Random Thoughts from a Restless Mind

Dr. Darrell White's Personal Blog

Cape Cod

High Standards

A helpful thought as I prepare to reengage as a practicing physician and surgeon, opening my office and welcoming both my staff and patients.
There will doubtless be plenty of folks with an opinion of what I do and how I get it done. Here is a re-post of how I will try to carry myself.

 

“When you go out that front door be the best version of you that you can possibly be.” Lisa F., MD.

My good friend and colleague Lisa says this to her son when he leaves the house each day, but this is applicable to each and every one of us every one of our days. Whether you are a kid trying out different versions of who you are while eating breakfast, or a fully formed adult off to work, what better goal can one have than to be your very best you?

“I have such high standards for myself, and I’m so hard on myself because of that, I have no room inside left over for someone to come in and judge me.” Again, Lisa F., M.D.

I think this is really, really important. There is a subset of humanity that just simply holds itself to an unimaginably high standard. They feel that they must not only do more, but they must do it best. Because of this they are frankly harder on themselves than is really fair. Indeed, if they saw someone berating another person the way their internal voice talks to them they would probably lead an intervention. It probably doesn’t matter what you do, there are people in your world who wake up every day knowing that they have set nearly impossible goals for themselves.

What sets my friend Lisa apart is her incredibly healthy ability to realize that she is already under the burden of living up to nearly unachievable standards, and that the outcomes she seeks are often outlandishly ambitious. Because of that she need not surrender to the tyranny of someone else’s opinion, “what they think of [her]“. Now to be sure Lisa is of unassailable character and moral fiber; such an approach is not healthy if utilized by a narcissist, for example. Nor does it mean that she is incapable of seeking advice or learning from another. No, what she is able to do is pre-forgive herself when her best effort may not reach her own very high standard, and thus inoculate herself against uninvited external judgement.

This is a powerful lesson for anyone who sincerely gives their best when they walk out that front door.

Funny, whether you are attending a medical conference or a CrossFit seminar, sometimes the most powerful, actionable, and lasting lessons are not necessarily those that are taught from the podium. Be always and ever open to all of the learning available to you. Hat tip to my friend Lisa for being my teacher today.

Contact Tracing: Lessons from the AIDS Era for Our World Today

“Harvey told me to find a bow tie for a preppy. I hope you like it. Thank you for taking care of him. He really liked you.” –Mrs. K. May, 1987.

90,000 died in the U.S. 90,000 Americans died of AIDS before life-saving treatments became available. First it was gay men, then people who were addicted to injectable drugs who shared needles, and finally people requiring transfusions who were unknowingly infected by blood contaminated blood products. All from a novel virus that seems to have “jumped” to humans from another primate. 100% mortality.

90,000.

Now to be sure, AIDS is a manageable chronic diseases treatable with a pill in the U.S. (and most developed countries), but it still kills–what?–a million people worldwide. Some of that is due to a lack of access to a diagnosis, and in those 3rd world countries where the diagnosis can be made there is a lack of access for a number of reasons to the effective treatments. In those cases AIDS is still 100% fatal. If a diagnosis can be made an AIDS “hotspot” can be cooled, if not extinguished, through a variation of something we are now all becoming quite aware of, contact tracing and physical distancing. Sadly, in many of those 3rd world countries where AIDS is still endemic, these very basic public health interventions contravene unalterable societal norms and culture; the virus spreads and people die.

What does this have to do with us today as we address a new, novel virus that as of yet has neither cure nor medical prevention in the way of vaccine? I’d like to share a little history from the earliest days of the AIDS crisis in America, and a little story about my own experience as a young doctor just starting my career in medicine. Let me first be very clear about my place in that history. I am a straight, cis, white male born at the tale end of the Boomer generation. At no time in my life have I felt the sting of real discrimination based on either something I am, or something I am presumed to be based on what I look like, what I do, or who I am (my father did face discrimination as a Catholic, something which was largely a historical remnant but the time I came of age). As such my story and my thoughts about both what it meant to be gay in the 80′s and the possible impact of contact tracing in an epidemic or pandemic are sympathetic, based on observation, only.

Looking back my first encounter with anyone I could say I knew was gay was in the first week or so of my freshman year in college. The phone rang in my dorm room (landline, rotary dial, no caller ID), and the caller addressed me by name and asked if I was gay. As I recall I laughed a little, thanked him for asking, and said that no, I liked girls. That was it. He said thanks and hung up. Now of course as a child of the 60′s and 70′s I had most certainly come across many gay men by the time I’d made it to college, I was just clueless to this fact. There was a teacher in high school who was “outed” by a couple of kids from school after I graduated; they saw him coming out of a gay bar in Providence one night. That was pretty much it.

For the most part I just ignored the fact that there were gay men (and looking back, women, of course). Without really thinking about it I guess I figured that if I was indifferent to this part of my college mates’ lives then pretty much everyone else must be, too. It never dawned on me that being gay might have very real, very serious consequences when it came to very normal stuff like getting a job. I was totally clueless, in reality to most things that didn’t have any direct impact on stuff happening inside my own personal little navel-gazing bubble. Like everyone I kinda knew who might be gay, but again, I was indifferent. Even during a year when what it meant to be gay on campus was the year’s issue the only time I really paid attention was when one gay male student was interviewed on the college radio station about being attacked for being gay by a fellow student chasing him with a machete. And only then because the machete-wielding student was one of my close friends taking out his anger at being dumped by a girlfriend by swinging his sword at the squirrels along the driveway.

For the record neither the shaken (but mistaken) young man nor a single squirrel was harmed in the “attack”.

And then came AIDS. Those of us of a certain age recall that the initial publication was titled something along the lines of “Acquired Immunodeficiency in Homosexual Males”, I think first in JAMA if memory serves. I remember reading it in the med school library. Heck, I may not have even been out of the classroom yet. My presentation at the conclusion of one of my “away” rotations in ophthalmology was on the ophthalmic manifestations of this disease, soon to be re-named AIDS. As an aside I wrote that hemorrhages and focal areas of ischemia (cotton wool spots) were the signature signs of the disease, a statement that was shot down as incorrect by the retinal attending in the room. Turns out that I was technically right; hemorrhages and cotton wool spots DO result from HIV, while the entities that the professor pointed out were actually secondary opportunistic diseases. During my residency at NYU/Bellevue 50% of the inpatients on the medical floors would have full-blown AIDS. Every resident would become an expert in all things AIDS-related in and around the eye.

But it was in my internship in medicine at Rhode Island Hospital (RIH, a Brown University affiliate) that I would learn what it meant to be a gay man in America in the 70′s and 80′s. There were very few AIDS patients on the floors at RIH in the summer of 1986. I had one very special patient, Harvey K, who was on my service each time he was admitted that year. Openly gay, Harvey had been one of the earliest activists in the gay community, speaking out initially on issues of discrimination in general, and then as his life was upended by AIDS, speaking out while he could on the plague that had descended on his community. Harvey was unfailingly kind, generous, and understanding of his rather unworldly intern, cloistered as I was in my cis-straight world. He answered all my questions about what it was like to be a gay man in those days; he was  brutally honest about everything, including some of the activities that  led to rapid spread of HIV from a relatively small number of initial individuals who harbored the virus but did not yet have the disease.

This is the part of what Harvey taught me that applies, at least superficially, with where we are today. In its earliest phases AIDS was a disease transmitted almost entirely through sexual contact. Public health strategies to address this kind of disease propagation had been pretty standard for decades by the time AIDS arrived. Once a diagnosis was made a detailed list of contacts was then assembled. These people were in turn tested to see if they had the disease, were treated, and their contacts were similarly identified for follow-up. Similar tactics were used in the early days of TB as well, even though TB (unlike diseases transmitted by sexual contact) was not as easily and successfully treated with antibiotics. Harvey gently pointed out that yes, contact tracing could indeed prevent an infected individual from passing on the virus, and it could also alert his contacts that they were at risk to acquire the disease. The disease was fatal, but that was only one part of the issue.

Since only one small segment of society was affected AIDS at that time, being identified as a contact meant being identified as being gay.

Remember, this was in a time when being identified as a gay man had very real consequences. Not only could it affect your employment, but it is reasonable to say that the majority of gay men were not “out”, either publicly or privately. Nearly every major religion openly rejected these individuals, and more than half of the states in the U.S. still had laws on the books essentially making it illegal to be gay. One of the very first protest movements organized by the new gay activist organizations was to stop AIDS contact tracing before it started. As a newly minted physician, enthralled with science and quite sure that standard public health initiatives were mandatory to treat this new epidemic, it was left to my patient Harvey to teach me about the reality of large-scale medical intervention on vulnerable populations.

As we fast forward to our world in these days of the Corona virus and the varying degrees of societal “treatment” applied at the federal and state levels it is first necessary to be very clear that being told that you cannot go to work if you had contact with someone who is  test positive is not the same as being told that you have been in contact with someone who had AIDS in the 80′s. Not by at least one or two orders of magnitude, not. That’s kinda like saying being Catholic in the 70′s was the same as being Black. Again, not the same.

But one thing that Harvey taught me is the same. People who are in the contact strand are afraid of more than just the disease itself. They are also afraid of what having the disease, or even being associated with the disease will do to their life. Will they be able to go to work? Feed their family? Whether or not they do get the disease will someone tell them who they can see, where they can go, and what they can do? For better or for worse there are an awful lot of misunderstandings about COVID just like there were about AIDS. If they are are identified as a possible COVID risk will people think differently about them? Remember, unlike the gay men of the 70′s and 80′s who had decades to thicken their skin and steel their psyche against these kinds of feelings, the people who will be tracked now (most without the knowledge that they are being tracked, or have triggered a tracking tract) are experiencing this for the very first time.

Again, the true consequences are small, one or two orders of magnitude less than that faced by gay men in the earliest days of AIDS. But I’m sure that Harvey, as gentle and kind and understanding as he was despite his reputation as a fiercely powerful activist before he became ill, I’m sure Harvey would suggest that we seek to understand why people may rebel against contact tracing today. Just as surely as he would then go on to teach anyone who would listen (and eventually those who came after Harvey taught everyone to listen), that this is different. That we do not have the same concerns that Harvey and his friends did back then. While we can certainly discuss how it would be done and how consent would be given, Harvey would say that in this instance the population that is vulnerable will only be helped by “by the book” public health measures.

Harvey and I became friends of a sort. He needed some really terrible things done to him while he was in the hospital and forgave me each time I had to do one of them. I spent a lot of time just hanging out with him when I was on call. He was very, very smart, and every story he told was one that I would never have heard in my life to that point. As I said above, he was very understanding and kind. I’ve written many times that I’ve tried to live a life without regrets, never looking back at decisions and wishing that I’d done something differently lest my life be altered today by that change long ago. You know, the Butterfly Effect. When Harvey was discharged for what we both knew would be the last time I told him that I wouldn’t visit him at home; I wanted to remember him as he was that day. Still handsome. Smiling. Well enough to be happy he was leaving. I told him I didn’t want my last image to be what we both knew was coming. In retrospect I wish I’d had more courage, for I’d very much have liked more time with Harvey. I know I shook his hand, but I can’t remember if I hugged him.

I still have the tie.

 

 

 

A Difference of Opinion is Usually Nothing More

This is from “Sunday musings…” 4/13/14, six years ago today. Seems just about right.

 

When did a difference of opinion become a de facto conflict? When did the evaluation of another come down to whether or not they hue to a fine line of agreement on a single, or a few, or G0d forbid every issue? When did this phenomenon then morph into one in which a difference of opinion then becomes the basis for labeling another ‘good’ or bad’?

Am I the only one who’s noticed this?

I’m not talking about a difference of opinion which is then followed by a concerted attack, one that forces you to identify the holder of the other opinion as ‘bad’, and enemy. There’s nothing new to see there. One only has so many cheeks to turn. Eventually you need to fight or flee an attack, but that’s not what I’m talking about.

On a personal, local, and national level we could once identify broad stroke issues on which we could generally base a level of agreement or disagreement, very few of which would be a ‘deal-breaker’ when it came to civil discourse. The first part of this, the existence of broad stroke issues, remains true. What is fundamentally different in my mind is how un-moveable many of us have become on ever more minute details as we drill down from the 30,000 foot view. All well and good, I suppose, to seek fidelity to an ever more granular level of agreement on whatever issue is at hand, especially in this age when we have ever greater ways in which to find and connect with people of a like mind.

What I don’t get is the subsequent labeling of any and all others as “bad”. Unworthy. Lesser in some way because they do not agree at every level with a particular–very particular–point of view. As I remember it the “80-20″ Rule pretty much applied to belief systems as well as business: if you shared 80% of your beliefs with another that was plenty good enough to allow a friendship, and certainly enough to inoculate against a conflict. Now? Seems like something more like the “980-20″ rule: only the smallest amount of the most trivial difference of opinion is permissible. Anything more than nuance between people and they’re going to the mattresses. Anything more than nuance and we’ve identified something other, something lesser, something to destroy.

What’s up with that?

You could say that anything other than full devotion to a cause or a concept or a worldview is not pragmatism but something more akin to weakness. An inferiority of spirit, perhaps. You could say that nothing other than full devotion to some grand theme or concept is acceptable and brook no deviation from a one, true path. I would say that the world is infinitely too complex to approach life in this manner. I would further say that to do so needlessly isolates you from people who might very well bring infinite joy to your life despite differential nuance or even a fundamental disagreement on one issue. Living and letting live rather than identifying a different opinion as identifying the other as an enemy might just mean a more pleasant life filled with more people who might be better described as friends, or at least friendly.

At the very least perhaps we could just agree to disagree and be on our way.

Easter Sunday musings…4/12/Pandemic

Sunday musings…

1) Indicator. The Sunday paper circulars are interesting. 2, 3, 4 weeks ago the Sunday paper was stuffed with the usual ads from drug stores, Home Depot and the lot. I couldn’t figure out if that was a hopeful sign. Typically there are 15 or more circulars; today there were 3. No mystery here; not hopeful.

The economy has capitulated.

2) Masters. It’s Masters Sunday. Each year I ask that it be ok for me to be allowed to check out from any responsibilities, take command of the TV, and watch the final round of the Masters. Not gonna lie, not having a Masters to follow this year was by far and away the strangest sports non-event for me. Bigger than no Opening Day, no Final Four. CBS has come to my rescue, showing the epic final round of the historic 2019 Masters. It’s almost normal. Beth is doing something useful, I’m bloviating via keyboard, as useless as can be, sitting on my keister watching Tiger.

For the first time in a couple of weeks it feels almost normal.

3) Lockdown. How long can our largest medical institutions in cities not yet “surged” remain at 50% census? I am told that the ophthalmology division at the Cleveland Clinic is down 80% in the clinic and 90% in the OR. In the community taking its lead from CCF it is 90% and 99%. The Clinic (and others such as the Mayo Clinic) are predicting annual losses exceeding $1 Billion at their institutions. Countless patients have seen carefully planned medical care disrupted, further inconveniencing them and their families, and in many cases causing significant financial hardship layered on top of that which everyone else is suffering.

Why the big draw downs in care? So-called “non-essential care” has been shut down, pushed out in order that supplies of equipment (e.g. ventilators) and material (e.g. PPE) be warehoused so that it would be available when the inevitable waves of sick patients are blown in on the winds of COVID. Again, I’m not gonna lie, this particular rationale is a bitter pill to swallow. Enormous institutions with the power to simply float their own loans and cover a loss are complicit in the egregious denial of the coming disaster, failing as fully as the federal government to stockpile what was necessary to be ready. My patients, my staff, and I are direct victims of their lack of vision.

What prevents me from being engulfed by bitterness at this particular aspect of the pandemic is the real reason that “non-essential” care was reasonably shut down and pushed out: medical offices, clinics, and operating rooms working under standard operating procedures are quite simply incompatible with any form of physical distancing. If I go to work and work is normal nearly a hundred patients move through the office in a typical day. Along with them come all manner of family and friends. On my days in the OR 15-20 patients will have surgery, again accompanied by family or friends. It’s not just the patients who are at risk due to the nature of busy offices and OR’s, but all of the staff and doctors as well. And trust me, an eye doctor’s office isn’t the place that all of those missing masks and other layers of PPE have been hiding out. We have been out of masks at our office for weeks. I could protect neither my patients nor my staff.

How long?

4) Compassionate. Again, Twitter is the double-edged sword of my quarantine life. There are some really super smart people hanging out there, and in the spirit of general goodwill most of them have been on their best behavior when “talking” with smart folks who aren’t necessarily smart in their particular area of, you know, smartness. Others, on the other hand, have been just as arrogant and dismissive as ever.

Yesterday I was engaging in one of many discussions of using medications that are either not yet approved for, or whose use for treating COVID-19 would be off-label. Newer medicines without a clear-cut history from which to judge safety pose one very specific problem: can their use in cases of last resort, so-called “compassionate use”, be justified while the option of enrolling randomized, controlled trials (RCT) is available. On the opposite end of the spectrum, is it OK to use older medications with a known track record that includes a very strong safety record in the hope that theoretical benefits will be proven to be actual benefits, again when the option of enrolling patients in an RCT is available.

No less that Dr. Anthony Fauci, the DC biocrat (my term for him coined last week) advocated for what he called the parallel course of doing both, enroll RCT’s and provide medications on a compassionate use basis, when he was faced with another new virus that was killing people at an alarming rate in the 1980′s. When the AIDS crisis was new he realized that waiting for the definitive proof available (though sadly not always forthcoming) from an RCT would mean that people afflicted with HIV and suffering from AIDS would die while the academicians calculated. Safer, older medicines where likewise studied as prophylactic medications in much larger study groups while at the same time being given to large numbers of individuals outside the trials.

When I posted that our present crisis, that includes both the terribly ill at high risk of death as well as the barely afflicted who may or may not end up in the ICU, was analogous to the 1980′s and AIDS I was insulted and belittled by the academicians. Not willing to engage on the ethical and moral grounds of the “parallel course” they instead played king of the hill on the head of the pin of RCT dogmatism. The use of unapproved medications in the most dire circumstances without clear proof that they are not harmful was declared immoral; those willing to even discuss the use of new anti-virals outside of an RCT were labeled naifs without the mental chops to even be given a seat at the table. Likewise the off-label use of an older medication with a sterling safety profile for prophylaxis. There was a barrage of condescending straw man arguments and outright ad hominem.

Why post this here, today? Listen, there were two important conversational threads to be had on this issue yesterday. One on the how and why of RCT’s in both the very ill and those who might become so. The other, no less important, was whether a “parallel course” of compassionate use originally discussed during the AIDS tragedy of the 1980′s by no less than Dr. Fauci, was appropriate. One conversation is cut and dried,  mathematical in nature and wanting only the mechanics to implement. The other is an ethical discussion, one that requires a different vocabulary and one that is open to a wider group of conversant, the insular and dismissive instincts of the academicians notwithstanding.

There will be endless armchair quarterbacking in the months to come. Dismissing people like me, with or without the backslap of insults and derision hitting my backside like the proverbial door as I exited the conversation, will not likely make it any easier for those who demanded the pulpit resting on the head of that pin. It will be hard to offer much in the way of understanding after the fact to those who have extended so little now, in the heat of the battle, to those of us seeking only to understand.

I’ll see you next week…

Is That All There Is? Comparative Religious Studies At the Dinner Table

A partial re-post of thoughts about religion and the afterlife on the day that Passover begins in 2020…

 

Some of our best, most meaningful discussions occur when we are left alone unexpectedly, though I’ve no idea why this might be. Over a typical “Primal Zone” meal we continued an earlier conversation: how does the rel!gion of the Native Americans and other Aboriginal peoples account for basic scientific facts such as the existence and structure of the solar system? Do they even try? Does it matter?

This particular conversation actually started as we walked by the cemetery on Key West. Surrounded on all sides by water nonetheless, the prevailing sense there was dry, the mausoleums and headstones bleached as white and parched as any bones in a desert. Is that all there is?

Despite the surface differences, however dramatic and however loudly trumpeted, there exist great similarities among the world’s great rel!gions. I think these similarities are particularly striking when you compare those of the landed, the American Indian, the Australian Aborigine, any number of Amazonian peoples, separated by millennia and miles, all of whom preach a type of filial duty to the earth that sustains them. Ashes to ashes; dust to dust. An ethic of harmony to be propagated between everyone and everything alive.

This differs, of course, from the major rel!gions of the developed world in the endgame. Today the Christ!an world celebrates its greatest mystery, its most deeply held faith. There is something after the end, after the ashes, after the dust! Heaven, a favorable reincarnation, Paradise…the ultimate carrot as reward for a life lived according to remarkably similar guidelines. Funny as well, isn’t it, how similar are the guidelines in the Old Testament, the New Testament, the Koran, the tenets of H!nduism, and those of the Sioux.

Similar but for one thing: no carrot.

Ashes to ashes; dust to dust. Headstones bleached as white as the bones beneath. Is that all there is?

 

Blessings to all of my friends as they begin the Passover season.

Contemplating End of Life Decision Making: Sunday musings…4/5/2020

Sunday musings…

1) Saturday. My brother (living in San Clemente at the time) once remarked that every day is Saturday in San Diego. Kinda like now, in lockdown during the Pandemic. Every day is Saturday. I literally didn’t know what the hell to do with myself yesterday.

It really WAS Saturday.

2) Nice. As I’ve gotten older I really have become a nicer human being. Some of that is real. I try to be a little nicer to everyone every day. Some of it is really undeserved; it’s been rightly observed that I am at least partly nicer by proxy.

People know who my wife is.

3) Cocktail. “It’s always cocktail hour in a crisis.” The Barefoot Contessa

Boy, isn’t this the truth.

Our dance card is filled every day with invitations to join friends via Zoom or FaceTime or Skype for a virtual cocktail party. My little professional group, C/A, has a standing 6:30 EDT invitation M-F; they have kept me afloat. Just for fun I am seeing how many days I can go before I have to repeat a cocktail. In so doing I’ve kinda usurped my college buddy John’s “Drinks Around the World” shtick by posting each night my “Drinking with John Starr” drink of the day. John, ever the good sport, has responded by sharing recipes and correcting my typos and grammar.

At some point the cocktail hour thing is gonna need to end, at least the daily partaking part of it. But not yet.

Not yet.

4) Walking. Have you seen the meme going around with the dog lying on top of the kitchen cabinets, looking down at its owner who is holding a leash and saying “No, not another walk!” Funny. My little Aussie is thus far insatiable. 30 minutes after I’ve walked her to a point where she stops pulling (usually about 2.5 miles) she’s barking at the closet and ready to go again. We’re both losing some weight (I’ve upped her daily rations), and she seems to have adjusted to our new normal: Dad is home all day, every day.

There have been a number of times over my adult life when  walking was what I could do. Just walking. Surgical recoveries, periods off work, stuff like that. I’ve never really contemplated any type of walking epic. You know, like in that Martin Sheen movie where he traces a walk his deceased son didn’t get to do. I think it may have been in Ireland. Never watched, actually. Or like the time the movie director Werner Herzog walked from Munich to Paris, a 500 mile hike, to visit a sick friend. His pithy observation afterward? “Tourism is a mortal sin, but walking is a virtue”.

One thinks of the wisdom of the ancients. Solivitur ambulando. It is solved by walking. One hopes very much that it is true.

5) Decisions. “If anything happens to Dad and me I’m sending contact information for XXXX who knows everything about our financial situation. Dad keeps all our important papers in files in his closet. We both want to be cremated when we die, and while we would like reasonable efforts made to save us, we don’t want to be on ventilators taking them away from young people who need them more. If a doctor advises that it’s time to end lifesaving efforts–do it (unless he’s drunk- or an ophthalmologist).” Mother of Dr. Glaucomfleken, semi-famous Twitter ophthalmologist

Do you have a last will and testament? Have you discussed what you want done if you are tragically, unexpectedly at the end of time and unable to express your preferences? As I look back I’m pretty sure that Beth and I didn’t really think about this at all until we had our first child, The Heir. I do remember how uncomfortable it was when my folks gathered their progeny around the dinner table one night to tell us what they’d put into their wills and why. The happiness of discovering that our parents had overcome economic disaster and (at the time) actually needed wills to disperse a rather handsome estate should they expire unexpectedly was tempered pretty much completely by the first real notion that they were going to precede us into whatever the next place might be. (My parents’ estate was rendered asunder during the “peak dollar” days in the late 80′s; we are blessed that thus far enough remained to carry them through their later years).

Please take some time to talk about this with the people you love. Even if you are young, like pre-”Heir”  Darrell and Beth young, carve out a little time and talk about this. Make this the one time “Sunday musings…” made a difference.

Listen, I’m not gonna lie, this whole thing has really got me down. The Black Dog (read: Hemingway) has come for a visit; he will eat his fill. Each day is a struggle. I’m OK enough, and likely to remain so. Like my Dad I am terribly afraid of death. What did he think of when he thought of dying? As a devout Catholic why did his faith not bring him more comfort as he grew older? As I’ve grown older I have become much more spiritual while drifting further and further away from religion. There is no peace for me in death, there is only loss. Thinking about leaving my people fills me with sadness. The thought of losing my people fills me with dread. There’s nothing new about that, only that now I find that I can no longer push those thoughts aside.

I’ll be OK. Or as I’ve taken to telling people when they ask, I’ll be OK enough. We’ve talked, Beth and I, and we will be prepared when our time comes, hopefully long after the Pandemic is but a blip on our timeline, but ready now if need be. We’ll not put our families in a place where they must try to divine our intent, nor my dear physician friends who have worked so hard to keep us around thus far. Like the delightful woman I quote above, we will make it simple (I almost said “easy”; it’s never easy) to know what to do. I like the approach taken by the author Stephen Gould after he was diagnosed with cancer in the 80′s:

“It has become, in  my view, a bit too trendy to regard the acceptance of death as something tantamount to intrinsic dignity. Of course I agree with the preacher of Ecclesiastes that there is a time to love and a time to die–and when my skein runs out I hope to face the end calmly and in my own way. For most situations, however, I prefer the more martial view that death is the ultimate enemy.”

For me, for today, that’ll do.

With luck and a tiny bit of grace, I’ll see you next week…

Sunday musings 3/29/2020…Prepare Each Day As If It’s the Last Time You’ll See Loved Ones

Sunday musings…

1) Feckless. Who would have ever thought that our country would look to a 73 yo mensch from Yellowstone, OH to lead us in the Age of the Pandemic. Or that the mayor of NYC, arguably the most important city in the Western Hemisphere, will forever be married to the single most derogatory term I have ever seen attached to a politician.

2) Answers. “I don’t have any answers at all.” Sabrina Ionescu, University of Oregon

Ms. Ionescu suffered a much more personal loss when the helicopter went down. Kobe Bryant had become an in-person mentor, schooling her not just on her game but on life as a leader. And now the crowning moment for the nation’s best college basketball player (not, it should be noted, best women’s basketball player) has been snatched from her grasp by the pandemic.

Like so many of us in so many other walks of life, a leader is left with no one to lead and nowhere to lead them if she could.

It’s hard to put into words, but at this moment in time, unbeknownst to this very special young woman, I have more in common with her than she could possibly imagine.

3) Endings. It is nothing short of heartbreaking to read the stories about people saying goodbye to a spouse, children, parents without knowing if it’s just a regular “see you later” or a real at-the-end goodbye. Just one example: so many stories about the agony of family members who have placed loved ones into hospice care only to learn that they cannot be there at the very end due to the all too real need to put physical distance between our bodies, no matter how much we need to bring our souls together.

Thinking for just a tiny moment about that, about the very specific question of hospice care and the intense desire to be there to shepherd a loved one to the beyond, the sage advice of my dear friend Bill, the surgeon, is there once again to guide us. It’s so much more important to be there just before the end. Before our loved one has begun their final journey. Before they are unable to hear us. Feel our hand in theirs, our tender caress. Bill has long said that the rush to be at the deathbed side has always confused him. What should we have left to say, he wonders. Peace is there to be made, love to be professed each and every day. For those entrusted with our loved ones under hospice care let Bill’s gentle guidance show you the way.

Allow, nay encourage, peace to be made and love to be professed, heartfelt goodbyes to be made upon entering your gentle care.

For the rest of us, those of us who need not address death at the doorstop just yet, allow me to return to the lovely advice offered by Ira Bock M.D., a doctor from Dartmouth who spoke at a conference held in memory of my late friend Ken a year after his passing. The talk was surprisingly moving, not only because it brought back memories of Ken but also because I would go on to lose my Dad and both of my in-laws in the not too distant future. 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 will try to apply now, today, as if the end of life was nigh.

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. But each one of those little phrases is a bit of a minefield, each one laden with a hidden meaning and a back story, each one the mid-point in a little journey with a “before” you know, and an “after” you can’t possibly predict. There’s a little risk in that “after”, too, and that’s why those 4 little phrases aren’t really all that simple, and why considering this is not at all trivial. All 4 of those little phrases make you look outward, look at another, and in the saying they force you to put yourself at the mercy of that other. Each one of those phrases is a little opening in our guard, an invitation for someone to accept or reject not only the sentiment but the sender.

I’ve spent several years thinking about those 4 essential things and about how they fit in a life that is not necessarily concluding, even today in the midst of the Great Covid-19 Pandemic. 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. How will my Mom react if I approach this when I visit? Does she know it’s now the 5th act, that we are tying up all of the loose ends in the story?

How about my friends, my kids, my darling Beth? 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 the relationship if I remember these 4 things. Patients and staff do, too. Come and go, that is. 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.

Don’t wait for the conclusion of your life to think about these. Don’t wait for the end of a life to say these things.

I’ll see you next week…

 

 

Love in the Time of Covid: Sunday musings…3/22/2020

Sunday musings…

1) Pace. None.

2) D. As in Vitamin D. Get outside and get you some.

3) Mask. For whatever reason we are in the midst of a national shortage of highest quality protective masks. As an ophthalmologist, an eye doctor, I am not in any way a front line, at-risk specialist. I do, however, get very close to my patients during an examination. Like 6 inches close. As such my staff and I could really use at least a little bit of a barrier.

Enter Beth, stage left, to the rescue. After about an hour of Google-fu she discovered how to make cloth masks that can hold a filter liner (originally quilt batting, soon HEPA filter paper) and can be washed after a day’s use (replacing the HEPA filter if necessary). I am living with one of our Better Angels.

But you already knew that.

4) Non-essential. You always know where you really stand in the food chain of life; the pecking order of importance, where you fit individually and where what you do fits in collectively. You can imagine it differently, behave as if what you do has greater meaning, but deep down you know where you stand. Where you fit. Although I already knew this any doubt about my own little place was erased this past week.

What I do is non-essential.

Along with dentists and perhaps dermatologists, eye doctors were among the first medical specialties to be so informed. My largest national organization, the American Association of Ophthalmology, sent out a letter demanding that all ophthalmologists immediately cease providing all but emergency care. Not suggest, not request, but demand. Patients were continuing to come to our door. The phones continued to ring. No matter. It is rare for a cataract and LASIK surgeon to do emergency surgeries. 15,000 ophthalmologists now sit idle. While their national organization held out for a week or so, 47,000 optometrists are now also mothballed.

Thus I was brought to the most agonizing decision of my professional career. After days of internal strife and nights of ceiling gazing it became clear that in order to save our practice, a business that supports some 20 families, we would have to shut our doors and close. My staff was almost entirely furloughed. We provided assistance in applying for unemployment, and we will continue to fund health insurance premiums for as long as there is cash in the till. On Wednesday I chaired the most difficult meeting of my life; on Thursday we turned out the lights.

It’s a rather sobering thing, to be told that what you do is non-essential. Let’s be honest, it’s a particularly bitter pill for a physician of any sort to swallow; we are, as a hole, rather impressed with ourselves. All work (that is legal) is honorable. All work has value. Saving, restoring, or improving sight certainly does. But times like this reinforce that some jobs are simply more equal than others, at least for the duration of our crisis. Think airplane, 36,000 feet, passenger down with chest pain. You want the 25 yo EMT in row 30, not the 60 yo ophthalmologist in row 10.

The longer this goes on the more we will be needed. What we do, what dentists, etc. do, will rise to ever greater levels of essential over time simply because there are very real problems that exist in our specialties that cannot be ignored forever. Our patients will determine what becomes essential and they will demand (not suggest, not request) that we re-enter the arena. My prayers will go out to my staff and their families. Not being there to provide for them is my greatest burden.

Until then I take my place on the bench, stay loose, and watch as the game unfolds. Like the proverbial back-up quarterback I will do what I need to do to be ready when I am called back to the field. When I am, once again, essential.

5) Dominoes. There was a video making its viral rounds on various social media places of a rather earnest-looking professor-like guy talking about the power of a tiny domino falling and hitting a bigger domino on its way to the ground. He starts the dominoes tumbling. The cascade of 15 ends with the fall of a domino weighing 100 lbs. and measuring >1 meter in height.

All from a domino so small he needs tweezers to place it.

The Professor ends the video with the observation that a 29 domino cascade would finish with the fall of a domino larger than the Empire State Building. Pretty vivid. As is so often the case on Sunday mornings I let the video rumble around between my ears for a bit. What I saw first was a vast space filled with thousands, nay millions of those tiny dominoes, falling down over and over again, never striking anything but the ground. Every now and again a tiny domino would fall against a massive domino, either bouncing or slowly sliding off, eventually finding its way to the ground either way.

It was discouraging to think about. It made me a little sad, to tell you the truth.

But as I thought about it a little more, spent a bit more time in my imaginary vastness filled with tiny dominoes perpetually falling, it occurred to me that in order to fall over and over again it was necessary for each of those tiny dominoes to somehow rise up to stand. More than that, each time one fell it moved a little bit. Sometimes further into the vacuum of the vastness, but sometimes closer to another tiny domino. Another domino falling.

Another domino that kept getting back up.

It’s probably trite–some would say I specialize in trite–but what stayed with me in the end was not the image of the massive domino falling at the end, but that of the tiny, delicate, fragile domino in the front of the line. The one that started the whole thing. What most of us ever see is the last couple of dominoes falling, the last tumblers settling into place. Who knows how many times that first, tiny domino fell and struck nothing but earth?

And got back up.

That’s the message, isn’t it? Always. Get. Back. Up.

I’ll see you next week…

Revisiting Some Musings on Faith

Here is a reprint of “Sunday musings…” from the weekend of my little Buggie’s baptism. In these strange and challenging times it is helpful to reflect on our faith. Whatever that may mean to us.

 

“I don’t believe in an afterlife, but just in case I’m bringing along a change of underwear.” –Woody Allen

Funny how stuff seems to come in waves. This week brings together parts of the White Family for a Christening, the death of the great physicist and atheist Steven Hawking, and a preview of an encyclopedic take on the five years of Pope Francis’ papacy and the controversies therein. We have an affirmation of faith, an implied revelation of whether or not faith should have been present (although the rest of us will remain unaware of the outcome), and an evaluation of the challenges inherent in attempting to alter 2000 years of the administration of faith.

Scientists from the time of Archimedes have struggled with the challenges of faith versus science. Hawking dismisses the afterlife out of hand: “[T]he brain is a computer; once its parts wear out it is simply done.” John Polkinghorne, Professor of Physics and former Anglican priest, offered a learned and respectful (to both sides) examination in the delightful (if challenging) “Quarks, Chaos, and Christianity”; he clearly aims to find the intersection of science and faith. My brother-in-law and I have been sorta, kinda exploring the possibility that an afterlife lives in the multiverse, that infinitely possible infinite number of versions of our own little slice of reality (see “Dark Matter”) that is implied in quantum physics.

At the moment I am just back from the Baptism of my youngest granddaughter, witnessed by the family member who has the greatest degree of faith in the classical sense, my Mom, Grambingo. Introspection and critical analysis is not necessary, nor even really something to be considered by one who is so faithful in the traditional religious sense. Mind you, this is not a bad thing at all. Indeed, classical religions all seem to share a commonality of decency, a moral code that is at its core one of kindness and consideration. Pope Francis is popular in part because the “optics” of his papacy all point toward this part of Catholic doctrine. This imagery, which it is reasonable to believe, is heartfelt and real. It is said to be attracting drifting congregants back to the fold. Controversy is only present when the details are laid out, the rules of the religion still as unwavering as they’ve been since Vatican II.

Still, it is the faith, and more than that the real desire (bordering on need) of human kind to have some sort of faith that there will be something at the end. Something more. Whether it is a trip forward or backward, at some point we simply run out of the real estate of time and we are left with a choice: faith, despair, or madness. We can only go so far back in time before we run into the Big Bang. What came before? When we depart that which we are calling life we run into, well, we don’t really know. If we do seek to know what came before or what comes after we run into an absolute road block.

For me, a casual scientist brought up in a very traditional religious environment, I have decided to leave behind both the angst that comes from the need to know, as well as the trappings of religion, in favor of faith. Just faith. Somehow, deep inside, I am comforted by the belief that there was something before and there will be something after, despite the fact that I, like everyone else, am incapable of knowing for certain what that is. There is an inherent comfort in the thought that I might live on in a state of some form or another, perhaps even one that is part of my granddaughter’s Christening today. One thing I know for sure is that without that faith the path for me is one that leads straight to madness.

Indeed, one wonders, especially after the lovely occasion this afternoon, if Mr. Hawking packed a spare pair of underwear. Just in case.

Our Better Angels: Sunday musings…3/15/2020

Steven Pinker’s breakthrough, at least from a commercial standpoint, was a book about human nature entitled “Our Better Angels”. It’s a few years old and I confess that I’ve skipped over it and instead have started his newer book, “Enlightenment Now” at the suggestion of Bill Gates and his annual reading list. (Gates calls it his favorite book of all time). As an aside I’m also reading “Fewer, Richer, Greener” by Siegel, a similar data driven thesis about our world being better than popular, perhaps prevailing sentiment.

Anyway, in “Our Better Angels” Pinker describes a world in which there has been a dramatic and meaningful decrease in violence (wars, uprisings, genocides, etc.) despite sentiment to the contrary. He posits that exceptions to this trend get disproportionate coverage in the press and on social media, creating a false reality that the opposite (that the world is more violent) is true. Further, he points out that at the most personal level the entirely human traits of reason and empathy have made the world kinder and safer at both the 3 and 30 foot level.

For quite some time now I have observed this in my daily travels, both at work as a physician and around the various towns of my “civilian” life. We cannot discount the effect of “othering”, the process by which the bitter and the bigoted seek to make their targets something less than fellow humans in order to justify their prejudice. But this, too, is likely far less prevalent in reality than it seems it is given the reporting we see (although “othering” and prejudice in all of their forms are loathsome and have no place in our societies). No, what I see as I move through a life that brings me into contact with people of all walks of life is a people who bear no ill toward their fellow travelers. Indeed, a people who, given the chance, choose to do acts of kindness both large and small.

What will we see over the next weeks and months in the time of Covid-19? Well, we will surely see silly, even stupid stuff judging by my Twitter feed this morning (people in bars, cattle-car crowding in airport Customs lines). There will be folks who will say stuff that will make you roll your eyeballs right out of their sockets (too many examples to pick one). Some will seek to profit from the pandemic (how about that knucklehead who bought 17,000 bottles of disinfectant and jacked up the price? Got his comeuppance he did. Maybe we should let Amazon/EBay handle the insulin market). Even more distasteful will be those who choose to use the pending upheaval for political gain (Really? Somehow we’re gonna use this global emergency to win an election?). Even our Best Angels cannot avoid the tiny number of folks who see only themselves, even when doing so is so much more damaging than it might have been last week, or last month, or last year.

But these will not be the majority of who and what we see now, regardless of what we see and read and hear from whatever sources we use to gather information about our worlds. No, the majority of who and what we will see is people who do the right thing. People who choose to be kind and understanding, who offer gestures of both in ways big and small that may be visible but will as often go unobserved. For sure there will be more of these acts of kindness now in a time when they are needed; our Better Angels will respond now because now is when we need them. We will find that things like watching a child or dropping off some groceries have been going on under the radar for, like, ever; the Better Angel within all of us will simply be more aware of the chance to help, to provide. It could be a tiny as opening the minivan door for the Dad carrying groceries and a toddler in the grocery store parking lot, as subtle as not buying toilet paper because you are set for a couple of weeks at home, or as grand as learning that you have recovered from the virus, you are at least temporarily immune, and you take every extra shift they’ll give you at work, wherever work may be.

9/11 showed Americans that we can rally around a common cause. Rally around each other. Looking back, with the exception of the greater NYC area, rallying as a nation did not require a terrific degree of sacrifice. Certainly not like those borne by our nation during our great wars or times like the Great Depression. Now, when it’s hard, when sacrifice will be asked of all, now is the time to seek the Better Angel within each of us. I’m getting to be an old guy now, and maybe I suffer from a kind of sentimentality brought on by my stage of life (rather than the cynicism of so many of my Dad’s buddies at a similar stage), but the more I look the more Angels I see around me. The more closely I look the more of what I see is kindness. Understanding. Caring. Now is the time to seek the Better Angel within.

I see you. I know you. I see the Angel within you. I know that Our Better Angels will prevail. Our Better Angels will triumph.

I’ll see you next week…