Random Thoughts from a Restless Mind

Sunday musings (lots to catch up on)…

1) Fonder. Absent last week. Never got to the keyboard. Miss me?

2) Timmy. Our little manster Tiny Tim passed away last fall. He was a great dog. Attached as if by velcro to Beth. He visited me last night in my dreams so vividly that when I awakened it was if my arms and my lap were still warmed by his soft, fuzzy body. It was a happy awakening.

I really miss our little floofball.

3) Savage. Did you know that Fred Savage from The Wonder Years is 42 years old? Not a typo. 42! I’m not really sure why this is so striking; I didn’t really watch the show and all.

Still, Fred Savage is 42 years old. Whoa.

4) Washing machine. Fun little article on hanging clothes to dry outside in this weekend’s WSJ. I can’t remember the last time I actually saw that outside of the beach. The whole washing and drying of clothes is yet another part of “the world is way better than we admit” thing I’ve touched on in recent months. For the price of a little electricity households are freed from the chore of washing and drying their clothes by hand.

Admit it. Unless you’ve done much travel in 3rd world countries or the whole bohemian backpack thing, you haven’t washed anything by hand in years. Maybe your whole life.

This does bring into play a few 1st world problems. Our washer drum is putting rust spots on our whites. Beth just ordered a new one to be delivered and installed on the 4th (in the middle of our party!). Top or front load I asked. Answer: “Top. The whole front load thing is annoying.”

There you have it.

5) PT. I threw on a backpack and took a walk to our local liquor store yesterday afternoon. Crazy good place that store. Anyway, I loaded up the back pack with “provisions” weighing ~20 lbs and walked on home. Only 2.5 months out from my hip replacement the extra load was actually pretty noticeable. Now when people ask what I’m doing for PT I have a new, and utterly perfect answer:

I’m a rum runner!

6) Words. How we express ourselves in the words we choose can make a difference in what others hear if we do, in fact, have the ability to choose. Those hearing us should extend  goodwill in that the vast majority of people speak with honorable intent. Still, when it is obvious that a choice has been made to alter a common speech pattern or phrasing it is heartwarming; the effort should be called out and those who made the effort applauded. A very important example, one that I have mentioned often, is to describe a suicide as “death by suicide” or killed by suicide”, opting to drop “committed” and all it carries.

So here’s to MLB and its tiny but meaningful gesture of changing the name of the list of players unable to play from the “disabled list” to the “injured list”, removing a possible cause of discomfort from affecting a vulnerable population. Bravo.

7) Equality. As I approach 60 I am frequently drawn back to times, places and people from the past. White privilege is a theme that is quite in the news of late. Other than being white it’s been rather hard to see how I’ve been otherwise privileged. Certainly I have never felt the sting of real discrimination based on the color of my skin; if privilege is simply the absence of discrimination then I have been thus privileged. But as I’ve written in the past my Dad grew up quite poor, and our very lower middle-class life in the earliest days of our family was remarkably similar in almost all ways to that of a super-majority of the families in the town where I was born.

Why was that? Southbridge was notably short of not only the truly rich, but even the upper-middle class. As far as I can remember there was only really one rich family (the Wells family owned American Optical, the big employer) who literally no one ever saw, and precisely one neighborhood that stood out. And that only because the lots were a little bigger. My memory is that the houses themselves were pretty much just like those in the rest of the town. Nobody took fancy vacations or traveled to exotic locations. Little League shut down when AO closed for 2 weeks in July, and everyone went to the local lakes. In my memory almost every family in town who wanted to belonged to the little 9 hole country club if Dad played golf.

What was really extraordinary was how it felt to be a kid in school. I have no memory of anyone standing out based on any type of affluence or wealth. The kids who had cars had them because they were car-centric families. Those of us who did not (my siblings and I were not allowed to own our own cars in high school and college) didn’t because our families just didn’t have cars for the kids. There are no memories of stratification based on the clothes we wore in school. In fact my only memory about clothes was how I felt because of our own family’s very strict dress code for school. No bellbottoms or blue jeans in school, and we could only wear sneakers on Friday. My hair never touched my ears or came within hailing distance of my collar. Remember, we’re talking the 60’s and 70’s here.

Although there was a regional Catholic high school in town almost no one went there despite the fact that at least 90% of us were Catholic. We all took French in school, even the children from Puerto Rican families for whom Spanish was the language spoken at home. Kids were “tracked” academically in those times; I spent each school day with pretty much the same 25 or so kids. In the hallways between classes you couldn’t distinguish which track a kid might be in, though. I was just as likely to be hanging out with a neighborhood buddy or a teammate with whom I never shared a classroom as I was to be walking with someone from math class. As I look back it seems remarkable.

For the boys at least, we all seemed to share our rites of passage on similar timelines. Sign up for Little League at 8. Basketball leagues started at the Y at age 10. We all played Pop Warner football in 7th and 8th grades. It surely seems like everyone I knew did all of that at the same time (girls sports were different in those pre-Title 9 days so my memories are skewed male, for sure). It seems like we all had our first beers and our first kisses within 12 months of each other, max. Despite obvious genetic differences in academic or athletic prowess we all seemed so much alike. There seemed to be so little that separated any of us from one another. I’ve often noted that the difference between the “good kids” and the “bad kids” may have been simply that the “good kids” didn’t get caught.

The White family moved on, moved to another state and another school system, and another way of life as my father became more and more successful. It was obvious that we now had more of at least some stuff, not least of which was house. There was a vast range of housing in our new town. Consequently there was a greater awareness of neighborhoods among everyone, including the kids. High school in the 70’s largely broke down this awareness and never let it be a barrier, but looking back that new town and new school were different. And I am left to wonder not why the new school was different (because I see now that it was actually more realistic and probably normal), but why my first school was really the one that stood apart.

In the end I believe that Southbridge in the 60’s and 70’s was different because of all the things that were the same. Everyone went to public schools. Most Moms stayed home. The only difference between Dads seemed to be whether they took their daily shower in the morning before work or at night after. Pretty much every household had the same philosophy on child raising, and consequently you were kinda parented by every parent in town. School was safe. We had only to behave there as we behaved at home and we were free to learn. Mostly we all had the same amount of nothing extra. Nothing that set us apart from one another. It seems that we only kept score in class and on the playing fields and had nothing to measure and to compete for otherwise.

Is this simply the rose-colored memory of a kid who was mostly successful in school? Maybe, but as my old school friend Jan pointed out yesterday I wasn’t really as successful socially as I was in the classroom and on the field. One wonders if anyone else who was there at the time has a similar memory. My sense from our conversation is that Jan might. Still, as someone who has since traveled  way up and way down the economic and social ladders, there was something there that I’ve not found anywhere else. It’s not obvious to me why that was.

My hope is that, having lived there and having experienced what I remember as an equality that was so natural and unexplored that it seems extraordinary and rare, that the greatest lesson I learned there is that it is always what we have in common that matters. And that we almost always have much more in common than not. Our default setting should always be set on “equal”.

I’ll see you next week…

“Life’s not fair.” –Scar

What does equality mean? What does it mean to be equal? This came up this week in my day job. A study was done that proports to show that male and female eye doctors are paid unequally. The conclusions are false at the outset in this particular case because by law, services in this particular arena are paid exactly the same no matter who performs them, when or where. Unfortunately, the sensational lede taps into all kinds of notions of fairness, and all kinds of perceptions about what people assume must be true, that women make less than men for equal work. There is no question that this is the case is some walks of life, but interestingly the data (some of which the authors ignore in their quest to prove their preconception) proves otherwise in medicine. An opportunity to examine real differences in how men and women practice medicine is thus lost in the pursuit of an examination of the spiritual quest to combat inequality, even where none exists.

Is this the unicorn of equality? Is payment under government programs the only place where equality actually exists? Heck if I know. What interests me is the fact that the first assumption is that inequality is present. Inequality is the default setting. That there is an inherent degree of unfairness in pretty much any and every setting. Know what I think? Equality doesn’t exist. It cannot exist if we are to have an ever-improving world. There is nothing unfair about that in the least.

A just civilization establishes a floor below which allowing people to live is ethically wrong. For example, in healthcare it is my contention that we have a moral obligation to see that every citizen has access to care when they are sick. Inherent in this contention is that there is a basic level of care that meets this moral obligation by ensuring the same outcome as any other level of care. One could apply this same concept to food, clothing, and housing without missing a beat. We can think of the rights enshrined in the U.S. Declaration of Independence as a proxy for this baseline if you’d like. Life, liberty, and the pursuit of happiness make a very fine baseline.

One’s right to “life” necessarily includes a right to be fed, would you agree? Equality would mean that if one among us dines on Beef Wellington, than each among us must do so as well. This is where unthinking and unquestioning fidelity to “equality” brings you. In so doing it forces everyone to expend energy protesting “inequality” better put toward fulfilling the moral obligation to see that no one goes without protein. In healthcare we see all kinds of protests againts the inequality of care demonstrated by the horror of a VIP of some sort or another recuperating from a procedure in a luxury suite, while the proletariat must recover in the equivalent of a Hotel 6. The reality is that the outcomes will be equal; the moral obligation has been fulfilled. Above a basic level in pretty much any domain you wish to examine, equality does not exist. Sorry. Scar is right. Life’s not fair.

Is he really though? Saying that it’s not fair is the same as saying that inequality above that level at which everyone has a right to live is wrong. Here is where I part company with those who hew to this viewpoint. What does it matter that someone drives a Cadillac while another drives a Kia? Do both not get you to work on time? Or that Beef Wellington again: do you not get the same amount of protein from a hamburger? The example I am using in another conversation about equality in healthcare is similar: if a medicine is effective taken 4 times a day, is the fact that someone can pay more for a version that must only be taken once a day a measurement of unfair inequality? I vote “no”.

My strong feeling is that energy spent in some way protesting “equality” is energy that is not expended on the much more important task of fulfilling the moral obligation of raising everyone to that acceptable basic level. In may, in fact, work against that effort. That constitutes unfairness in my opinion. Advocacy and protest should be directed there, toward making sure that everyone has that most basic obligation covered. Once universal entry is accomplished across all applicable domains, the next task is to continually raise that basic level for everyone, no matter how far the gulf may be between that level and whatever the “sky’s the limit” level might be. One need only look at “poverty” or “hunger” and how the bar has moved ever upward there to see how this might work.

We have a moral obligation to see that true rights are available to all. It is unfair to those who have not yet achieved that most basic level when efforts to help them are diverted to the pursuit of an unachievable conceptual goal that neither feeds nor clothes nor cures those in need: equality.

In 2011 I wrote an essay in response to an article I read in the WSJ on the coming physician shortage. In short I agreed with a letter that pointed out the effect of physicians working fewer hours than they had traditionally worked. In that letter the effect of the changing demographics in medicine (more women physicians, generational shifts) was pointed out. My essay agreed with the points in the letter. My thesis is that you can’t “have it all”, in medicine or anywhere. Someone, somehow, always pays.

While reading about “Equal Pay Day”, the day on which the “average female wage earner” achieves the same amount of pay as the “average male wage earner” acquired in the previous 12 months, a couple of things strike me. First, the general thesis of my essay continues to be accurate, at least in medicine. Income is determined by the choice of specialty, as always, but beyond that it is driven much more so by the number of hours a physician works and how productive that physician is during those work hours. Work more hours, get paid more money. Perform more of your doctorly duties in each one of those hours, get paid more money. There are fewer and fewer physician jobs in which seniority on its own drives income, thereby negating any lack of seniority which may be caused by a career “pause” to have or care for children. Physician income is largely gender-blind. As an aside, the dirty little secret of physician pay is that production-based compensation is the norm everywhere, even at those institutions that claim otherwise.

The second thing that strikes me is the malignantly erosive effect of ineffectual, unnecessary external regulation on the practice of all medicine on effective physician work hours. In 2014, whether you are a man or a woman, the bureaucratic load associated with practicing medicine is oppressive, and hours that just 5 years ago may have been spent caring for patients is now spent caring for charts, bills, and other paperwork. These hours generate no real health benefits for patients, and do not produce any revenue that pays the doctors for working them. In a particularly cruel example of Murphy’s Law, or at least the Law of Unintended Consequences, the specialties that are hardest hit by this relentless onslaught of the unnecessary are those that tend to pay physicians the least. Fields like Family Practice and Pediatrics. On “Equal Pay Day”  it is particularly ironic to note that those hardest hit specialties tend to be staffed by the highest percentage of female doctors.

A final note as I read this post 3+ years after the initial writing: the choice of “Mommy-Track” to describe those women who graduate from medical school and work fewer hours than their male peers because of their choice to prioritize their families seems needlessly pejorative and provocative. I’ve left it in for this Epilogue because to edit it today seems dishonest in a way. Besides, I’m a little bit better at writing in 2014 than I was in 2011. I can be plenty provocative now without resorting to the pejorative.