Random Thoughts from a Restless Mind

Dr. Darrell White's Personal Blog

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Archive for October, 2018

Smaller, As Time Becomes Shorter

This weekend was spent in Chicago at the annual meeting of men and women with whom I share my day job. As I noted in “Sunday musings…” I’ve been suffering a bit from some sort of degenerative issue in my hip. Traversing the longest indoor “bridge” outside of the Providence airport rental car connector, my discomfort made me think of my Dad and the back pain that grew to consume him as he aged. Mind you, my discomfort is minimal in comparison, and my particular problem is quite amenable to a surgical fix with a high success rate. Still, it made me feel older, and it made me think of my Dad, gone these 3 years.

Below is what I wrote some years ago when I started to notice the changes in Dad.

 

When did my Dad get so small? Close your eyes. Think of your Dad. What does he look like? How old is he with your eyes closed? He’s younger, isn’t he? And bigger. MUCH bigger.

I spend most of every day in the company of people decades my senior. I’ve watched some of them age over 20 years or so. There are a few with whom I’ve bonded, who I remember and can conjure up an image if asked. I never appreciate the change in size in them, though.

It’s a strange phenomenon. It’s uncomfortable, no? There really IS a physical change that occurs as we age; we really DO shrink physically. No, it’s more than that when you look at your Dad, more than the physical decrease in size, the loss of vigor and all that goes along with it, the stuff I might actually notice in my patients. What makes it so striking when it’s your Dad is that it’s more than just physical, but a diminution in all dimensions and domains including the one inside your head.

He WAS strength when I was a kid. Literally, a rock. Immovable and unshakeable at all times. Unmoved by excuses or explanations when he knew he was right, or if he MIGHT be right. The final arbiter of discipline (“wait ’til your FATHER gets home…”) in a very traditional family, every thing about the guy was just huge.

When did he get so small? It’s almost scary, you know. He was the guy who stood between me and everything that might be dangerous, at least figuratively. At least in my mind. It’s hard to reconcile the guy I just put on a plane back to RI with my Mom, and the guy who’s there–right in front of me–when I close my eyes. So small now, almost frail. That classic love/fear thing now replaced with something more like love/protect. Does he see it, too? How small?

Will I see it, when I’ve become small?

Sunday musings 10/28/18

Sunday musings…

Old is as old does. Kinda Forrest Gumpian there, I know. Sadly, even a relatively minor injury or degenerative issue can turn even the fittest of individuals into an older version of themselves. So I’ve been learning after a tiny little jolt to my hip while doing a power clean that was just enough to make a heretofore unknown degree of degenerative arthritis become an every minute part of my life.

As they say, getting old ain’t for sissies.

While the discomfort is certainly noticeable for a significant amount of my day, it’s really what it keeps me from doing that brings on that oldish feeling. All of my usual fitness activities are curtailed. In no way am I attempting to be any type of super version of the middle-aged dud I am, but feeling as if I was physiologically 10 years younger was a really big part of who I’ve been for some 12 years. That’s slipping away as I find more and more stuff I need to avoid in the gym. For sure, modern medicine (sick care) is all over this, and I certainly have any number of friends and acquaintances who have already crossed this bridge.

Was it CrossFit that did in my hip? Nah. Some of my less fit colleagues are almost delighted to tell my about what their doctors and PT friends say about CF. But my buddy Dr. Bones pointed out all of the miles I ran in my 30′s, the pounding I took as a rather small guy playing a big guy’s game. Is there some kind of little injury from that power clean making stuff worse? Who knows. The X-rays show the effects of decades of heavy use on both sides.

That first step to a fix, though, is as daunting as the first time you walk through the front door to a new gym. No matter; having spent 12 years doing high intensity exercise that included a heavy dose of lifting heavy stuff, the guy who will put humpty dumpty back together is kind of excited to get to work. Why? Well that’s the lesson here this week: prepare for whatever tomorrow may bring. Your work in the gym makes you stronger, more resilient, and more able to bounce back from adversity of all type. In the end only my hips are old. At least at the moment. More work now while I figure out when I go into the repair shop should have me street-ready afterward that much faster.

The fountain of youth flows freely in the gym.

I’ll see you next week…

–bingo

Sunday musings 10/21/18

Sunday musings…

1) Banal. Ordinary. Most tragedies begin with something banal. A tiny misstep. Truth bent just a little bit. Took a wrong turn.  Tragedy averted or avoided is likewise usually accomplished by the banal.

When doing the next right thing, in spite of an error either forced or unforced, is the ordinary thing.

2) Proximity. To greatness that is. What must it be like to spend your life in the presence or proximity of true greatness? I’ve long publicly held that I am not in possession of the genius gene. Rather I seem to have a rather dominant expression of the “Salieri” gene, that certain ability to both identify and promote the genius of another. Unlike the real Salieri I also inherited the gene that prompts me to protect any of those geniuses with whom I may come in contact (Salieri famously was said to have destroyed Mozart the man while promoting, and profiting from, his genius).

To be in the presence of the giants in any field is a privilege. In my day job I have reached a stage (I’m old enough) and have acquired enough status (a few people know who I am) where I occasionally share a stage with the giants upon whose shoulders we all ride. Just last month I sat next to Ken Kenyon and Hank Perry, two of the pioneers in the tiny slice of eye care where I might yet make my mark. Not gonna lie, it’s hard not to be a little bit starstruck up there.

Which makes me wonder what it must be like to spend your entire career recording the exploits and the thoughts on the same of some of the best “whatever” in the world. More than that, what if in so doing you become one of them, so good at how you let the rest of us into the world of whoevers, athletes or musicians, artists or scientists who are simply the best at what they do. Sometimes the best ever. Hemingway taught us about soldiers and war in his early works. Jimmy Chin and Jon Krakauer have likewise opened the eyes of flatlanders everywhere to what it’s like to stand on the top of the world.

Sportswriters are classic examples of individuals who spend their days in the presence of varying degrees of excellence. Of genius. Most give us a fair rendering of the facts, sometimes leavened by insight, but an occasional writer stands out among the others through their own sheer excellence. Grantland Rice, Red Smith, and Jim Anderson form a kind of Mt. Rushmore of pioneers. Perhaps Dan Deform and Bob Ryan belong there as well. If you follow athletics at all you have favorites. At some time, though, these men and women either pass from this life or simply pass from writing. My point, then, is a simple one: those who spend their working lives in the presence of other types of genius who are, themselves, the very best at putting together the words that let us, those who are at best a Salieri, see into the world of the best athletes should be treasured. Recognized and enjoyed while they ply their gifts on our behalf. Their words, like “A Farewell to Arms”, will live on, but there is something special about reading those words when they are fresh.

Do yourself a favor. Pick up or surf to Sports Illustrated and read Tim Layden’s piece on Tommie Smith and John Carlos. It’s a story 50 years in the making that in the hands of Layden feels as fresh as last week’s news. Yet like so many of his pieces you know that it will feel just as important 5, or 10, or 50 years hence. Read it and be in the presence of greatness.

3) Judgement. Who am I? Today, that is. Who am I today? Who is it you know if you know me today? My friend and I were chatting a bit about our college years and who we were (and who we thought we were) back then. Make no mistake, we both loved our years in school (though we went to the same college our paths did not cross until many years later) and look back on them with great fondness. Recent events in our country have prompted us to look back and view our college years through a slightly different lens. While we were enjoying our college experience, how did our experience impact others there at the time? How have we grown as men and women since then?

Who are we today? When you think of us, judge us, choose whether or not to associate with us, are you thinking of who we are today or who we were (or you thought we were) at some time in our past? Which version of who we are–for you cannot escape any version of yourself–is the one that makes you choose to stand with us or agin us? Nobody is the same person today that they were yesterday, and who you are today is only how you start out tomorrow. Which version do you see when you see us?

No answers here my friends; the answers are for you to divine when you look at all of us in and around your life. For my friend and for me we appear to be mostly cut from similar cloth, two men with some of the standard issue flaws of humanity who have simply tried to be better in all ways each tomorrow since we started thinking about it. We were hardly “bad boys” but we are both saddened when we look back and realize that we could have done better, been better. We want to give our children a head start by sharing this; they are often already there, instead guiding us to be better now.

We are who we have become today, and who we will continue to try to be for a forever’s worth of tomorrow’s. Because we did want to be better, even as we were learning what that meant. We still do. Who am I to you today? Who do you see when I stand before you today?My friend and I have spent many yesterday’s trying to be better so that who you see today is worthy of you.

I’ll see you next week…

–bingo

The End of the Age of Volunteerism

Ladies and gentlemen, we are gathered here today to mourn the death of the Age of Volunteerism. While there exist tiny spaces where true volunteers live and thrive in a bilateral exchange of freely given goodwill, by and large volunteerism has been extinguished by the actions of its historical recipients. Sunday marks my last day ever of hospital ER call, the end of 2 years of receiving token payment for making my expertise available following 25 years of doing so for free. My experience is typical, as is this denouement.

Once upon a time all of your doctors were in private practice. We all had tiny little cottage businesses, did our work, and billed you or your insurance company for the work we did. Some of us worked in tiny little groups, but it was the rare doctor who was part of a large group or business whether in a big city or out in the country. Even the slickest Madison Avenue internist was basically a country doc, just with a better, more expensive wardrobe. In addition to having a greater familiarity with our patients we also enjoyed a very clubby relationship with all of the other doctors where we practiced. There was a collegiality, a sense that we were all in the struggle together. Folks who shirked their duties, foisting them off on other docs, were quickly educated about proper protocol or left to toil alone.

Hospitals were different, too. Local or regional, they were hardly the gargantuan mega-businesses they’ve become. The org chart was shallow, and most local doctors were on a first name basis with the few administrators on the hospital payroll. You took call for the ER as a volunteer; the ER respected that you were donating your skill and your time and handled everything it could before calling you. Same thing for consultations. Your colleague only called you if they couldn’t figure out a problem or ran out beyond their scope of practice. There was a faint air of apology with each request, and a definite unspoken appreciation for the help that would be given. You helped because you were appreciated.

This is really no different from all manner of volunteerism in America. Smallish, closely knit organizations depending on the goodwill and generosity of members of their community pitching in to ensure success. Think local memorial 5K races, or CrossFit Games Regionals in the days before ESPN or the Home Depot Center. Countless small private schools that depended on the largesse and time offered by the families who sent their children there. You gladly accepted the opportunity to volunteer because you knew that without you the organization would not be able to function. You also knew that the recipient of your generosity not only appreciated your contribution, they really had no other options. Not only that, but if that organization somehow existed in your professional space you knew that it would never, not ever, abuse the trust necessary for volunteers to continue.

What happened? Money. Money and size and the distance that they create between an organization and its volunteers. Let’s go back to the hospital and the ER for a minute. Where once your efforts as a volunteer were deeply appreciated and those efforts rewarded with respect and care for your time and your expertise, the growth of employment of doctors by hospitals opened a gap between colleagues. No longer was there the esprit de corps, the shared notion that the primary target of our efforts was the patient was replaced by so very many doctors by the reality that they worked first for a business as faceless and uncaring as GM. Work that was once done by your colleague was now pushed to the volunteers whenever possible. It’s cheaper that way. Worse, boxes to be checked by the employed (to maximize revenue and minimize risk) meant demands made of volunteers, not requests. Worse, still, were discoveries that some “volunteers” were more equal than others: they were paid.

Innumerable examples are there for the picking. Some times it was just a case of laziness. Other times the insult was a clear effort to dump work on the volunteer. A critical care fellow requested a consult for acute narrow angle glaucoma. For those of you not medical this is one of the few “drop everything and go” consultations in eye care. When I arrived in the ICU I found a young patient with a black cornea who was mildly uncomfortable. I did what every highly experienced specialist does when they start a consultation, I asked the patient: “Hey, what’s up with your eye?” Turns out they had a blind, painful eye as the result of a surgical mishap, and surgery to remove the eye was already scheduled. Their discomfort was because none of the eye medications had been ordered; the fellow never asked. No doctor (or nurse) would have allowed this to happen in the Age of Volunteerism.

While this is nothing short of tragic in health care, it was inevitable once medical businesses were incentivized to grow ever larger. It is not confined to health care by any means. How do you think that volunteer at a Spartan Race feels when he learns how much his “team leader” is being paid? Have you ever “discovered” how much the Executive VP of your favorite professional organization is paid? As a people we Americans are generous to a fault. That generosity usually continues right up until we discover that we have been duped, and even worse that we have been purposely duped by the people who run the organizations for which we volunteer.

And so we gather here to mourn the passing of the Age of Volunteerism. Like so many things of wonder and goodness there remain pockets of resistance, little oases where the goodwill, honesty, and appreciation beget the kind of ebb and flow that made things so much better, kinder, more collegial at the apex of Volunteerism. My friend Tom Gardner was just named the president of the Society of Alumni of our Alma Mater. Tom has given tirelessly of his “spaces”, his timespace, brainspace and emotionalspace to help shepherd tiny Williams College as it flows on though time. Is this truly different? A tiny refuge from the Zombie Apocalypse of corporatization of all things to which we once volunteered?

We can only hope. Hope that Tom and those like him who continue to find places and causes where their volunteerism is met with what we in medicine have had to bid farewell. We can only hope that there will be places where being a volunteer means receiving the respect and appreciation and even a kind of love in return for what we have given. We can only hope that there will continue to be places where the incessant drive to grow ever bigger, size measured on a spreadsheet rather than by heart, will be resisted. For if it can happen in medicine, if volunteerism can be killed in what is arguably the most noble of all endeavors, I fear that it is doomed everywhere.

We mourn the end of the Age of Volunteerism. We wait with equal parts sadness and fear for arrival of whatever comes next.

 

Sunday musings 10/14/18

Sunday musings…

1) Feral. Abbie the Wonder Dog was feral for the first 6 or 9 months of her life. I can’t remember exactly. She was live-trapped and rehabilitated by a Border Collie rescue organization in north central Ohio. When she frustrates me it is always helpful to remember this.

Having a formerly feral creature living in our midst is also a very good counter to the frustrations of modern life. I try to remember how far I am from true privation whenever I find myself railing agains the insanity and inherent indifference that the world clearly has toward my existence.

A quick thought of my clever (read: sneaky) pup is usually all it takes to quell my urge to explode when I encounter the tragedy of a poor internet connection…while hurtling through a mountain pass in a car going 80 MPH.

2) Test. Some 10 years ago or so I proposed that a true measurement of health should be possible. Something that combined the most basic of classic medical knowledge (weight, %BW fat, BP, Cholesterol, etc.) and the breakthrough notion that physical fitness could be measured and tracked. My theory included the necessity of including some sort of measurement of “well-being”, a mandate that was initially openly mocked but seems to have been rather meekly accepted as both logical and necessary.

Creation and launch of such a value, call it “Total Health” or something along that line, has fizzled due to the lack of consensus–nay, even interest–in coming up with a way to measure Fitness. Imagine, in a place like CrossFit where the very definition of Fitness was created, no one save me and a tiny group of equal obsessives has so much as let fly a tiny trial balloon. The original owners of CrossFit LA were the first to use a standard entry test. 500M Row/40 Squats/30 Sit-Ups/20 Push-Ups/10 Pull-ups. I suggested pulling from both traditional sources (The President’s Fitness Test) as well as CrossFit and the larger endurance communities: 2:00 each of PU/Push-Up/Sit-Up/Squat, 1RM Deadlift, 1 mile Run. We ran a competition once called the “Fittest Eye Doc” using this.

What is necessary is a test that is a) doable by the general public, and b) capable of creating a single value that can be measured and tracked. Once that is done mathematicians and statisticians can be let loose with the various factors and given the task of coming up with a formula that includes all three categories. Why bring this here, again, when thus far my previous dozen or so postings have been met with crickets? With the pivot to health and the rapid build-up of a cadre of physicians who are at least superficially interested in using high intensity exercise for the purpose of increasing health, I am hopeful of a broader dialogue that comes to an agreement on a test.

Challenge: create a test of fitness that is broadly accessible in all ways (scalable) that can be included in a definition of health. 3-2-1…Go.

3) Volunteerism. Ladies and gentlemen, we are gathered here today to mourn the death of the Age of Volunteerism. While there exist tiny spaces where true volunteers live and thrive in a bilateral exchange of freely given goodwill, by and large volunteerism has been extinguished by its historical recipients. Today marks my last day ever of hospital ER call, the end of 2 years of receiving token payment for making my expertise available following 25 years of doing so for free. My experience is typical, as is this denouement.

Once upon a time all of your doctors were in private practice. We all had tiny little cottage businesses, did our work, and billed you or your insurance company for the work we did. Some of us worked in tiny little groups, but it was the rare doctor who was part of a large group or business whether in a big city or out in the country. Even the slickest Madison Avenue internist was basically a country doc, just with a better, more expensive wardrobe. In addition to having a greater familiarity with our patients we also enjoyed a very clubby relationship with all of the other doctors where we practiced. There was a collegiality, a sense that we were all in the struggle together. Folks who shirked their duties, foisting them off on other docs, were quickly educated about proper protocol or left alone.

Hospitals were different, too. Local or regional, they were hardly the gargantuan mega-businesses they’ve become. The org chart was shallow, and most local doctors were on a first name basis with the few administrators on the hospital payroll. You took call for the ER as a volunteer; the ER respected that you were donating your skill and your time and handled everything it could before calling you. Same thing for consultations. Your colleague only called you if they couldn’t figure out a problem or ran out beyond their scope of practice. There was a faint air of apology with each request, and a definite unspoken appreciation for the help that would be given. You helped because you were appreciated.

This is really no different from all manner of volunteerism in America. Smallish, closely knit organizations depending on the goodwill and generosity of members of their community pitching in to ensure success. Think local memorial 5K races, or CrossFit Games Regionals in the days before ESPN or the Home Depot Center. Countless small private schools that depended on the largesse and time offered by the families who sent their children there. You gladly accepted the opportunity to volunteer because you knew that without you the organization would not be able to function. You also knew that the recipient of your generosity not only appreciated your contribution, they really had no other options. Not only that, but if that organization somehow existed in your professional space you knew that it would never, not ever, abuse the trust necessary for volunteers to continue.

What happened? Money. Money and size and the distance that they create between an organization and its volunteers. Let’s go back to the hospital and the ER for a minute. Where once your efforts as a volunteer were deeply appreciated and those efforts rewarded with respect and care for your time and your expertise, the growth of employment of doctors by hospitals opened a gap between colleagues. No longer was there the esprit de corps, the shared notion that the primary target of our efforts was the patient was replaced by so very many doctors by the reality that they worked first for a business as faceless and uncaring as GM. Work that was once done by your colleague was now pushed to the volunteers whenever possible. Worse, boxes to be checked by the employed (to maximize revenue and minimize risk) meant demands made of volunteers, not requests. Worse, still, were discoveries that some “volunteers” were more equal than others: they were paid.

While this is nothing short of tragic in health care, it was inevitable once medical businesses were incentivized to grow ever larger. It is not confined to health care by any means. How do you think that volunteer at a Spartan Race feels when he learns how much his “team leader” is being paid? Have you ever “discovered” how much the Executive VP of your favorite professional organization is paid? As a people we Americans are generous to a fault. That generosity usually continues right up until we discover that we have been duped, and even worse that we have been purposely duped by the people who run the organizations for which we volunteer.

And so we gather here to mourn the passing of the Age of Volunteerism. Like so many things of wonder and goodness there remain pockets of resistance, little oases where the goodwill, honesty, and appreciation beget the kind of ebb and flow that made things so much better, kinder, more collegial at the apex of Volunteerism. My friend Tom Gardner was just named the president of the Society of Alumni of our Alma Mater. Tom has given tirelessly of his “spaces”, his timespace, brainspace and emotionalspace to help shepherd tiny Williams College as it flows on though time. Is this truly different? A tiny refuge from the Zombie Apocalypse of corporatization of all things to which we once volunteered?

We can only hope. Hope that Tom and those like him who continue to find places and causes where their volunteerism is met with what we in medicine have had to bid farewell. We can only hope that there will be places where being a volunteer means receiving the respect and appreciation and even a kind of love in return for what we have given. We can only hope that there will continue to be places where the incessant drive to grow ever bigger, size measured on a spreadsheet rather than by heart, will be resisted. For if it can happen in medicine, if volunteerism can be killed in what is arguably the most noble of all endeavors, I fear that it is doomed everywhere.

And so we mourn the end of the Age of Volunteerism. We wait with equal parts sadness and fear for arrival of what follows.

I’ll see you next week…

–bingo

 

Good and Bad. Right and Wrong. Sunday musings 10/7/18

Sunday musings…

There is such a thing as right and wrong. Good and bad are different. My reminder came while reading about Dale Murphy, the retired baseball player most famously remembered for his days as an Atlanta Brave. Mr. Murphy was noted for his career-long insistence on doing the with thing. If you are a baseball fan you may remember that he retired 2 HR short of the magic 400 that likely would have guaranteed his election into the Hall of Fame; he could no longer stand to be the shell of his former self and so he went home rather then extend his career with PEDs.

Dale Murphy is a good man who did the right thing.

We have been living in an age of moral equivalence for a very long time. Certainly no less than 30 years. A time in which the ends justify the means. Something is not really wrong if it was done by or directed at the right people. Generations ago one could enunciate a coda of what was nearly universally recognized as good, as right. Be honest. Don’t steal or cheat. Work hard. Don’t cause harm to another on purpose. As a society Americans had an ethic of working together toward a common goal, a common idea of what was good. None other than de Tocqueville observed this and included it in his historic musings about America and Americans. As a people we had a sense of what was right and what was wrong, a clear understanding about the difference between good and bad for a couple hundred years. Sometimes we got it wrong, but in general we strove as a people to be better.

This is the place where naysayers jump in with comments about various types of discrimination, about groups for whom this ideal was simply not a reality. I fully acknowledge these facts. Racial discrimination was terrifically worse in previous generations, as was the unconscionable treatment of women (entire categories of people could not vote for 150 years). All true. Still true. But as de Tocqueville anticipated, there has been an inexorable (albeit painful and often excruciatingly slow) movement toward more of better. It has hardly been a straight line from bad to better, but that is the journey we have taken.

Dale Murphy is looked upon with a kind of wonder, as if he and his life are somehow not of this time. Marry someone you love. If you have a family prioritize raising your children to be good citizens who know the traditional difference between good and bad. Be honest. Don’t hurt people. Be kind and generous to those outside of your family whenever you can. Do these things in a quiet manner, not out loud in self-aggrandizement as you build “your brand”. There are certainly others who fit this mold; Denzel Washington and Neil Patrick Harris come to mind. Lots of no-name folks, men and women  you will never meet who will never be famous are doing the same thing.

You could say that what I bemoan about our present society has always been thus; that I, we,  simply know more about it now because of newer, freer information streams. I cannot argue against this possibility. Still, it seems as if even knowing this, that a return to an acknowledgement that there is a clear difference between good and bad, between right and wrong, can only strengthen the fabric of our society. Different, on its face, is neither good nor bad, it is simply different. Something that is unattractive or distasteful may be just that and nothing more. We can disagree in the great middle. Good and bad is bigger than taste or style or personal preference.

In the dark we are all the same. We live together unseen. We have the same dreams and the same fears. Though we cannot see we still feel. Right and wrong are different. There is such a thing as good and bad. These things do not change when the lights are turned on. Seek the good. Do the right.

I’ll see you next week…

–bingo

 

 

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