Random Thoughts from a Restless Mind

Dr. Darrell White's Personal Blog

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Cost, Convenience, Quality: Paying for Healthcare in the U.S.

At the moment I am sitting in a hotel in mid-town Manhattan, between speaker slots at a convention and wishing I’d accepted a less ambitious schedule. Typical of me when away alone, I’m trying mightily not to get on an early flight home. Still, as predictably homesick as I may be, it is good to once again be out “in the wild” among my tribe of eye peeps as we seek more and better ways to stamp out all manner of blinding disease.

While we rail against the vagaries and insults rained upon both patient and doctor by the healthcare payment “system” that exists in the U.S.

Last night I had a very illuminating conversation about some of the maddening nuances that exist in the endless games played by the government and health insurance companies as they plot to thwart the makers of pharmaceuticals and devices from being paid for the use of their products. These producers of products respond with gamesmanship of their own. This, in turn, creates vast inequities in access to both drugs and devices for patient that need them. Safe Harbors compete against Most Favored Nation clauses while middlemen called PBM’s extract a toll at every juncture of the process. Doctors (and their staffs) bend under the weight of misdirected blame and bile for treatment roadblocks they neither built nor can they demolish. Frustration rules the day.

A while ago Beth and I had a rather spirited discussion about how we in the U.S. might be able to pay for the healthcare of our citizens. Being ever practical, and also owning the job of writing the checks that pay for the “health insurance” our company offers its associates (including us), Beth in effect is arguing for a national consensus on something we might describe as a baseline ‘value’ for healthcare. Others would label her concept a ‘floor’, but you get the idea.

What Beth intuitively understands is the tension between cost, quality, and convenience. You pick a baseline or a floor and offer that to everyone. With training as a nurse and 15 years in healthcare administration, her idea of what constitutes the sum of cost, quality, and convenience naturally overweights the integers for cost and quality: outcomes should be essentially equal across the board at both the baseline or floor level, as well as any level that might be considered “luxury”. The costs of achieving that should be in some way equitably shouldered by something we could describe as “society”. Very practical. A strategy that lends itself to being observable and measurable. What’s the rub? Well, only two of the three elements that make up value are covered. To obtain an agreed upon level of medical outcomes (mortality, morbidity, longevity, etc.) the cost is covered.

Ah, but HOW you obtain those outcomes is still a variable. It is the FLOOR of value that is guaranteed. The cost of achieving that baseline universal outcome is covered, the “what you experience” in doing so is not. Our family experienced a bit of this with Beth’s Mom. She was living in a setting that provided excellent care at a reasonable cost, but in a setting that did not provide any extras; it was old, not very pretty, and had we not moved her she would have had a roommate. Her (and her daughters’) experience, what we might call “convenience” in our formula, was found to be lacking.

Therein lies the problem with any discussion about literally anything that we might discuss as a “right”. If we examine food, something we are very conscious of in the White house (Beth and I stopped eating meat 1 1/2 years ago) we find something quite similar. No one among us would say that X Million people should go without food. Indeed, we don’t even really talk about true hunger in the U.S. anymore, we talk about “food insecurity”, the concern that we may become hungry. By the same token, though, no one asserts that everyone is entitled to the same food experience. Not even a little bit. Even the most extreme in the “equality” set do not assert that EVERYONE gets swordfish if ANYONE gets swordfish; it’s the protein that matters and you can get that from a can of tuna. No, quite the contrary, all that is discussed is cost and convenience (access).

Now, of course, in my old CrossFit world (and to a degree in the medical world) it is argued that quality is an ineluctable part of nutrition, that one must extend the equation outside of food alone so that an explicit choice is made that prioritizes quality calories over other purchases. While this is accurate and proper we can reasonably define adequate nutrition as consisting of comparable protein, complex carbohydrates and beneficial fat and keep it separate from other needs, at least for the purpose of our discussion. “Quality” here would be more accurately be called the food “experience”.

How about medications? After all my conversation was with a team from a pharmaceutical company. A complete description of the morass that prescription coverage has become is way beyond the scope of this essay. Hewing closely to Beth’s proposition, each individual should have the right to obtain a medication (or device) that works. Consistent with my further interpretation of the three components of value, the floor of the care continuum is just that, the medicine that works. One should expect to shoulder the cost of more convenient forms of treatment. A 4 time per day pill versus once daily, for example.

The interplay between cost, quality, and convenience holds true in nutrition/food on a global, grand policy making level: From the value components quality, cost, and convenience, you can pick any two, but only two, when you are declaring what is the minimally acceptable level. As Beth intuits, this is similar in healthcare.

My formulaic approach to the coverage of healthcare needs has a little wrinkle that should be mentioned: quality cannot be increased ad infinitum. In all examples we might evaluate there is a practical limit to the ability to improve quality. The law of diminishing returns arrives in the form of asymptote as quality rises. For example, there is little statistical difference between 0.03% and 0.035% when we discuss the risk of a surgical intervention; it becomes similar to chance.

On the other hand, cost and convenience are unbound and can rise almost infinitely. Using an example which is more dramatic than my swordfish/canned tuna offering, alcohol in moderation is consistently shown to reduce mortality. Note that it is the alcohol in a drink that confers the health benefit; the same outcome occurs no matter what you drink. One person’s jug wine from Costco is another person’s Chateau Lafite served in the Gulfstream V.

You get the picture.

What will become of our conversations about issues such as healthcare? Will we arrive at a similar juncture to the one we have now in food, clothing, and shelter? Where quality (outcomes) and baseline cost are addressed and everyone is left to make their own call on convenience/experience (e.g. private or shared convalescent care room, filet mignon or a burger)? Beth can’t see how it can be any other way.

Me? I’m much less optimistic. That old “want vs. need” thing just keeps popping up. Confusion arises when a truly generous people confuse what people WANT with what they NEED. Need is measurable, and therefore finite, whereas want is neither. We can, and should, work to pick up the check for the true needs of each: equal outcomes at a universally affordable cost. “Want”, on the other hand, is the proverbial “free lunch”. I’m all for “a chicken in every pot” , but if you want yours to be Coq au Vin, you gotta buy your own wine.

There ain’t no such thing as a free lunch.

I’ll see you next week…

The Cardboard in the Shoes Kid

A reprise and an update on the weekend of my Dad’s passing 6 years ago.

My Dad would have been 90 this year. The “cardboard in the shoes kid” who grew up poor during the Depression and became the embodiment of the American Dream. We lost him six years ago yesterday, 10/9/2015, at 8:30 in the evening. He slipped away slowly and peacefully with my Mom and my sister Tracey present. Dad was something of a medical miracle. He survived a 4-jump bypass at age 54, lost a kidney to some weird cancer undoubtedly caused by his experience as a nuclear test “observer” in the army in the ’50’s, and lived pretty well for a couple of decades while ignoring his diabetes. His active life slowly eroded due to terrible pain caused by spinal stenosis.

His life was effectively ended when he suffered the “never event” of a spinal infection from a pain injection.

Even though he didn’t actually die for almost 3 years, we lost the Dad we knew in the ER when he was given medication which turbocharged his otherwise very mild dementia. 3 months of hospitalization later the smart, funny, kind man with back pain who entered the ER was replaced with a fearful, angst-riddled guy who couldn’t remember if he’d had breakfast 15 minutes after getting up from the table. The sole consolation in the entire endeavor was that he not only was pain free from the surgery that cured his infection, but his dementia was such that he had no memory of ever having it.

We had two and a half years to prepare, a kind of “pre-mourning” if you will. Don’t believe it. There’s no such thing. Staring at the specter of a slow, tortuous decline with all of the indignities associated with it, I was still wholly unprepared for what turned out to be an unexpected and surprisingly quick demise. Nothing of these 2+ years of knowing left me the least bit prepared.

Some time ago I attended a talk on end of life care, the first in a lecture series honoring a friend I lost to cancer a few years ago. The talk was surprisingly moving, not only because it brought back memories of Ken but also because while attending it I knew I would likely lose my Dad in the not too far future, and I thought of my folks throughout the talk. What the speaker discussed as end of life care and end of life preparations also offered a very important take-away that I tried try to apply every day since, especially with my parents.

The speaker’s thesis is that one should say 4 things often and with ease, not only in the course of completing a life’s work or concluding a life’s relationships, but in the course of living a life.

Please forgive me. I forgive you. Thank you. I love you.

Sounds simple, huh? Maybe even a little trite. I’ve now spent several years thinking about those 4 essential things and about how they fit in a life that is not necessarily concluding (at least I hope not!). We are, each of us, part of a tiny little ecosystem; thinking about using these phrases encourages us to look outward and see the others in our own worlds whether we are approaching the conclusion of a life, or smack dab in the middle.

Actually, without really knowing it I’ve been on this path for some years now, probably guided by Beth and her inherent goodness. Friends come and go; either way I’ll likely feel a sense of completeness in any relationship if I remember these 4 things. Patients and staff do, too. I think I’m a pretty good boss and pretty user-friendly for patients as far as specialists go. Bet I’ll be better at both if I’m thinking about these, even just a little bit, even now.

Please forgive me. I forgive you. Thank you. I love you.

I hope, sweet God do I hope that I remembered enough, said these enough. I pray that I remembered to say them to my Dad before he lost the ability to remember that I said them. Don’t wait as the end of someone’s life approaches to say these four things. Don’t wait for the conclusion of your life before you think about these.

Richard E. “Dick” White 6/21/31-10/9/15.

I really loved my Dad.

Happiness is the Ultimate Non-Zero Sum: Sunday Musings…10/3/2021

1 Anorak. Greek for geek or nerd. You thought it was just a pullover too, didn’t you…

2 Ryder Cup. I always miss my Dad the most when stuff like the Ryder Cup is being played. An event that brings back memories of a special time I got to spend with him doing something he loved. This particular one was also shared with my brother and one of my brothers-in-law when we spent a weekend together at Oak Hill in the fall of 1990.

I want to talk to him every day. Hear his voice. See his smile. All the more so on a day like Ryder Cup Sunday when we would have watched this year’s matches together and reminisced. It’s days like this that make it hard.

I miss my Dad.

3 Happiness. “We should allow others to expand and contract without taking it personally.” –Kasey Musgrave

Life, liberty, and the pursuit of happiness. The three pillars upon which our country was built. It bears repeating that we are only guaranteed the right to PURSUE happiness; we are not guaranteed the happiness itself. The great conservative writer George F. Will posits that the pursuit of happiness actually IS happiness, though I doubt he’d get much uptake on that from the masses.

At the moment I am sitting in an airport with the love of my life, on the way home from visiting our daughter and son-in-law. I am quite happy. Belly filled with something called a “womelette” (an omelet poured into a waffle iron), couple of newspapers nearby, TSA successfully transited. We checked in on our new “toehold” here in the low-country, a small condo about 20 minutes from Megan and Ryan. Nothing special, just a place to call our own when the time comes that we can travel for more than a week at a time. Seeing it for the first time made us happy. Taking the 10 minute walk to the beach (and dreaming about an electric beach caddy) made us happy.

Our happiness does nothing to detract from anybody else’s pursuit of happiness.

In my travels, and those of my oldest friends and acquaintances, I have come across scores of people who are truly happy. Capable of feeling and giving in to joy. It’s such a special thing to see, and even better to in some way feel a part of that joy, wherever it may be from and whatever may have brought it to life. It’s out there, you know. Sometimes it’s subtle, as gentle and quiet as the proverbial footstep of a butterfly landing on a leaf. Other times it is raucous and riotous and simply blasts through your space like a runaway train.

We took in an R&B performance like that last night.

Sadly, there are others out there who resent the joy in others. Whether they are themselves happy or not so much, the happiness of another feels to them like losing. It’s more than envy in these unhappy people. For these folks it’s as if there is a finite about of happiness and joy in the world; no matter how much of either they may have at any one time they cannot see another’s joy without feeling as if it is somehow draining the reservoir from which they may drink some time in the future. Weird, huh? They sometimes seem more fixated on the blessings of others than on their own, so much so that their own joy slowly seeps away.

Happiness and joy are not limited resources. Quite the contrary. My happiness, my joy is not predicated on your unhappiness or your sorrow, and vice versa. Heavens, if one person’s happiness could come only from another’s despair we’d have long ago slipped into a rather dismal anarchy. No, joy is the ultimate non-zero sum measure. More than that, joy is an exponential multiplier. When you find or see joy in someone else and that vision makes you happy, the amount of happy you get is a full order of magnitude greater than it otherwise would be. If that joy and happiness should come to someone who has lately had little of either, well, that’s just that much better.

Life is pretty good around Casa Blanco right now; Beth and I are returning refreshed and renewed from our too quick trip. Beneath our masks (after all, we’re in an airport) we are smiling ear-to-ear. As much as I’d like to think that means it will always be thus, that’s not how life works. We will “expand and contract”, too. Regardless, if I should stumble upon you in the midst of something joyous, you can be sure that no matter what happens to be going on in my little world I’m surely not going to resent you or your joy. Quite the opposite.

Whether the skies be cloudy or eggshell blue, a glimpse of the sun always warms everyone there to see it.

I’ll see you next week…

Bucket Lists

This weekend has been filled with investigations of where Beth and I might land for different parts of the year once my full-time work life comes to a close. For some people this is the ultimate bucket list pursuit: where will I retire? Or if you are a Clevelander or denizen of some other locale far to the north of the Mason-Dixon line, where will I spend my time as a “snowbird”? (In case you’re wondering the leading candidate is Bluffton, near our daughter Megan.)

But I don’t really think I have a bucket list. At least not a proper, traditional bucket list filled with items I’d like to check off before I check out. Beth has an informal one (we knocked off fly fishing in July); her really big remaining item is to visit Alaska and North Dakota and thus lay claim to membership in the elusive “50 State” club. The closest I have to a bucket list is my desire to help Beth knocks this one off.

After a lifetime of planning events, packing vacation trips with as much motion as possible, trying to visit the newest, bestest restaurants and “in spots”, now 78I can barely be bothered to answer the question “how would you like your Sunday afternoon to go?” let alone come up with a bucket list.

Duke divinity professor Kate Bowler was handed the terrible news that she likely had a terminal illness. Well-meaning mental health clinicians counseled her to create a bucket list of items to pursue as a way to “find her meaning.” She comes to view this advice with something much stronger than skepticism. “A bucket list disguises a dark question as a challenge: What do you want to do before you die?” She wonders if the focus of one’s life really ought to be the collection of experiences. “[I]t is much easier to count items than to know what counts.”

Our weekend up until Beth’s well-meaning inquiry about my Sunday afternoon desires illustrates what counts for me, for us. On Friday we drove 3 1/2 hours to join our closest couple friends for dinner. Now, anyone who knows me even a little bit knows that I loathe driving. But at the other end of that drive was a dinner that our friends Bill and Nancy really wanted to share with us. After a very short night it was back in the car for the drive home so that we could…wait for it…drive an hour to celebrate another couple’s 25th wedding anniversary. What counts for us has always seemed to be more about the “who” than the “what”.

Yet I can see the issue. Feel the pressure. “You must want to do something.” To which my response seems to pretty consistently be “sure there is”, as long as I’m doing it with people who mean something to me. Who count. When I look back I do actually remember what I was doing, but I always seem to remember stuff better if I was doing it with someone I cared about. I once read that we may not remember the details of our experiences terribly well, but we always remember how we felt at the time. Being with the people who count always seems to come with more intense, and ultimately more positive feelings.

A bucket list seems kinda like a scorecard, doesn’t it? Having an elaborate bucket list seems to promote a kind of scoring of the rest of one’s life. At least for me it might. Did your decisions pan out? Especially the big ones, the ones that came at a true crossroads moment. Each one of those decisions put you on the path of a singular life to the exclusion of all of the other lives that might have occurred had you chosen otherwise. Those lives may take place in a parallel part of the multiverse postulated by quantum physics and brilliantly illustrated in the Blake Crouch masterpiece “Dark Matter”, but in our one life each decision effectively ends an infinite number of other lives you might have lived. Is the encouragement to curate the remainder of life via a bucket list of big moments also a call to assess the road that brought you to the first item on your list?

Not for me. At least not by way of scoring or grading the journey, although I do enjoy recalling highlights, or those times when I, or some “we” I was part of, persevered or overcame. In this I find myself in sync with Dr. Bowler: “What strange math. There is nothing like the tally of a life…Our lives are unfinished and unfinishable. We do too much, never enough, and are done before we’ve even started.” On occasion a day may be hard, but for the most part they’ve been either good or great (HT Lance Armstrong, early post-cancer). Therein lies the single item on my bucket list: time. More time. I find myself immensely grateful for the time I’ve had. Profoundly fortunate to have been able to spend that time alongside Beth with people like Bill and Nancy. Our family. What particular moment, what specific experience, what winter’s nest is so special that it warrants a place on a bucket list?

My bucket list is nothing more than to be with the people in my life who count, making whatever time I’m fortunate to have left with them count for us all.

The Tyranny of Expectation

“What would you do if your didn’t live here anymore?”

Sunday morning breakfast on the porch are usually rather easygoing affairs. A little Facebook here, a bit of the Sunday Times there. “What are your plans today” constitutes high pressure conversation. Not so much this morning after my darling Beth dropped this little bomb into my oatmeal!

“No, really, you’re not really content. You’re antsy and I can’t figure out why. We’ve been talking about winters, about the last chapter, where and with whom we’ll be and why. What would you do differently in Florida or Bluffton or wherever?”

Doubling down as that splashed in my coffee. What, indeed, would be any different anywhere else?

To answer that requires me to look in a very critical and brutally honest way at where I am, what I’m doing now, and why it seems to both of us that I am on edge. We have no real roots where we live, at least not the kind of roots that one is tethered to when you are living in a generational location where it’s not just you and subsequent generations that are presently domiciled. With two sons and their families here the seeds for that generation have been planted, and of course the opportunity for us to cultivate that exists. We have friends and acquaintances, most of whom are also not born of this exact soil. In our ever on-the-move society those friendships are the de facto family roots for many.

Why, then, the angst? Why not satisfaction, even a sense of triumph? As a couple we chose to forge our own path away from family at near and successfully launched 3 offspring into the world with no local assistance (note: we chose this; there is no criticism whatsoever of either of our families in that statement). We survived my leap beyond the leading edge onto the bleeding edge of business models in the world of my day job, avoiding ultimate financial calamity and arriving at a place of comfort and likely security. The whole “where do you want to be” and most of “what do you want to do” is possible because of this.

We spent a couple of hours this morning pondering this. Every place we might go there is something that Beth does, something she knows and loves. there to be had. As we went round and round looking at me, my choices as well as changes that feel like they were forced on me when they arrived, we inexorably return to the same conclusion: location, for me, is irrelevant. What matters is only what I decide to do there. And not only in those hours of the day when I am solely responsible for the filling, but also as the day carries over into our shared time as a couple. After all, the happier and more fulfilled and content I am coming out of those “solo” sojourns, the happier and more content I will be as a partner.

So what is it then? Could it be regret? Has my happiness urn stealthily been aerated by regret and become a sieve? I don’t think so. Regret, at least to me, seems incompatible with any happiness at all, and to be honest I am more happy more often than not. I’ve done one really big thing really well over the years and that’s my part in our marriage, our partnership. That makes me happy every day. It’s the kind of partnership where one of us can look at the other and say “what’s wrong” and not have it sound like “what’s wrong with you.”

No, I think it’s one of the other scourges that probably would get classified under the Great Seven Sin of coveting: expectations. I think that deep down I have a case of miss met expectations that are quietly gnawing at me. Again, these are not, and I certainly do not look at them, as true hardships. Not in the classical manner of hardships. Nobody has died prematurely. Not only do we have a roof over our heads, but that roof faces an inland sea. I eat well, and I eat of my own choosing. Heaven knows I drink well. These expectations are not existential. They are personal, emotional, almost entirely self-centered, and in many instances so nebulous that even the most caring, selfless and generous soul would be completely thwarted in any effort to resolve them.

These expectations exist despite a lifelong effort to live without any expectations whatsoever. Disappointment is a metaphor for miss met expectations. The more I think about it the more it seems like my state of mind is being driven by disappointments that have been created by expectations that I have either consciously or unconsciously created for myself and others. Some are nothing more than bad luck; I trashed my right shoulder in 2008 and haven’t been pain free enough to swing a golf club until very recently. Without a private club to call my own, I very much still had the expectation that I would continue to have golf as a core activity that would not only bring me joy, but also bring me people who brought me joy. Not only that, I very much expected that a I would continue to be a very good golfer. Not playing golf separated me from an experience I had expectations of continuing. I don’t know what to think about playing post-injury, just that I know it’s not what I expected.

I’m disappointed to find myself in the position of having to work. Sounds rather arrogant when you put it that way, doesn’t it? Still, the reality is that I have made a couple of decisions about my working life and work circumstances that were epic disappointments. If they had all turned out as planned would I still be working? Probably. I really do like what I do, and it’s always satisfying if you are not only good at what you do but are continually thanked by the people you do it for. What is disappointing is that I can’t really do it just for the pleasure of doing it, you know? All of the regulatory BS and the manufactured nonsense about what’s “wrong with medicine” would be so much more palatable if it wasn’t forced down your throat because it’s a job you need. Subtle point to be sure, but looking back it seems like I had a quiet expectation beginning very early in my adult life that I would be able to walk away at this stage if I chose to do so.

What’s next then? It’s a bit scary to be honest since so many of my expectations about where I’d be, what I’d be doing, and with whom I’d be doing them haven’t come to pass. Lives evolve and the game board changes, eh? We never lived around family and now we do. What’s that gonna look like? Likewise our friendships here in town and elsewhere. Everything changes as I’ve said so many times, and yet the most honest assessment I can offer is that I’ve probably expected that they would all stay the same as they were when our kids were in grade school. Or maybe they’d be like the ones my folks had, a stable group of couples who congregated around a couple of similar interests and a bucketful of shared, or at least similar experiences. What are ours really going to look like? Beats me. Past performance means that at least some of my unspoken expectations are already way off the mark.

So my Dollie, the answer to “why?” is disappointment. Expectations I barely knew I had weren’t met and I’m disappointed. What am I going to do about that, here at Casa Blanco, in South Carolina or wherever? Well, I’m not gonna get anywhere unless I man up, face the fact that disappointment is a damaging as regret, and move on. Like Rafiki said: it doesn’t matter; it’s in the past. I can swing a golf club without pain, however poorly, and that means I can hang out around golf and golfers again. My job is enjoyable, bureaucratic BS notwithstanding, I can see the fruits of my labor, and I come home with thankful people in my wake. Not everyone can say that. We have children and grandchildren to fill our days with wonder and love. Friends with whom we do, indeed, have shared memories and experiences upon which we can build, and a lifetime of practicing our philosophy that you can never have enough friends.

I don’t think the “where” matters. Not as long as I leave behind disappointments however big or small they may seem. Like regret, now that I’ve identified the issue of expectations I can address it. Go all Timon and Hakuna Matata on it. Or channel Myamoto Musashi: “Accept everything precisely as it is.” “Where” isn’t an issue as long as “where” finds us together. I’ll figure it out and I’ll make it work wherever it is we happen to be at any time. Because nothing about us has ever been a disappointment and no matter where we’ve been everything about us has always made me happy.

I feel better already.

Memory Serves

“I used to remember everything, but now I only remember the things that never happened.” –Mark Twain.

Twain never disappoints, does he? There’s all kinds of meat on that bone. Is he saying that he no longer remembers things that really happened, only those things he imagined at the time, or imagines now? Or is he rather saying that looking back on his life he only remembers those things that SHOULD have happened, but didn’t?

Knowing Twain, my bet is that his answer would be:”yes.”

Memory is a funny thing. Partly accurate reportage, one’s memory is leavened by equal parts wishful thinking and regret. At least according to Twain. Think of your own narrative, the telling of your story. How much is fact, how much is embellishment (never let the facts interfere with a good story!), and how much is what you wish had happened? We were telling stories at dinner the other night, stories we all knew, ones we’d all taken part in creating and ones we’ve told countless times. Each time they are told they get a little better. Does this happen with you? Some of the stuff in our stories probably never really happened, but we remember it just the same.

But Twain also touches on regret in this quote, don’t you think? Things that could have been, or should have been, but for one reason or another, never were. Dangerous ground, that. Regret can turn the urn of happiness into a sieve. In his later years Twain was said to be increasingly bitter. One wonders if his regret fertilized the weeds in the garden of his memory.

Ticking time bomb, or soothing balm over time. Memory serves.

Sunday musings…7/25/2021

1 Frustum. Part of a pyramid or a cone remaining after the top has been cut off. No reason. Just a cool sounding word randomly encountered while reading about a new building in Chicago.

Built by stacking Frustums.

2 Volunteer. Random plant growing in an otherwise homogenous crop field. Often useful, like an cornstalk. Pretty sure I’ve mentioned this one (from my mother-in-law) previously.

Just too cool not to mention again after passing a few to and from the barn.

3 Invitations. My daughter once said of the “snobby pops”, the cool girls in high school, that they never really graduate, they just move. What she meant, of course, is that many of them never again reach the heights they perceive that they have reached in high school, and so they never really grow beyond what it was that made them popular in the first place.

They just move to a new “school” and play the same tiny games until it’s time to move again.

4 Costs. No matter how you shake it, obtaining healthcare in the U.S. costs a lot of money. Popular perception has it that doctors, and what doctors are paid, represents the lion’s share of those costs. Interestingly, no matter where I look, the highest percentage of healthcare costs associated with care by doctors (office visits, etc) is 22%. The lowest is usually somewhere around 15%. These are % of costs, not doctor salaries; one must remember that the fee you pay for your office visit does not translate directly into your doctor’s salary. Overhead expenses such as rent, staff salaries and the like come out of that fee, too.

Still, 22% of $2.5 Trillion is a lot of money. If you get in an accident, or you are diagnosed with cancer, your doctor bills are the least of your worries. Health “Insurance” was designed to cover these big ticket events. By and large, it does, if you have health insurance. Most of us won’t need this part of our policies. What those policies do is pre-pay for what is largely health maintenance, with the occasional modest trip to the repair shop (for example, cataract surgery). In these cases, even if you have a very high deductible (the amount of money you pay out of pocket before your insurance company starts to pay your bills) and you write a check for the entire amount in your bill (for example $1496 for standard cataract surgery), your insurance company has negotiated that bill way down from the “list price” (again, cataract surgery, ~$8000).

Here’s (part of) the rub: if you don’t have any health insurance, nothing from your employer or the government like Medicare, the largest healthcare organizations typically demand full price for your care. This is particularly true of our most famous non-profit medical institutions like Yale, Harvard-Pilgrim (Partners) Health, and our local behemoth the Cleveland Clinic Foundation. These institutions have taxes forgiven that are on the order of 10 times the amount of discounted care they provide to the community, even when that care is computed using their outrageous list prices.

This treatment of cash-pay, uninsured individuals by large, powerful for-profit and non-profit institutions is unconscionable.

In my reading I came across a very interesting idea. The Wall Street Journal did yet another exposé on this, once again focusing on Yale (they don’t seem to learn). A follow-up letter to the editor from Paul Horvitz, a professor at the University of Houston, offers an elegant solution: allow health insurance companies to sell products with an infinite deductible, or one that is so high that it only covers true disaster care (e.g. cardiac bypass).

Most of your insurance premium isn’t buying you real insurance; as noted above you are simply pre-paying for your healthcare services. Some of the remainder of that premium covers the processing of your claim. Neither of these expenses would be borne by the insurance company if you are going to pay for your care out of pocket. What they would be doing, though, is selling you the right to pay for your care using the rates that they, the huge insurance company, have negotiated.

Like $1496 rather than $8000 for cataract surgery.

There are certainly details that would need a bit of working out before something like this was ready for prime time. Imagine, for a moment, if this “negotiation for hire” plan was coupled with a more robust Health Savings Account, for instance. I think I’ll chew on this a bit and then revisit it when I’ve worked through some of the likely objections. It’s interesting though, and Dr. Horvitz is to be congratulated for the idea.

5 Three Rules. It’s always a huge compliment when something I’ve written or shared is passed along to another generation. Even better when the passing along is in a setting that is similar, or identical, to the original. So it is that I harken back to the days of my residency at NYU and world famous Bellevue hospital, transported by a note from my friend and colleague (and former junior resident) Dave, who has taught ophthalmology residents for 30+ years now.

Dave was a year behind me at NYU. He was (and is) brilliant in every respect, except for one, at least at that time: he was categorically incapable of holding his tongue when he was right. Mind you, Dave was (and is) right nearly all of the time. His meteoric rise in academia and the myriad alphabet organizations that run our world is testament to the fact that he has acquired this skill, acquired the ability to gauge when it will be most effective to share his thoughts and hold them until such time is nigh.

What Dave shared with a young resident in whom he sees the seeds of leadership (and perhaps greatness) were my three rules for surviving, and perhaps thriving, in an organization or institution: Knowledge is power. Perception is more important than reality. Evolution is better than revolution. Like any set of rules mine has caveats and exceptions, and it has evolved over the years. But as a strategic building block upon which you can construct your tactical responses, this list is as good as any others I have encountered. It has served me, and Dave, very well over the years.

I used to say the the more knowledge you had, the more likely you were to succeed in any organizational structure. As the years have gone by I find that the power inherent in knowledge, or more precisely information or intel, is dependent more on the quality of the information than the quantity. Being in possession of nearly all of the information necessary to make a proper decision or foray, but not holding that key bit of knowledge that forms the crux of the issue, is akin to not having any knowledge at all. Since we do not even possess the information crunching ability of our phones, Power comes from having the right knowledge. The actionable knowledge. Still, what hasn’t changed is the absolute absence of power you face when you are not read in to all of the information necessary to make the decision that is most right for you.

Once you have enough knowledge it is time to learn what everyone around you perceives. How do they see the situation? To lead one must understand not only the cold, bare reality of what is on the ground before you, but also what and how those around you THINK is the reality. I’ve admitted in the past that this, too, may fall under the “knowledge” axiom, but separating it out emphasizes its outsized importance. It’s awfully hard to lead from spot #1 to spot #2 if your group is convinced that they are presently sitting on “M”.

Finally, in general, evolution is a better route to effective and lasting change (hopefully improvement) than revolution. There are certainly circumstances where revolution cannot be avoided; I’ll leave it to you to reflect on some historical note or another that proves the exception. But there is so much damage, much of it collateral damage among “non-combatants” in revolution, that it has to be an awfully big deal bad thing you are hoping to change to lead the revolution. In our case back in the Bellevue days Dave was almost certainly trying to solve for a chronic administrative barrier to providing care or receiving an education, or both.

Once again let me emphasize that Dave was almost always right. In the end, by acquiring the proper knowledge he saw where the power to make the change lay. Seeing the issue through the eyes of everyone else involved allowed him to avoid the obstacles erected along the straightest path to success. By biting off small pieces of the problem, each small step leading inexorably to the proper change event, whatever it was that Dave sought to change was achieved in such a way that it came to be seen as the only plausible outcome possible.

While I admit a bit of “discoverer’s bias” these three rules work in almost every group setting. Work, family, your Sunday softball league…doesn’t matter. They’ve worked well enough for me, and for Dave, that they are still being passed on to the next generation of young people who will lead us all through the next evolutions.

I’ll see you next week, a week made better by the evolutionary changes you have brought about through obtaining the key knowledge necessary, and seeing the problem not only as you see it, but as others around you see it…

“Expiration Date”: Sunday musings…7/11/2021

1 7/11. Heh. Always makes me laugh when I come across these numbers together.

Can’t remember the last time I was in one, but still.

2 Huber. Getting a lift from one of those ubiquitous golf carts cruising around at a horse show. Horse Uber. Right? Right?

Should be a word.

3 Aren’t you? It always tickles me when someone recognizes me. Not that it’s a very common occurrence, at least not any more. Maybe once or twice a year at a conference, especially if I’ve done a couple of professional videos around the same time. In the CrossFit world, back in the day, it would happen pretty much any time I showed up at an event. I was always tickled when it happened.

Walking around the show grounds with Beth and her trainers it was cool to see them recognized by folks from all around the horse world. The twist, though, was having their HORSES recognized. Again, pretty cool, but totally foreign to any of my experiences anywhere, ever.

Still a rookie at this game.

4 Expiration. As in expiration date. For whatever reason I’ve come in contact with several people who have received dire medical diagnoses with a terrible prognosis. Really, nothing short of being presented with your own expiration date. A couple us who’ve been more fortunate got to chatting about this on the way to dinner after yesterday’s show sessions. You know how it went, of course:

What would you do? How would you structure the rest of your life if you pretty much knew what “the rest of your life” was going to look like from the calendar’s point of view?

There’s nothing really very new or unique about this question, of course, and it’s quite likely that when I’m done writing this morning I won’t have covered any untrod ground or come upon any revelations or epiphanies. But still, the question is out there and it’s rather interesting that it has come to rest in the “Restless Mind” while I’ve been doing mental gymnastics around the issue of finding new ways to occupy myself when/if I hang up my professional spurs. What would your days look like, how would you paint the final canvasses or pen the final chapter if you pretty much knew when the show was going to close?

There’s a very poignant song, I think it’s by Graham Nash but it could be David Crosby, titled “Encore”. It’s about leaving the stage behind but carrying on with the rest of your life. More like #2 up above, “aren’t you?” or “didn’t you used to be?” than “clock’s ticking”, and more in line with a healthy retirement. I thought I’d address that until I met another soon to be released soul, and to be honest I think the “expiration date” is bringing a welcome clarity to my “Encore” internal dialogue.

Like everything else there are poles to the question. Extremes, if you will, on either side. The person I’ve been with this weekend is simply ramping up the intensity of what you and I would see from the outside as their “regular life”. They go to work, although maybe not quite as often or for quite as many hours each day. There’s been no effort to check off any bucket list items. No fantastic or fanciful travel. Dinners mostly at home and only on the road if the destination is family. To be sure there are no sacrifices being made, financially or otherwise; if there is something there to be had in the moment that will make that moment a bit more special or memorable, whatever it is gets “had”. No fools are suffered, although what little I know of this person leads me to believe that they’ve not suffered fools any time anyway.

On the other end of the spectrum, I went to college with someone who was presented with a diagnosis that had a high likelihood of causing a calamitous end to the journey at any moment. No medicine or surgery exists that can change the odds. This person could do literally anything they wished; the risk of disaster seems to be the same no matter what they do after they make their bed in the morning. Their choice was quite different: they retired when most of us were just barely getting going with our careers and our families, and they have been off on a lifetime of the kinds of adventures that the rest of us will put off until we are too old to even think of them, let alone pull them off. They suffer fools and pharaohs equally; it’s all a part of the journey when you can literally expire in minutes, any minute.

So what would it be for me, then? You may remember my friend who passed some years ago from cancer. The one with whom my friendship deepened in the brief 22 months between his diagnosis and the day he died. It’s a shame that it has taken another dire diagnosis to see that my friend Ken gifted me with the answer to the question of an “expiration date”, as well as the answer to my interminable quest for some kind of meaning if or when I retire.

If I were to get stamped with my own expiration date I know now that I would simply live each day with the joys of being with Beth, our family, and our friends. Where I am or what I might be doing doesn’t seem like it would matter all that much. Heck, I’m sitting in an empty stall at a horse show, listening to an auction for young horses in Europe and picking straw out of my shoes. Not my personal groove at all, ya know? And yet, I am happy. Content. What I am is content in a place and around an activity that is not me or mine because I am around people who dream of being here and doing this. These people are mine, and I, theirs. I am literally basking in their happiness.

Why would I want to be anywhere else, or doing anything else, no matter when?

Silly, this, to find myself with this answer as if I needed to be looking for it, since I come around to this “answer” so often, here and elsewhere. We all have an expiration date, after all. It’s just that most of us don’t know when it is. Blessedly, myself included. If we do, certainly if I do, I just can’t find anything other than my people to think about. Like Ken did. Be with my people doing the things we do that make us think of each other as “our people”.

I’m flattered and happy to have spent this weekend in the company of a person who has received their “stamp” and chose to include me in what time they have left. It made me smile to think of my college buddy, doubtlessly off on an adventure that will make us all a tiny bit jealous if not for the price of their “stamp”. In both of their honors, and in honor of Ken, it’s been a privilege to remember that it’s not really a very difficult question for me to answer if it ever comes my way.

Looking ahead I’ve already got everything I need to be happy with whatever time I have left, and looking back I’ve had everything I’ve needed to be content with the time I’ve had.

I’ll see you next week…

Fourth of July musings 2021…

There’s Something about the Fourth of July. Such a complex day around Casa Blanco, at least the part of Casa Blanco that lives between my ears. Many years ago the first two weeks of July meant a family vacation. We lived in a one-company town; American Optical shut down for the first two weeks of July and the town pretty much did, too. Little League games went on hiatus. Everyone who could left town.

When I was super young my maternal grandparents would scoop me up and take me to their Jersey shore beach house for a week or two in June. My folks would then come in on the first and we would have a cottage in the town next door for the two week holiday. Funny, but I just now realized that we almost never saw my grandparents during those weeks even though they were just one town over. I have no memory of fireworks there, either with my little family or my grandparents.

We spent every day on the beach. It must have been funny watching our little caravan of kids carrying chairs and an umbrella. Mom or Dad pulled a wagon with a classic styrofoam cooler containing tuna sandwiches and store brand soda. Full on sugared soda. There was an outing to the boardwalk carnival and miniature golf. I remember a Saturday dinner at Esposito’s near the beach in one of the other of the towns. The kids would fill up on the bread and my Dad would be furious when we ate maybe a bite apiece of dinner. Happened every year, our own little Groundhog Day at the beach.

Still, it’s funny that I am just now after more than 50 years realizing that the vacation was a single family affair. No grandparents, aunts or uncles, or other families. Just us.

Some time after my sister Kerstin arrived (5 years after Tracey) the beach trips ended in favor of Webster Lake in Massachusetts. Also known by its Native American name “Char gog agog man chog agog chabunga munga mog”, it was our summer vacation spot for 2 summers. Not many memories from those days to be honest. Our family was of very modest means in those days. What I remember is kinda like what I remember of the Jersey Shore–day after day of just hanging with my siblings and my parents near the water. Not many memorable outings. Well, no outings, really. Fireworks were a couple of Roman Candles my Dad fired into the lake.

Anyone who has read any of my stuff is familiar with what has come to be known as “Cape Week”. In truth what we call Cape Week is actually Cape Cod v2.0. In the waning years of our life in Mass and the first couple of Rhode Island years we spent the first two weeks of July on the Cape at a place called Radio City. As an aside my brother married a girl whose family had a home there right on the beach. Small world, eh? We crammed the whole fam damly into a two bedroom cottage (my folks slept on a fold out couch) with a classic beach community outdoor shower. My Dad cooked every meal on a grill he bought at a gas station on the way there. Fireworks? We sat in the dunes at the far end of the beach and watched as they burst over the public beach across the river.

Cape Week v1.0 was also pretty much just us. 4 kids, two parents. All of my Dad’s people summered just down the road, maybe 20 or 30 minutes away, in Buzzard’s Bay. Grampa White was there full time, and my Uncles Larry and Kenny had tiny cottages there, too (Larry would go on to retire there, and two of his daughters would spend at least part of their adult lives there as well). Did we visit them over vacations? No clue. I’m pretty sure they never came to Radio City, though. Just 2 weeks of alternating between beach and pool, basketball and tennis, each day bookended by Dad handling the kitchen duty.

Things changed once we all got to high school and started working during the summers. Kerstin is still bitter, or at least she feigns bitterness, that our “away” family vacations came to an end after one Radio City trip where I stayed behind to work. Leaving a teenager alone at home made Mom nervous, although we were all so afraid of my Dad that not a one of us would have dared to crack a beer at home, let alone throw a party. The 4th became just another working day for us, just another round of golf or day at the pool for my parents. We never did spend Independence Day on the Cape during Cape Week v2.0; the family that owned the cottage we rented kept that week for themselves.

Some things didn’t change though: Cape Week as we all know it was still just us, Mom and Dad and the four kids, our spouses and children. With rare exceptions visits from extended family really just didn’t happen.

There’s something about the 4th of July that resonates, isn’t there? Like we are all supposed to do something, SOMETHING, to mark the day. Preferably with some sort of family around. Several years ago I said I’d like the Fourth to be a “thing” at Casa Blanco. I really had no idea what that would mean, what it would look like, but I did the “Field of Dreams” thing, just sort of “built it”, and hoped family might come. How’s it going? Like I said up top, it’s complicated. Kinda like Cape Week all those years. Lots of moving parts, lives moving in and out of each other. There are no rules for my “thing”; Casa Blanco is Beth’s house after all, and “Dad’s 4th of July thing” is an open, casual, fluid invitation, not a command or call to action.

So how’d it go this year? I’m going with great. We saw all of my kids over the weekend. Megan flew in for the Fourth AGAIN! Dan arranged a “field trip” to a local winery where the wine was California good. My sister Tracey and Steve came with all three of their’s. Randy spent an afternoon playing all sorts of beach games with his cousins, just like Cape Week. The lake was calm and all the toys got wet. Fireworks? Compliments of the neighbors, thank you very much! It could have been any summer weekend at all, really, but it was the Fourth, and somehow that made it just a little more special.

And so I sit here with Beth, a cup of coffee in hand, and finish this version of “Sunday musings…” on a breezy Monday morning, happy to have had this Fourth. I close my eyes and the little waves on Lake Erie sound just like they did on the Jersey Shore and the Cape. I feel the sand between my toes on the beaches of my childhood. There are eggs scrambling in the bacon fat, and my Dad is burning the toast. Mom is reaching into the styrofoam cooler pulling out tuna sandwiches. Someone just got a hole-in-one at miniature golf. The wine was just a little bit better, the beer a little bit colder, the sun a little bit brighter. I open my eyes and I am here with Beth on the day after a Fourth of July weekend where just for a bit we had us all.

There’s something about the Fourth of July…

A Brief Father’s Day Visit From My Dad

Jason Gay, the WSJ sports columnist/comic relief editorialist gets it. He gets Father’s Day. No escape to the golf course or tennis courts for him. Jason is the father of two. No communing with the boys fishing or tearing up the backcountry on a bike for Jason. His idea of a great Father’s Day is to get his hands dirty in the act of being a Dad. Makes some muffins and mess up the kitchen. Pretend to plant some flowers so you can dig in the mud. Raining out? No problem. Rain means puddles to splash around in with the kids.

I like to think of Father’s Day as the day when I get to hang with my kids and just be Dad. It’ll be a bit weird this year as the gang is even more spread out than usual. Randy and Beth just landed in Florida with L’il Bug in preparation for an appointment early tomorrow morning. Megan is home in the Low Country, gearing up for a work week while keeping a watchful eye on her growing family of alligators in the back yard. Dan is hopefully going to get a few hours off (young lawyers don’t really have days off!) to chase after his two bundles of joy. I’ve heard from them all. My “extras” Alex and Whitney have checked in, too.

Being a Dad (and a Papi) is a joy!

Tomorrow, the day after Father’s Day, my Dad would have been 90. Father’s Day with him when my brother and I were young was pretty special. Dad was an incredible golfer; he gifted the game to my brother and me when we were quite young. We got to share golf with him on Father’s Day by caddying for him and three of his close friends until we were old enough to join him and one special buddy (my brother’s favorite loop) for a round. Randall and I got to see our Dad in his element, surrounded by loyal friends and joyful at his good fortune.

It’s been almost 6 years now since my Dad died. Six years since I’ve been able to wish him a Happy Birthday, a Happy Father’s Day. I think of him often, as I do my Father-in-Law who passed away in 2017. Here is what I wrote after visiting my Dad on Father’s Day, the last time I visited him for his Birthday, re-printed on Father’s Day as I’ve done each year since:

My siblings and I only need to remember one weekend each year when it comes to celebrating my Dad. His birthday almost always falls within a day or two of Father’s Day. So it was that I found myself in Rhode Island the past couple of days, in the company of my Mom and a guy masquerading as my Dad, a guy who was very curious about the new fella who’d dropped by for a visit.

Getting old is not for sissies, my friends.

Somewhere inside, deep inside, there’s still some of my Dad in the jumbled up connections of his mind, carried by the body that failed him in such spectacular fashion 2 ½ years ago. Dad is extremely intelligent, the only family member in his generation to have gone to college. Quite the athlete, he used football and the GI Bill to pay for school. Like so many in his generation he then worked, raised a family, and put himself through grad school. He won his club championship in golf twice at the ages of 50 and 60. No typo. Beat the reigning RI State Amateur champ on his home course for the first one.

As we sat on the porch of his house overlooking the par 5  14th hole, I had an ever so brief visit from that guy. From my Dad. Like a citizen of Brigadoon he came slowly through the mist of his mind to join me for a bit. We’d always bonded over golf. My brother and I never turned down an invitation to join him on the course, either as partners or as caddies for him and his buddies. It was quite a privilege to do either; my Dad’s most elemental essence was expressed on the golf course.

A light breeze was blowing through the forest in the back yard just beyond the rough. We chuckled at the golfers who failed to take the wind into consideration, sheepishly trying to sneak into our yard to retrieve their out-of-bounds second shot. Dad talked about caddying as a kid in the Depression. We both noted the absence of caddies as the foursomes passed in and out of view. It was really very nice.

I quite like the Dad of my adulthood. Quick to smile, slow to anger, unfailingly loyal and kind. It’s hard to imagine now how distant he was when I was a boy, his friendship as an adult is so easy. I’m not sure how long we sat there to be honest, nor when I noticed that he was slipping away. As surely as the village of Brigadoon disappears, the mist had returned to claim him. I got up, walked over to his chair, held his hand and gave him a kiss. I wished him a Happy Birthday and a Happy Father’s Day, hoping that I’d made it on time. That he was still there. That he knew it was me, Darrell, his oldest child. I told him I loved him.

He smiled and gave my hand a little pat as he disappeared into the mist.

I really miss my Dad.

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