physicians. Depending on the study, within the next several decades we will be short tens of thousands of physicians (61,000-95,000 by 2016 numbers released by the AAMC). At the same time many physicians are reporting dissatisfaction with their occupation and high rates of burnout with many physicians stepping away from seeing patients to retire, find another occupation, or employ their expertise in a non-patient setting. Therefore one way to alleviate the shortage of physicians is to keep more physicians in practice for longer.

People go into medicine for many reasons. Many good, some not. Whether said or unsaid, many go into medicine because of the challenge, because they find the human body interesting, and because they enjoy solving problems. And medicine certainly provides a venue for solving challenging problems associated with the human body. Howeveras important if not more important than raw intellectual power is the need to be able to relate well with others even when going through difficult circumstances.

If I were to make a prediction, it would be that those medical students and young physicians who first and foremost were interested in the patient and secondarily were interested in the disease process were the ones who went on to have successful and happy practices. With the push for humanism in medicine, perhaps we will see this trend alleviatethe projected physician shortage and help to make healthier physicians and patients.

New

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In marketing and advertising, one of the key, eye catching words is NEW. Everyone likes new things. When was the last time you saw something advertised as “old”? If something old is being advertised it usually gets labelled as “retro” or “throwback”. As a culture we are obsessed with new. Which is great. Forward progress requires some aspect of new but every new thing is not progress. New companies, new churches, new books, new technology, new currency, and new entertainment have been used to create progress. But in markets saturated with new things, often refining and perfecting the existing can be the way forward. Running through the city within the span of several miles tens of churches, mostly empty on Sunday litter every block. On the same run the same is true of businesses and homes. Very often new churches are started, everyday new businesses are created, and continually new houses are being built. Often these become consumables, hot for a moment, stagnant for a year, and liquidated soon after. Are new things actually better? In some cases yes, but often no. Take books for example. While new books can be excellent, how many guaranteed excellent books have you and I not read? Have we exhausted the classics and other books which have stood the test of time? (I would list excellent old books and authors but surely would offend someone by including or not including a specific book or author). Instead of being taken in by the word NEW we should find how that new or old object will fit into our larger goals. If we understood everything about the “new” object, perhaps we would go back for something old we “knew” more about.

With Great Joy

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In the locker room during one of the NBA Finals games, Golden State Warriors coach Steve Kerr, encouraged his player to play with “great joy” because they were enjoying an opportunity that very few people in the world would be able to enjoy- playing for an NBA championship. Although you and I will almost certainly not play for an NBA championship or become a sports star, there are many things in life that we must rediscover with “great joy”. We are all creatures of routine, and with that comes the danger that we will become desensitized to the privilege which we have. Each season the NBA players play 82 games, with additional pre-season games, summer games, and then, for the good teams, playoff games. This can amount to 100 or more games a year. Despite this repetition, the challenge to the Warriors team was to recognize their privilege and enjoy the opportunity.

Often rewording our occupation or our educational responsibilities helps put this privilege into perspective. During undergraduate studies, almost daily I would think of college as an extended summer camp- meals were provided or easily accessible, my friends were housed nearby, and I spent the day exploring interesting things. This emphasized the privilege of attending college. Conversely I could have spent each day thinking about how mundane the classwork was, how rainy the city could be, and how uninspiring some of my fellow classmates could be. Simply reframing my daily routine could turn it from a privilege to a chore.

Now that I am working on medical and graduate studies I have the opportunity to rethink or reframe my routine again. On the one hand I can spend the day considering how inefficient some aspects of the system are, how unclear some of the requirements are, and how long some experiments can take. This can make even the shortest program feel like a lifetime (and certainly doesn’t endear one to peers and colleagues). On the other hand, I can spend the day realizing that this is a new form of summer camp where I can pursue questions that interest me while learning new techniques, and interacting with many people that inspire me. The switch from the routine as a chore to a privilege, while a small mindgame, must be done intentionally and consistently. Just like the Warriors, you and I all have the opportunity to do things that are a privilege, that other people dream of doing. Focus on those and do these things with great joy.

A Founding Father and the Fourth

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Ron Chernow’s book Washington: A Life chronicles the life of George Washington from his childhood years through 8+ years of leading the Continental Army to the postwar years and his presidency. As many have noted, perhaps the greatest thing that George Washington did for the nation, something that few other great men in history have done and which enabled the establishment of the United States, was that he repeatedly stepped aside from positions of power and returned the power to the people. This was evident both when he was the General of the Continental Army and became even more apparent when he stepped aside from additional terms of being President of the United States. What Washington, and many of the founding fathers at that time, understood so well is something which we have lost sight of- democracy is neither permanent nor guaranteed.

Timothy Snyder, Yale professor and author, rightly notes that there are a not insignificant number of democracies which have transitioned from democracies to totalitarian states. These changes, typically begin and are completed within 1-3 years and without the full recognition of the masses until the transition has actually taken place. Remember, even now, that there have been, and always will be, minority groups looking to exploit world events to gain and hold power. Democracy must be something that is guarded, protected, and sacrificed for, because even greater sacrifices will be required if it is ever lost. One of the final points Snyder makes is that if “if none of us is prepared to die for freedom, then all of us will die in unfreedom.”

Happy belated Fourth of July

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Information, obtained through freedom of the press, is our first and best defense against a tyrannical government. While the second amendment (right to bear arms) is certainly a part of the Bill of Rights, the ability of the people to utilize this method to defend themselves against a tyrannical government should not be glamorized. Far more effective and far more quickly is good journalism investigating the doings of our elected officials which is read with a critical eye by informed voters. This is the most disturbing current trend in the United States today. Not a lack of good journalism, but the growing chaff of bad journalism and the seeming indifference of the people. People often contrast Orwell versus Huxley and argue that, in the western world many aspects of one outweigh the other. However one of the unifying messages in both Brave New World and 1984 is the suppression of information or brainwashing of the masses. In Brave New World sing-song rhymes and conditioning tapes are used to brainwash each group of growing children into believing and doing certain things. In 1984 the records are constantly being scrubbed and history rewritten to make Big Brother appear infallible. Being part of the informed masses, unwilling to accept alternative truths is absolutely essential to a free democracy. As history notes, democracy is not a guaranteed entity, and the trend in the United States today is away from democracy as more power is being placed in the hands of the few instead of spread across the masses. Instead of planning revolution use information for deconvolution of falsehood and voraciously pursue truth from ourselves, our officials, our leaders, and our neighbors. A free press and freedom of information is the bedrock of a democratic society.

Read widely, think critically, require truth unconditionally.

Good and Evil: The Changes Inside

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In the George McDonald book The Princess and Curdie one of the main character Curdie, is able to see through the facade of the outer man and tell what kind of animal lies within them simply by shaking their hand and feeling the paw or claw. In the C.S. Lewis book Prince Caspian Lucy exclaims “Wouldn’t it be dreadful if some day in our own world, at home, men started going wild inside, like the animals here, and still looked like men, so that you’d never know which were which?” The stories we celebrate are those of good versus evil. We celebrate our role in the world wars because these are stories of freedom overcoming tyranny, and hate being overcome by love. Movies featuring alien invasions or a robot takeover are easy to watch because the us versus them mentality has clear cut lines. In human conflict, either in war or simply in daily interactions, determining where the line between good and evil is can be less obvious. In many of the military conflicts the United States has engaged in over the past half a century, there was an obvious evil-  a dictator or violent organization on the other side. However it was more difficult to determine if simply being opposed to that dictator denoted being on the good side. In some cases the answer was yes, in other cases it was less clear. In daily life determining who is your partner on the journey and who is an obstacle to be overcome is difficult. In truth people or even groups of people cannot be categorized as just good or evil. Reading Hitler: Ascent 1889-1939 by Volker Ullrich one could not have recognized a youthful Adolf as the monster he would become, least of all himself. Likewise we read about pillars of our community, politicians, religious leaders, shrinks, professors, and CEOs who have an evil side to them amidst all the outward good. One could not say that all the Germans were evil in the rise of the Nazi party as there were those, such as Dietrich Bonhoeffer, who appeared to take the wrong side, even for the most noble reason, such as a plot to overthrow Hitler. The good news is that good and evil exist in everyone, in varying degrees. In The Princess and Curdie the type of animal a person was inside could change for better or worse. The dwarf in Prince Caspian moves from skepticism and selfishness to loyalty and honor. The stories we enjoy have good and evil, certainly, but they also involve a transformation, and awakening. In both of these stories, as well as many others, it is not force of will that changes the character but their friends, their trials and struggles, and beginning to see the good in others. Perhaps the most important question everyday is not “what type of animal am I?” but “to what type of animal am I transforming by my actions today?”

Finding Home In Friends

20170318_170936.jpgOne of the most read novels on medicine is Samuel Shem’s House of God. The reaction of people is most often to either love the fact that it dispels the facade of the all-knowing physicians and ideal medical educations or they hate the book due to the fact that it portrays medical residency as horrific and bleak. What is often missed in the story chronicling the intern year of Dr. Roy Bash is the point. Everyone needs someone. Everyone needs a team. Everyone needs a squad. During the course of the year the interns realize they need one another and they need their leader (the Fat Man).

Often medical students (and pre-medical students) buy into the notion of competition. That those students around them, in the classroom and on the wards, are their competition. In general this could not be farther from the truth. What Roy Bash realizes, and what medical students and residents alike come to realize is that the competition is not peers. Medicine and science contain enough challenges and enough problems by alone; imagined competition has no place. Most of the time medicine and science are enjoyable challenges. However, as with any pursuit, there are moments studying, days in the lab, and interactions with patients that are difficult. At these times it is the students and residents working together that get you through the day.

Recently I was working on a team trying to resuscitate a patient in full-code. Although I’ve seen people coding before, I had never actually played a part of the resuscitation effort. We worked for almost an hour. As I compressed the patient’s chest, a whirl of activity surrounded the patient. As part of any team, communication is key, so the room buzzed with commands, stats, questions, and observations. Alarms were sounding constantly. At some point it became apparent that additional resuscitation efforts will not yield any better response and after asking for any additional suggestions from the team, the time of death was called.  What I did not expect was the silence. After an hour of hustle and activity, an odd hush fell over the room. As we took off our gowns, and gloves, the attending thanked everyone for their efforts. I was covered in sweat and the gown clung to my arms. Gloves and gown both had blood on them. Three minutes after the time of death was announced we were off to see other patients. I strangely felt nothing. The rest of the evening passed and I left the hospital late that night still without processing what had happened.

One of the struggles with pursuing a career as a physician-scientist is, unsurprisingly, that you bounce between medicine and research. The next morning walking into the lab I began to think about the resuscitation the night before. With patients found down out in the field, resuscitation efforts are often not successful. I knew that the team (with some of the best physicians, nurses, and residents) had done everything that could be done. But I still had it stuck in my head. The alarms. The smells. The rhythm of the compressions. The spurts of blood. Arriving in lab it was difficult to concentrate. With the patient dying in the back of my head, did I even care if a protein was being phosphorylated or dephosphorylated by a particular enzyme? It was the conversations and related experiences of other students that helped me process that night and prepare for more medicine, and more research, in the future.

The Tibetan saying goes “ Wherever you have friends, that’s your country. Wherever you receive, love, that’s your home.” It is said that students and residents more or less live in the hospital. It is the kindness, love, and camaraderie of fellow students and interns then, that must make the hospital a home.

Categorizing Millennials

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One of the popular ideas today can be summarized as “Millennials are ruining everything”. The recent closing of J.Crew, the struggles of restaurant chains, and many other market trends have been blamed on millennials. Those who are upset over this trend demonstrate a misunderstanding of the indifference of the market. However the more significant problem associated with this thinking is the categorization and stereotyping of people into broad groups. While the “kids these days” mentality has certainly been around for many generations, selecting out one generation, grouping them into one stereotype, and then heaping the nation’s problems at their feet is disconcerting.

This type of stereotyping and categorization are exactly the types of behavior frowned upon as racist, sexist, elitist, or bigoted if something besides birthday is used to categorize people. Insert a race, sex, gender, or social class in for the word millennial in any of these statements and you will see my point. Absolutely there are differences between generations, but in a similar fashion to any other category, the difference within a generation far outweigh the differences between generations. There are extremely hard working and extremely lazy individuals in every generation. There are extremely moral and extremely immoral individuals in every generation. Knowing the date of someone’s birth does not allow you to say anything about them just as knowing someone’s race or gender doesn’t allow you to say anything. Date of birth is a poor way to categorize and stereotype.

Returning to the issue of blaming shifting millennials spending habits for the closure of J.Crew and other industries. This is backwards. This would be the first time that the inability of a company to adapt to a changing consumer base was let off the hook and instead the tastes of consumers was the problem. To his credit Mickey Drexler admitted that he had been slow to shift with the climate. However both in the J.Crew instance and in many others just within the last year, millennials, not a poor business strategy and inflexible corporate structure, was blamed.

Do people in the millennial generation need to change? Absolutely. Each and every one. But that is because they are human, because they, like every other generation is on a lifelong quest to become something more, something greater. If we are to bin people into categories, let us bin them as humans and again as individuals. Anything more or less is inaccurate and destructive.

On Balance and Efficiency

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My research focuses on the immune system and specifically how inflammatory diseases such as Crohn’s disease, ulcerative colitis, or sepsis can be targeted with specific therapeutics. In contrast to cancer, where the goal is complete eradication of the cancer cells by whatever means necessary, or infectious diseases where complete stasis or death of the offending pathogen is key, therapies involving the innate immune response in inflammatory disease implement a goldilocks principle- too much inflammatory response and an inflammatory disease results, yet a total suppression of inflammatory response also leads to inflammatory disease resulting from an expansion of pathogens against a weakened host immune response. This is intermediate therapeutic zone is much more difficult to design therapies for and determine what the optimal level of response would be. Yet this is how much of life works- at an optimal intermediate between two extremes, with either extreme seen as unhealthy. The ideal would be to have both: an immune response that is robust against pathogens but is self-limiting, in effect not just finding a happy intermediate between the two but strengthening both the aggressive response to invaders as well as the attenuating factors downregulating inflammation.

I have always found the term work-life balance to both mask the real problem as well as cause confusion about what both work and life entail (as an aside Schrodinger’s essay “What is Life” is certainly a worthwhile read). Certainly we need balance in life. Certainly we need to work. And certainly everyone is in favor of life over the alternative. However calculating the minutes spent in an occupation or hours spent at home is surely a poor way to measure either as well. And as great as “Rent” is, love isn’t a terribly concrete way to measure anything. We live in a unique time in human history where our occupations can be our passions and not merely the basis for sustaining life. I enjoy research and medicine, and much of the large quantities of time that I spend working on either could be thought of as a sort of recreation in that it is interesting and non-arduous. However you certainly need time for family and “life” as well. The importance for both work and life is being present in both. What is interesting is that when many people refer to needing down time or “life balance” this is more of a way to say they enjoy time on the couch being entertained as opposed to being intentional about the human interactions between family and friends that we value so much. At work many people avoid thinking about how to push the envelope occupationally and instead escape to pleasant day dreams about their life outside of work. In running there is the idea of junk mileage, that is miles that you run but that don’t necessarily help you become faster or more in shape. Getting rid of “junk” hours both in work and in life is critical. Innumerable “junk” hours can be spent at work without making progress or with family without building relationships or caring for one another.

To find success in work-life balance both work and life must be pursued with intentionality, curiosity, and enthusiasm. Often the balance between work and life is not between work and life, but between efficient use of the time we have and a squandering of that which has been given to us.