Random Thoughts from a Restless Mind

Somewhere, somehow, someone did something that gave you the opportunity to be a success. Chances are you are aware of both the who and the what. Are you thankful? Have/do you express this?

It starts early. Your folks did something, or didn’t do something, and that laid the foundation. If it was good, did you thank them? If you still have them around it’s not too late; they remember, and they will be blown away if you tell them that you remember, too, and that you are thankful.

Was there a Coach or a teacher who had a particular influence on the younger you? Someone whose voice still shows up every now and again, just when you most need to hear them? They may or may not remember either you or what it was they did, but they might. Either way, if they’re still around, chances are your unexpected thanks will make their day. Maybe their week or month.

How about now, as an adult? I’m betting there was someone who paved the way for a greater kind of success for you. If you are lucky you might even still be on good terms with whoever this might be, but even if you are not, and even if you can’t call them, and even if stuff ended badly, are you still thankful for whatever it was they did once upon a time?

I think about this every time I bump into someone on third base and wonder how they got there. In most cases they made it to third because they hit a bloop single and then moved up when someone else got a hit or bunted them over. Some folks really DID hit a triple, but they are the exception. All of them got there because someone saw something special enough in them to put them on the team in the first place.

Remember, even if you did hit a triple, and even if you manage to steal home, someone somewhere at some time did something that got you in the game. Spend a minute thanking them.

Posted by bingo at October 30, 2011 10:21 AM

There is an antielitism in the air in much of society, Western and otherwise. Succeeding in a big way, being the best, creating something new and fantastic that makes you rich? All very bad nowadays. Just ask the folks over at Google. It all seems new and shiny and unique to the young, but it’s just that part of the cycle right now. We’ve been here before, we’ll move past this soon, and we’ll get there again. A part of the nastiness of today’s particular version of this antielitism seems to stem from the intimate knowledge that we all have of the minutiae of the lives of the elite, in all its presumed glory. Moreso, a substantial portion of our modern elite seems not immune to the rampant over-sharing so prevalent today. And that just feels like bragging, doesn’t it?

There’s a danger to this antielitism, today and always, for there exist individuals who have truly reached some elite level, and all of the rest of us are pulled along in their wake. Whether these folks are humble or arrogant, noble or venial, generous or a black hole of selfish, we as a society, a people, even as a species need to allow for a place for those who openly strive for elite. As individuals, as citizens, as countries, it is critical that we set aside what appears to be a species-wide tendency toward jealousy with an attendant need to bring all of those elites back to the comfort of the mean. OUR comfort.

There needs to be room for elite and elitism and elites, though, and there needs to be this room in all walks of life. Even more importantly, there needs to be room for those people who openly seek to become elite, better than most, maybe the best. Elitism is simply a harsher form of “meritocracy”, the notion that one can be rewarded for being better in some way at some thing. Elitism is synonymous with “best”, at least when the elite are gracious enough not to rub the rest of our noses in it (see above).

What’s hard for us who are not elite is to separate our jealousy and our anger at those who are truly elite from a couple of important things. We must realize that, without the elite we would forever be mired at the mean. Part of a curve under which the volume never changes. It’s also vitally important that we rein in our apparent need to stop any and all who openly express their desire or their efforts to achieve anything above the mean by aspiring to something elite. After all, who knows which of those aspirants will become an elite thinker or doer, one who will drag us all to a higher mean?

The essential error in the logic of the non-elite is that every system is a zero-sum proposition. The only way someone could ever have more is if someone else has less. There’s no understanding of an expanding universe. The tide never rises, and the number of boats in the harbor is fixed. No one ever benefits from the trickle down of new and the better, they only complain that someone else got it first.

That’s not really how it’s worked so far, though. Whether it’s in fitness, or in science or finance or philosophy or letters, the area under the curve is driven upward by someone who had whatever it took to become elite. We can learn from them, become a bit better at whatever it is that we do or we are, if we spent a bit less time seeking to drag them back to us.

Friendship has a cost. There’s a price for each friendship, a certain trading level if you will. Think about your friendships, where you are financially with regard to your friends, how you talk about money together, deal with money when you are together.

People are weird about money. I was reminded about a couple of stories last week that illustrate this. I grew up with two small groups of friends, one older and one my age. We were all sorta middle middle-class economically, and our folks made all of us work for our spending money. I don’t ever remember “owing” any of these guys any money, and I don’t ever remember any of them owing me. We kinda fell into this “it’ll all work out” kinda thing; whoever had money bought the beer and/or the pizza. Clan bingo dropped in on one of these guys en masse a couple of years ago and nothing had changed. I don’t remember, but I’m sure we bought some food or some wine or something; I’m equally sure that Tom doesn’t remember, either.

When I was a young physician in training, missing both nickels to rub, Mrs. bingo and I chose to live near some college mates, all of whom were doing very well, thank you. We received many very nice invitations to spend time with them at some very lovely places in and around NYC, Dutch treat, all of which would have required both nickels and then some. We couldn’t go, of course, and our invitations for them to join us in our very modest apartment for burgers and dogs always found them busy.

Only one friend understood, the one who had less when I had more as youngsters. His family accepted all of our invitations, and his invitations were either to his home or on his dime, making it clear that it was HE who was getting the better of the deal because we were together. He remains my closest friend on earth.

I’ve been fortunate as an adult in that I’m relatively free of needs, and there have been times when I could cover the wants of my friends, or cover my wanting to cover them even if my friends were able. What’s interesting is how difficult it can be to have it be comfortable when someone is “treating”. Think about it a minute: do you feel owed when you treat or that you owe when you are treated? It took 10 years AT LEAST for my closest local friend to stop keeping score when I was the one more able, to understand that I was actually the one getting more out of the deal because he and I were doing stuff together.

There’s a cost to every friendship, a trading range if you will, and the greater the range between those involved the more difficult it can be if you look at it that way. For me, with those friendships that have passed the test of time, the money involved is nothing more than a measure of how much that friendship is worth.

The more we ignore the cost, the more valuable the friendship.

How good is that phrase? There are all kinds of ways to draw that particular curve. The comic strip character “Crankshaft”, a bus driver who had a cup of coffee as a minor league pitcher, limits himself to very rare occasions of reminiscing. He wanted more in those days, and he misses those days terribly. Yet, in his tortured wisdom, he realizes that he can’t go back, and he can never change either what came before or what came after.

So he visits that time, opens the window to that little room tucked away in his attic only rarely, and for the briefest of moments, lest his yearning increase.

Times like those, times like Crankshaft’s stint as a pitcher for the Toledo Mudhens, are a classic double-edged sword. When distressed a quick visit can re-set your compass or fill your tank just enough to get through whatever it is that’s got you down. Spend too much time there, in Toledo for example, and nothing in the here and now might measure up. The yearning can overwhelm the living.

Some places and some times were so special that the yearning can become an irresistible force, driving you back in real time to bring your present day self to Toledo. The yearning curve as a boomerang, if you will. My in-laws gave in to this and recently visited Cap Ferrat in Southern France. They yearned to walk the quaint streets of their young marriage, to eat a breakfast of fresh milk and baguettes left in the box outside their tiny apartment while gazing at the impossibly blue waters of a harbor dotted with tiny sailboats. What they got, of course, was the hustle and bustle and hurley-burley of a modern tourist trap and a harbor choked with mega-yachts .

The yearning curve is never a circle.

A very nice bunch of college buddies, mostly football teammates, recently included me and a couple of other “youngsters” in an epic email thread dedicated to college memories. It’s been fun reading it for sure. We all ran the 40 in 4.5. Everyone maxed his bench each time we lifted. Each or us had a full head of hair, and we always got the girl. A magical place and a magical time, indeed. It can be easy to yearn for a place like that.

But it, like Cap Ferrat ca. 1975, is no longer there. It only exists in a picture, or an email thread, or behind a door or a window in the attic of our minds, available for a brief visit when the yearning curve peaks.

Like Toledo.

“Hilarious…a sensational novel.” –Golf Magazine

“Will leave you howling.” –Florida Times-Union

“An entertaining, revealing, thought-provoking, and cautionary tale.” –NY Times

“A must-read.” –Yahoo! Sports

Really? Did they all read the same novel I read? “The Swinger” by Michael Bamberger and Alan Shipnuck? Can’t be. The book I read was exactly none of the above. In golfspeak it was that most horrific shot imaginable…a shank.

“The Swinger” is the story of Herbert X. “Tree” Tremont, the best golfer on the PGA tour, who happens to be black, married to a beautiful white woman from Europe, who manages to blow up the most ideal life imaginable by being a selfish, self-centered serial philanderer. Hmmm. Sound familiar? Of course it does. The veneer covering this “fiction” is thin to the point of non-existence. We are invited, nay, led to believe that we can assume that all of the details are true; the names have been changed to protect the guilty.

Laugh out loud funny? Please. I picked up the book mostly for the amusement. I looked for the funny parts. I don’t think I got so much as a chuckle out of 200 some odd pages of drivel. The hilarity of near misses and hair-raising escapes? Nah. Each sordid episode was more soulless than the last, and each escape only dulled any inclination that I might have had to find some tiny iota of sympathy for Tiger…er…I mean, Tree.

“Is this how it really happened?” asks one of the reviews? Well, that part is at least a little bit interesting, at least as far as the writers are concerned. I found myself wondering which one of the authors was/is “Josh”, the aging, good guy golf writer who gets sucked into the cesspool and becomes Tree’s publicist/apologist. Which one got suckered and is now trying to weasel his way out of accountability?

Nope, in the end “The Swinger” was a disappointment in every respect. Simple prose steeped in simile and bereft of metaphor, the writing equivalent of a cheap muni course not worthy of joining the Muirfields of golf literature. The characters were as flat and two dimensional as an Oklahoma City track. Where is all the complexity in Tree? The Americablinasian,n,n,ness? Is THAT part true, too?

I felt empty. Cheated. Did you ever pay to play a really famous course only to find out that you have to take a cart, you have to keep the cart on the cartpaths, and all the greens and tees were just plugged? Pretty pictures on the scorecard but nothing but “no fun” from the 1st tee. Yah…that. It was totally contrived, like a porn movie without the goofy, repetitive jingle in the background.  I neither laughed nor cried, and I couldn’t work up an ounce of “I care” for a single soul in the book.

Frankly, I get more emotionally involved in Satellite Tour events on the golf channel in the middle of a sleepless night. My most prominent reactions were sadness and boredom, and I really like golf. And I really like Tiger. My advice for someone looking to pick up “The Swinger”? This one’s as gimmicky and trivial as a vacationland miniature golf course; it’s not worth the green’s fee.

For Mike and Alan? Take a mulligan, boys. That was one, ugly shank.

Someone posted on Facebook something about always wanting more. NEEDING more. Always striving for more. The sense I got from the post, and indeed the theme that ran throughout the comments, was that to NOT be ever–striving for more, to not EVER be satisfied, was the ideal. Anything less was to somehow settle. Settle for less. This was pretty much universally agreed to be a bad thing.

But where does happiness fit in here? If one never has enough, if one can never even be content, how is it that one can ever be happy? Frankly, I spent most of the day looking for the vocabulary to explain this. It’s just another version of the “want versus need” issue, complicated by a misunderstanding of the concept “ambition”.

I am ambitious. I have aspirations. Some of them are grand (reform organized youth sports, save the city of Cleveland), and some of them are quite trivial (own a home in Park city again, buy a watch). The difference, though, is that I’m really quite happy with what I have, who I am, where I am, and what I’ve done right now. I am thankful, openly and consciously thankful, for each one of those things.

W0uld I like more? Why, yes thank you. I’ve HAD more and it was really quite lovely. The only thing better than enough is more, eh? But there’s the rub: the man who knows when enough is enough will always have enough. We could say that one who is thankful for enough is living a life of gratitude. That certainly does not rule out ambition or aspiration, but it does leave a great big open door to happiness. People who are thankful for what they have, even those who constantly strive for more, tend to be quite happy.

I’m really quite happy. You?

Randy and I had a breakfast conversation once upon a time with a couple of other CrossFitters. We, Randy and I, thought we were having a discussion about nutrition and performance. After a bit it became clear that it was actually a discussion of religion. At least for the other two.

Has this happened to you? You engage someone in a conversation about something or other, something usually peripheral to the core issues of life but not quite so peripheral that it is trivial (being generous here), only to discover that the subject is the ONLY thing the other person thinks about? Worse yet, their thoughts have so ossified that there really isn’t a conversation going on at all, just a presentation accompanied by a vehement offensive against non-orthodoxy.

Logic, rational thought, and informed discourse have no role for these people. It’s not just nutrition, it can be literally anything. It seems to be a real problem in the politishpere–one issue voters or the true-believers on the extreme ends of the political spectrum don’t do breakfast.

There’s a chink in every armor; there’s another side to every argument. What’s good for the goose is not always necessarily what’s good for the gander. What if that gander really DID want to gain weight? Or that goose needed to shed some weight before an epic annual trip south? It’s rare that a single answer exists to some of this stuff, but it seems pretty clear to me that if one DID exist it would stand the test of a breakfast conversation.

Very few Theories actually progress to become Laws. Be more open.

8:00 p.m. on a Friday night. An urgent page from Express Scripts. “Approval needed for sleeping medicine, Agnes Jones*. 800–333–4444.” Agnes Jones is a nursing home patient with a brain tumor.

4:59 PM, Friday afternoon. Telephone call from CVS pharmacy. “The nonsteroidal anti-inflammatory eyedrop that you prescribed is not covered by Mrs. Jones’ insurance company. We need your authorization to change to the generic version.” We told Mrs. Jones in writing that the generic version was inferior, caused pain, and had 10 times the complication rate. On Monday.

7:30 AM, Sunday morning. Telephone call from answering service. “Doctor, the prescription that you sent electronically on Tuesday for Mrs. Jones was written incorrectly. Please correct this and refile it immediately. Please remember that your status as a provider is contingent upon meeting our customer service standards.” Confirmation of receipt/prescription filled was received on Wednesday.

And, my very favorite, most recent telephone call, this one from the daughter of one of my patients. “Dr. White, NALC needs you to send them a letter proving that my father’s eye drops are not prescribed for cosmetic purposes.”

Welcome to the world of the American physician in the modern era. There are, of course, a host of entirely appropriate responses to all of these pages, beeps, and phone calls. However, this last one put me over the edge. I sat at my desk with the message in front of me, closed my eyes, and thought about how I’d REALLY like to respond. The totally, truly amazing part about this request to justify the eyedrop prescription was that, not only was all the information necessary to cover this already on file at NALC, and not only did a real, live human being actually look at this file, but she admitted that and gave me her name! Ya can’t make this stuff up.

“Dear Alex:

Thank you for this opportunity to express my thoughts about some of the pitfalls associated with the pending ‘meaningful use’ regulations for computerized health records. After you personally reviewing the record you requested information about eyedrops that I prescribed for one of my patients. There is apparently a concern about whether or not this patient is using said medication for cosmetic rather than medicinal purposes. As you know, among the more significant ‘meaningful uses’ of electronic medical records are to make sure that everyone has the same exact information about a particular patient, to utilize this information in such a way that proper care is ensured, and to be more time-efficient for the patient, doctor, and everyone else involved in the care process.

If you will open up your file again regarding the patient in question, JOSEPH Smith, you’ll see that, had meaningful use activity actually been applied, this entire communication could have been avoided. Had you actually read the file you would have seen that MISTER  Smith is an 87 YEAR OLD MALE with a long-standing diagnosis of GLAUCOMA. As your software no doubt shows, the eyedrop Lumigan  is a first line medical treatment for glaucoma. All of this information is contained in your database since Mr. Smith has been taking this medication for no fewer than five years, and the bill for his office visit was paid in full by NALC, diagnosis: glaucoma.

A copy of this letter will be forwarded to my US Rep. and two senators, the FDA, and CMS along with a note asking how they propose that all of their fancy new laws about EMR and ‘meaningful use’ will prevent lazy and incompetent file clerks from blinding my patients.

I trust that the information in this ‘old–school’ letter is meaningful enough to prove that Mr. Smith’s use of Lumigan is not for cosmetic purposes.

Sincerely,”

——————————————————–

“Dear Alex,

Attachment: Pic.JSmith.jpg

Seriously? Really? You would like me to prove that my toothless, 87-year-old patient named JOSEPH is not using his glaucoma drops for cosmetic purposes?! The guy with the electronic bill in your system with a diagnosis for glaucoma, taking three other glaucoma medicines, all for 20 years? The Joseph Smith who can’t be bothered to remove the 11 skin cancers growing out of his face like barnacles on a sun-scorched barge? COSMETIC?

This is a joke, right?

Sincerely,”

——————————————————————-

” Dear Alex,

You caught me! But please, don’t tell anyone else. We have the largest population of semi retired 87-year-old drag queens in America in our practice. They just can’t let it go! We have been prescribing medicines so that they could maintain their long, luxurious eyelashes forEVER. I mean, who WOULDN’T rather have long, thick, natural lashes, especially after a lifetime fussing with those falsies and all that icky, sticky glue. Joe has been SO happy!

It’s amazing how important it is for him and all the ‘girls’ to be able to bat their eyelashes at those cute boy orderlies in the nursing home.

Not that there’s anything wrong with that…

Sincerely,”

Sigh…

*All names are fictitious, of course. The examples are not.

It’s become one of those trendy phrases, “unnecessary care”. When you hear it on television or talkshow radio it’s usually said with a sneer. Indeed, the speakers almost spit the phrase out–“Unnecessary care”–like it tastes bad.  It’s almost always accompanied by “fraud and abuse”, or a not so subtle accusation that some doctor is profiting off this “unnecessary care” at the expense of some poor patient. But is this true? Is this always the case? Are there no longer any circumstances whatsoever where the doctor really DOES know best?

I’m an ophthalmologist, an eye surgeon.  Every single day in the office I see several patients who have enormous cataracts which have dramatically affected their vision, and yet they are not only totally unaware of this decrease, they are militant in their rejection of surgery to improve their vision. Some of them have vision which has decreased to a point where, not only would they fail their drivers license test, they are nothing short of a menace to society behind the wheel. Because cataract surgery is an elective procedure, the patient gets to choose whether or  not to proceed with surgery. In other words, operating on a patient with a cataract who does not feel he has a problem would be “unnecessary care”.

The opposite version of this happens every day, too. In about 25 states there are strict, numerical guidelines that insurance companies (including Medicare) used to determine whether or not cataract surgery is “medically necessary”. Not a day goes by when I don’t see a patient who is bitterly unhappy with her vision, and yet her measured visual acuity is better than the threshold for “medical necessity”. Despite the fact that this patient feels handicapped by decreased vision caused by a cataract, operating on her is considered “unnecessary care”.

It kinda tricky. Sort of a damned if you do, damned if you don’t thing. I know it seems like a rather fine distinction, but cataract surgery is actually a big deal when it comes to the economics of medicine in the United States. Did you know that there are almost 3,000,000 cataract surgeries performed every year in the United States? Could some of these surgeries have been “unnecessary”? I dunno. I’m really struggling with the definition of “necessary”, frankly. Is cataract surgery in my two patients unnecessary? Says who?

You can achieve the same relative mortality rates for atrial fibrillation with either a cardiac ablation, or a cocktail of medications. Maybe you are medicine–free with the ablation, and therefore free of not only the yoke of your daily medicine schedule and side effects, but also the considerable burden of navigating your health insurance-approved medication list. The ablation might be 10X the cost of the medicines, but does that make it “unnecessary”? Too much? Says who?

So how do these two cataract patient scenarios play out at Skyvision? Well, the very unhappy patient with a cataract of any size whose vision does not reach that threshold level of “medical necessity” always chooses to wait until her insurance will pay for the cataract surgery. Always, whether she is a retired schoolteacher or a wealthy heiress worth tens of millions of dollars. She leaves the office unhappy, frustrated, and frightened. She cannot enjoy her daily activities because she cannot see well enough, and she is frightened by the prospect of normal activities like driving.

The other patient? Well, this patient typically has a monstrous cataract, so brown and cloudy it’s like looking through beef broth, or even beef gravy. This patient gets angry, too, but he is angry at me. He’s angry and offended that I would have the audacity to suggest that his vision is poor, too poor to drive, for example. He doesn’t understand what 20/50, or 20/80, or 20/100 vision means, and frankly he doesn’t really care. He’s got a drivers license, dammit, and he’s legal to drive. These visits almost always end something like this:

Me: “What kind of car do you drive?”

Patient: “A crown Vic.”

Me: “What color is your Crown Vic?”

Patient:” White. Why?”

Me: “Because my wife and kids are driving on the same roads as you, and I’m going to tell them to stop and pull over every time they see a white Crown Victoria.”

I say THAT’S “necessary care”!

The secret ingredient to success just might be failure. Not abject failure, of course (although it’s always cool to use the word ‘abject’), nor consistent failure. But failure while pushing one’s limits, or while exploring the new and the unknown, might be the magic ingredient in the success recipe.

Why? Success is not simply the absence of failure, it is the defeat of failure. Success is over-coming failure. Indeed, without having failed at something at some time, how do you know what success is? How do you know what it’s supposed to feel like?

Neither success nor failure need be any particular size. Small successes build confidence, and smallish failures teach valuable lessons. It’s important to qualify acceptable failures, though. Failure caused by sloppiness or laziness is ALWAYS bad. On the other hand, failure encountered while stretching beyond one’s limits, while reaching for something new, large, or important…well…that’s the type of failure from which lessons are learned.

It takes a certain chutzpa to put one’s self at risk to fail while in the act of reaching. I like Churchill’s take on it: “Success is never final. Failure is never fatal. It’s courage that counts.”

Be brave.