S2.1 Pandemic, the new normal


We have been worried about a global pandemic, something akin to the Spanish flu of 1918, for some time. Whether SARS or Ebola or the new coronavirus, there are always possible pandemics lurking on the horizon. We have dodged the bullet on avian bird flu and swine flu, although that may have had as much to do with luck than with successful intervention from the health system. Is the new coronavirus “the one?” The unfortunate reality is that we live in a time when “the one” is a foregone notion and we will always live with the threat of epidemic or pandemic on the horizon. No innovation currently in the works will completely remove that threat. Here, I outline a few, brief thoughts on what we can be relatively certain about concerning the next pandemic(s): 

  1. There will be other outbreaks of varying severity with a handful reaching pandemic levels after this current outbreak of coronavirus.
  2. Many will originate from Asia. This is due to varying reasons including population density and proximity of animals, including birds and other livestock, to people.
  3. Pandemics will likely be a strain of influenza or a similar virus that is spread through respiratory droplets. Although a bad disease, Ebola was much easier to contain than Tuberculosis or the Coronavirus for which respiratory precautions must be taken and spread is much more difficult to contain. 
  4. Pandemics will likely begin by a known virus mutating to behave in new ways, recombining with another virus to spread or evade the immune system by a different mechanism, or gaining the ability to jump from species to species. In particular the ability to transmit to humans and then transit from human to human will be a likely feature. 
  5. Those with comorbidities will be hit the hardest. Underlying heart disease, lung pathology, cancer, diabetes, and other health problems all make fighting the infection and maintaining homeostasis more difficult. Long comorbidity lists will generally be predictors of lower chances of survival. 
  6. Isolation and low population density will be protective. Especially during the period of an epidemic or pandemic where not targeted treatment exists, preventing human to human transmission is critical. One of the easiest ways to prevent human to human transmission is to be in a community with a low population density and with a low volume of influx from the outside. 
  7. Vaccines or targeted therapies will take many months to affect the population. In the meantime containment measures and supportive care as well as screening similar therapies for efficacy will be critical in mitigating the effects. As always, wash your hands, cover your mouth when you cough or sneeze, and …did we mention wash your hands? 
  8. Hospitals and other healthcare settings will be high risk places where disease is readily spread. This can be limited by the correct preventative measures and precautions, but the simple fact that many of the known cases will come through the hospital means the risk will always be high. Healthcare workers and their families will be at greater than average risk of contracting the disease. 
  9. In advanced stages the flow of goods, including food and water may be affected. Our lives today are enabled by trade from all corners of the world. Our medications, food, clothes, and everything else come from many miles away and require many people to get to us. In the advanced stages of a pandemic, food scarcity, loss of power, water shortages, and medication shortages may all be realized. Having an emergency supply of food, water, and other vital supplies including medications for chronic diseases will be essential. 
  10. Recovery will take years. Similar to recovering from a World War, the loss of human power and faith in economic and political systems will require years, not months to rebuild. 

“God is in control”


Copy of 20180705_140525The family of a patient who was unresponsive after a major bleed in the brain posted a card on the clear glass door to her hospital room.

“God is in control”

It struck me how many different ways this could be read.

A question thrown out to the universe, a shout into the void. A query as to whether there was a God and if anyone was in control.

A prayer that in the midst of trials and difficulties there was a compassionate God holding the patient in forefront of his mind. A plea that as their world spun out of control a loving God remained sovereign and sufficient.

A statement of faith proclaiming a truth, a belief that God had not abandoned them, had not grown weary, and remained capable and intimately concerned with the ultimate good of the patient.

Most likely it is all three simultaneously. With each reminder that “God is in control”, a question, a prayer, and a statement of faith are simultaneously made. This was the way of many of the Psalms… a progression from doubtful to prayerful to faithful in one breath.

Regardless of whether today was life-altering or routine may our prayers carry the same pattern. A question as we struggle with the difficulties of reality, a prayer demonstrating our insufficiency and throwing our hopes on another, and a statement of faith confident in the character and nature of God.

A New Straw Man

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In a debate, constructing a straw man argument provides a neat way of constructing a foe from your own imagination who is easily and conveniently destroyed. For better or worse technology has allowed us a neat way of avoiding the trouble of gathering the straw and propping up a straw man ourselves. Instead of carefully creating the shape and character of the hapless scarecrow that we will later destroy, we decided that even this task was too great an effort. Now lounging in bed or draped across a sofa we can, by activating only one thumb, scroll through our feed of news and friends and interests until we find something ridiculous to which we can respond. ‘How dare they’ we cry, forgetting the thousands of reasonable thoughts and suggestions we passed by to get to this atrocious viewpoint. We mutter under our breath and type furiously our response. As we hit “post” we sigh contentedly knowing that we have made the world a safer place, a better place, a smarter place. That was one small post for man, one giant comment for mankind. Settling back into the cushions we begin to scroll, but what is this? Our foe has replied? Surely our wise insight must have brought them to their senses, and they have merely returned to thank us for bearing the lone light of knowledge in a sea of ignorance. But wait, they are doubling down? How could this be? And the ridiculousness has spread to multiple points each of which we must address. Settling in to begin to type, we realize that what began as a quick strike has now become a war of attrition. And thus passes a perfectly serviceable afternoon. But at least we were fighting the good fight against… who again?

To Appear Busy


Intentionally or unintentionally we, as a society, have begun to equate the importance of someone with how busy they appear to be. What this has inadvertently led to is an atmosphere where people feel that they must constantly appear to be busy even when they are not doing something necessary, enjoyable, or productive. How many of us actually have to be reachable at any time of the day for any reason? Very few. In one interview Jeff Bezos, founder of Amazon, comments on the fact that he tries to focus on one thing at a time and is intentional about avoiding a constant stream of emails and calls. And yet there are many people who’s decisions matter significantly less who are glued to their phones and are willing to interrupt anything they are doing if they hear any email or come in. The problem with multitasking and believing that our importance goes up if we have many different things going on at once is that multitasking actually makes us less productive in the tasks that matter and decreases our happiness and satisfaction while performing a given task.

Whenever we get sick this seems to reveal itself the best. Something about feeling ill and uncomfortable motivates us to cut out the chaff from our schedules and focus on what actually matters. Most of our emails do not need a reply. We realize that many of the tasks we think keep the world going are actually just fillers. We realize that we actually have time to get 8 hours of sleep per night and that many of the tasks that we thought that we were absolutely essential for actually do not require us to the degree that we once thought. We realize that many other people are willing and more than able carry on without our attention.

There are very few things as valuable as your attention. Consider how much advertisers are willing to pay for your attention. In the United States in 2016 just short of 200 billion dollars was spent specifically on advertising. That amounts to hundreds of dollars per person each year. We should begin to value our attention and focus as much as advertisers value it. For definite increments of time make yourself unavailable to interruption. Focus on one and only one task. Realize that the more valuable your time is, the fewer interruptions you should have. Be productive not simply busy. Productivity is the end goal, not busyness.

With the Best We Have


Fast forward 20 years into the future and we will be able to answer research questions that it took me 4 years of work to figure out in a matter of days or even hours. In 20 years many of the treatments and principles that we use in the clinic today will be replaced by better techniques and interventions. In 20 years the devices that we use to communicate and conduct business and pleasure will be radically different.

To an already existing example of this rewind 20 years. Molecular cloning and cell based assays for biological research were long and arduous with ambiguous readouts. Cancer treatments were far from targeted, contained a wide array of severe side effects, and we had a poor understanding of what actually contributed to the genesis and spread of the disease. And it would still be another 9 years until the first iphone was introduced.

However, as J.R.R. Tolkein writes through the words of Gandalf, “All we have to decide is what to do with the time that is given us”. We can look back at times in the past or dream of the days to come, but what our main concern must be is to decide how we can best use the time that has been given to us now. Likewise we can wish that our talents and gifts were different. Perhaps we think about how much greater of a difference we could make if only we were naturally a better athlete or naturally more intelligent.

The goal then is to be productive and efficient with what we have been given without pressure to perform outside of those constraints. Future advances and the achievements of others do not diminish what we do today. And at the end of the day, we are the ones who know if we did our best; our best after all is the most stringent and valuable metric of all.

Consider what it will be like to be gone


Hindsight is 20/20. One of my memories of first grade was on the playground in the line for tetherball. A disagreement arose centered around the ambiguous guidelines we were calling the “rules” for playground tetherball. With tears welling up in his eyes at the perceived unfairness of the situation, one of the popular kids disinvited another one of the popular kids from his birthday party. A hush fell over the playground. Disinvitation from a birthday party was the pinnacle of first grade anger and hatred.

Looking at people who are in a stage of life through which we have already passed through, such as elementary school, high school, the first job, or any number of other stages, it is easy to maintain a context and objectivity. However when actually living through those stages, it becomes extraordinarily difficult to maintain context and objectivity. As stupid as a birthday party sounds now, when you are 6 years old and can only remember 1 or 2 of your own birthdays, these trivial cultural celebrations become of ultimate importance. Relationships, awards, publications, jobs, and tests that felt like they had the weight of the world resting on them can be looked back upon with barely an afterthought.  Peter Thiel, co-founder of paypal and venture capitalist, writes about how difficult it was to quit at his law firm. From the outside it looked easy to quit, simply walk out the door. But from the inside the difficulty in leaving was more akin to an escape from prison.

Often the opinions of our current peers and supervisors feel like they mean the world to us. It is often helpful to imagine what leaving your current job, social circle, or school will feel like. That supervisor who you were always trying to please, well their opinion no longer has any bearing. Your arch enemy in the adjoining cubicle is reduced to a mildly annoying memory. Your work, while certainly having some meaning, likely will not have the same life and death consequences that you imagined them to have. What you will take with you is the experiences and knowledge you gained as well as the friendships you DECIDE to maintain. Everything else will be like an invitation to a 6 year olds birthday party.

So even as you work hard in your current phase of life, consider what it will be like to be gone.

Never Quit on the First Day



Starting things are difficult. Whether it is living in a new city, starting a new job, going to a new school, or standing at the beginning of anything for which you do not have a good routine, the start is rough. When I run, the first three miles are always painful. When I start a new service in the hospital the first few days are always disorienting and confusing. I often get lost several times a day, am generally of very little help to anyone, and am not too certain of what my actual job or responsibilities in this new team are. Whenever I have moved to a new city the first month is always difficult. Where to get cheap gas, find good food, and connect with new friends is difficult and leaves one wishing for “the good ‘ole days”. During these periods of transition I will often give myself a date or time in the future when I can quit if I so choose. When I run that’s at the 3 mile mark since I know that by that time I will have found a rhythm and adjusted to the exercise. When I start a new service it is generally a week since I know that by that time I will have made some friends, figured out what I am supposed to be doing, and have established a general map of where things are in the hospital. When I move to a new city it has generally been after I have accomplished something such as the end of the first quarter of college or the completion of one cycle of medical school. At that point I have found a routine and can ride a sense of accomplishment into productivity and a happier frame of mind.

When starting something new try to avoid thinking about how you feel and whether you are enjoying your time until after the first day. Because invariably the answer is that you are uncomfortable, slightly tired, and generally wish you were back in bed. But keep going and often you will find a new rhythm, a new pattern, and a new satisfaction. If nothing else you will have developed a strong sense of grit and a new set of experiences that will be informative in the future. Whatever you do, never quit on the first day.

On Pacing


DSCN0030 long distances there is a sense of panic and urgency that can sneak up at unexpected times. It is an insidious breathlessness that creeps up when you are not paying attention. Beginning with a slight feeling of discomfort and a desire to get to the finish line faster your pace picks up a small amount. You extend yourself just a little bit too far with each stride. This discomfort increases the desire for the end and the pace picks up a little bit faster and the strides become just a little bit longer. Twenty minutes of this slow acceleration with deteriorating form leads to a feeling of frantic breathlessness accompanied by a confusion as to how things went downhill so fast. The key at this point is to drop the pace, to focus on your breathing, even to walk at an aid station if needed. To recenter, recalibrate, refocus. Resetting the stride at this point, reaching a rhythm in your breathing, and recognizing how much farther you still have to go is essential to finishing, and finishing well.

The same can be said of many other aspects of life. Slow increases in stress or hours at work push us at a pace that we cannot maintain. We begin to lose the enthusiasm, the why, that is crucial. Weeks to months down the road, we end up burned out, gasping for breath, unsure if we want to continue or even if we can. The journey is no longer fun, and our pace keeps increasing at a frantic rate to try to get somewhere, anywhere a little bit faster so maybe all of this can stop.

In running you can use technology and intentional self-awareness to avoid the breathless panic. Watching for spikes in heart rate and paying attention to the rhythm of your breathing are essential. But it is not enough just to pay attention, you must also adjust. Slow your pace, enjoy the view, take in some fluids and nutrition. The same is true in life. You can track markers like work hours and do gut checks from time to time, but you also must be willing to change. To leave early and take a weekend off. To drop everything for a day or two. To take advantage of the slow times to regain your breath. To settle in for the long haul and make accommodations so that the long haul becomes a journey of joy instead of a painful slog.

After all the tortoise versus the hare is best understood not as advice for a day-long run but a lifelong pursuit.

What is your metric of success?



How do you judge if you are doing well or poorly? How do you know if you need to change something? How do you decide what the right course of action is? Is it the feedback from your boss? The surveys from customers? The smiles of patients? The profits that come in? The respect of those who are important to you? Most people, including myself, cannot provide a logical and concise answer to this. In reality for most of us the answer is probably yes… all of the above. We take surveys, feedback, smiles, profit, and respect, run those past the internal compass of who we are are and what we believe to be important, and then judge ourselves based on that.

The third year of medical school is the first clinical year. The first year in the clinic and thus the year at the bottom of the hierarchy. In medicine, as with many other fields, things can be right for two reasons: One, there could be empiric evidence supporting the fact, or Two, there is no empiric evidence but only the preference or dearly held belief of someone higher up the ladder. The point of education is to gain the first and disregard the second without damaging the tender egos above. Reading Ayn Rand (The Fountainhead and Atlas Shrugged) while in this environment is simultaneously amusing, ironic, and bewildering. Yet it also is centering. Although Rand’s ideas are not all correct, the radical juxtaposition of her ideals and modern medical education is enlightening. It highlights what aspect of the education that really matters, in this case excellence in evidence based medical practice and a deep personal enjoyment of the work, and what does not matter at all, in this case petty arguments,  myopic practitioners, and patients who refuse to take responsibility for their own health.

So whether the field be medicine, law, business, or any other field, slowly yet intentionally developing a base of empiric evidence and discovering a personal pleasure in the task is the most important method of judging success. Everything else, feedback, surveys, and profits are superfluous and peripheral if they do not align with first two.

A simple guide


Everyone is constantly offering their advice and their opinion about how you should act. And no matter how strongly stated, it is just that- their opinion. People can be displeased with you. Scratch that. People WILL be displeased with you. There’s no avoiding that. But very few people, far less than we imagine, can actually impact our lives in a significant and negative way if we do not let them. Reading biographies of successful people, they all had habits, opinions, and preferences, many of which do not align and often contradict. Elon Musk has mentioned on several occasions how rude Steve Jobs was to him when they met. Even beyond the obvious competition within the computer industry, the personal lives and habits of Steve Jobs and Bill Gates could not be farther apart. George Washington and Alexander Hamilton had a dramatic falling out after many years working together closely. Even Lewis and Clark strongly disagreed at points in their famous journey. Some people tell you to be deferential and mind your place, other urge you to be bold and to make your presence known. Some are all about book knowledge (most great people have been voracious readers), while others count on experiences to teach them all they need to know. People who have done well have opinions. People who have done poorly have opinions. People who have no idea what they are talking about still have opinions. Many people think your goal in life should be to become just like them. Others just assume that your goal has to be the same goal as theirs’.  

I realize the irony in prefacing my advice with an argument that we should discard many of the opinions of others. So instead, consider this as guidelines for myself, should I lose my way in the sea of voices:

Approach every new endeavor with curiosity, interested and ready to learn new things. Allow experiences to change you but hold tight to the core of who you are. Work hard with a tenacity and a resilience that few can match. Be humble with your head up and your shoulders back. And finally, be grateful for the opportunities and the people around you.