Random Thoughts from a Restless Mind

Dr. Darrell White's Personal Blog

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Posts Tagged ‘eye’

Cost + Quality + Convenience = Value

My wife 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 level of value 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 the baseline or floor level, and 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. Our family is experienced a bit of this recently with Beth’s Mom. After a hospitalization she was living in a setting that ws providing excellent care at a reasonable cost, but it was a setting that did not provide any extras; it was old, not very pretty, and she could  have had a roommate. Her (and her daughters’) experience, what we might call “convenience” or  in our formula, was found to be lacking. The girls opted to move her to a nicer setting, one that will eventually involve a higher cost because of the enhancements to the experience, with no change in the already best possible outcome, or quality.

Therein lies the problem with any discussion about literally anything that we might discuss as a “right”. Is everyone entitled to anything other than the minimal amount of convenience/experience necessary to obtain the best outcome at an affordable cost?

If we examine food, 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 quality of food. Not even a little bit. No, quite the contrary, all that is discussed is cost and convenience (access).

Now, of course, we in the CrossFit world (and to a degree in the medical world) argue 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 (cell phone, cable, fancy car, etc.). While this is accurate and proper I believe that we can reasonably quarantine nutrition and keep it separate from other needs, at least for the purpose of our discussion. The universal concept of the interplay between cost, quality, and convenience holds true in nutrition/food on a global, grand policy making level:

You can pick any two, but only two, when you are declaring what is the minimally acceptable level.

My formulaic approach to the coverage of 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 or outcomes. The law of diminishing returns arrives in the form of the asymptote as quality rises. On the other hand, cost and convenience are unbound and can rise almost infinitely. 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 cost issues are addressed and everyone is left to make their own call on convenience/experience? 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, all work to pick up the check for the needs of each. “Want”, on the other hand, is the proverbial “free lunch”, and we as a society will need to agree on that before we can even begin to discuss begin to talk about the mechanics of paying the bill.

TANSTAAFL. Heinlein was right.

 

The Outer Edge of Inside: Where Innovation Occurs

“[True] innovators are on the edge of the inside.” Friar Richard Rohr

I once wrote that “if you’re not living on the edge you’re taking up too much space.” This is a bit different. Effective innovators and those who are early extenders of their ideas cannot be so far outside of present orthodoxy that their innovation is ignored, however correct they may (turn out to) be. An innovation or discovery that is too radical to even be examined might be shelved simply for being too far outside the inside, thereby denying countless individuals its benefit. Incrementalism occurs in the middle, but innovation that scales happens just barely inside the border.

Think about my fitness program, CrossFit. What would likely have been the result if step one had been the spectacle of the CrossFit Games, ca. 2017? We all know the answer to that: Constantly varied functional movement at relatively high intensity (CVFMHI)  would have been deemed ludicrous for all but the elite athletes we are seeing perform in the East and South Regionals this weekend, rather than a legitimate option as we seek a public health solution to the well-being of a broader population. The sentinel signal of the innovation was initially ever so slightly inside the outer boundary of the fitness/health orthodoxy: train consistently using irreducible full-body exercises at higher intensity utilizing proper movement patterns. Others have noted the importance and effectiveness of interval training, notably Michael Joyner, M.D, at the Mayo Clinic. While a sense of the importance of the glycolytic energy pathway existed before CrossFit, it took an innovator far enough outside the middle to realize its potential and make it the primary focus of a program.

The world of my day job is also populated by innovators who were just radical enough to nearly become outcasts. I always think of the great Charles Kelman, M.D., the inventor of what we now know as phacoemulsification. When Dr. Kelman began his research on using high frequency ultrasound to dissolve a cataract through an incision roughly 15-20% the size of what was then typical, no one could fathom why that would even matter. Fast forward to our present day ability to remove a cataract through a 2mm incision. Because of that first innovation I can now replace a cataract with an implant that allows someone to see both near and far with no glasses. Imagine!

Once true innovation occurs it moves inward, but a next wave of innovators lurks near the edge. Like so many benign Salieri’s to Mozart they build upon the original innovation within their own, smaller zones. This is no less disruptive than that original innovation; it simply occurs in a different part of the world. Shortly after CrossFit erupted in the general fitness world a second wave was brought by innovators in youth fitness by Jeff and Mikki Martin of Ramona California. Their program is now known as The Brand X Method and they lecture on their evolved programs for youth fitness all over the world. In a similar fashion Brian McKenzie, an ultra runner looking for a way to train more efficiently and with fewer injuries, used the principals of CrossFit as applied to endurance training in what was originally known as “CrossFit Endurance”. B Mack is also continuing to push the envelope in his PowerSpeedEndurance program.* It was only the growing acceptance of the original innovation that prevented these next-wave innovators from being OUTSIDE the edge of their particular parts of the fitness world.

The logical extension of CFVMHI, what we are witnessing each weekend as The CrossFit Games season is upon us, has long since passed me by. It turns out that for me all I’ve needed was an early update to the original inspiration (classic, early vintage CrossFit.com with CrossFit Strength Bias v3.3 layered on); more and more actually brings me less of everything. Others who I am quite fond of have had a different journey. One of my daughters-in-law is doing a modified CrossFit Endurance protocol for example, and is winning her age group in 5K races while pushing my granddaughter “The Nugget” in a race stroller. My grandson “The Man Cub” will doubtless train using the Brand X principles that have evolved from the original CrossFit Kids program. My friend Julie continues to push the limits of human everything as she competes on a CrossFit Games team while developing new medical paradigms, all before graduating from med school here in Cleveland. Unlike yours truly, more and more brings Julie more and more. Innovators in the world of eye care similarly bring us new techniques from the edges of our world, the latest being the once unthinkable ability to treat floaters with a laser.

CrossFit is now firmly established as both a system and a business. Small incision cataract surgery using ultrasound is the standard of care. We would do well to remember that time when this was not at all the case, a time when only one innovator sat just inside the outer edge. What is to come in any number of other areas–medicine, finance, digital, what have you–will come from the same place. Some of us caught on to CrossFit really early. Wouldn’t it be great to be out near the edge and catch something like that right in the beginning again?

*To my knowledge neither the Martins nor Mr. MacKenzie are presently associated with CrossFit, Inc.

 

Tyranny and the Culture of Grievance.

Thomas Sowell, an American sage, laments the “huge degeneration” in America toward “the grievance culture”. Indeed, I have written on this before. The near reflex response to be aggrieved, to be offended first, and to ponder and reflect later, if at all. There is a certain and definite lack of goodwill, a reluctance or refusal to extend goodwill, or the assumption of goodwill, on the part of others. Rather, the culture of grievance mandates that we impugn malintent in the deeds and actions of others, especially if in some way those others (them others) have values or beliefs that don’t completely and consistently line up with those of the aggrieved.

On CrossFit.com, especially in a prior “Wild West” era, this phenomenon could be seen every 4th day with the publication of a libertarian-leaning article, or something that ran counter to the progressive drumbeat in the halls of academia or government. The simple act of speaking against the orthodoxy of a group sent said group into a paroxysm of aggrievement. This is no different from what we see in the now limitless wilderness of the internet and social media. Context is irrelevant. Intent is irrelevant. The provenance of the offering is irrelevant. Once unleashed the only thing that matters is the bleating of the aggrieved, however large or small their numbers might be, however trivial the insult, if it can even be called an insult at all.

While away at a professional meeting this weekend a new ad campaign for a product in my professional world dropped. It is irreverent and funny, and it was conceived and created by members of the same group that is on the receiving end of the joking. There were three reactions, as is probably typical of something like this. One group thought it was clever and funny, and realizing that it was the first in a series this group looked forward to seeing where the campaign was headed. By far the largest group saw the humor, realized what the intent of the campaign was, acknowledged that the humor was harmless and without intent to harm, but cringed at what was a rather large misstep. Seemingly in love with the joke both the creators of the campaign and the company that authorized its launch failed to see that, while funny, it was in very poor taste. This second group shook its collective head at how tone deaf the company was.

The third group was mortally wounded by offense. The aggrievement was existential. A firestorm was unleashed upon the company. The agency and its employees were excoriated despite their inclusion in the group supposedly aggrieved, saved only by their anonymity as individuals from a very public shaming among an influential cadre of the advertised company’s customers. That ire was directed at the CEO of the company, an exec known quite personally by a majority of his/her customers. The attacks were pyrrhic and personal despite an obvious lack of malintent. There appears to be no amount of shame that can possibly atone for the sin of humor without intent to offend that misses its mark and does just that, regardless of the size of the cohort offended.

The grievance culture allows progressively smaller and smaller numbers of individuals who care about narrower and narrower issues to hijack larger and larger institutions and paralyze them. One need only look at the tragicomedy that played out 2 weeks ago at Middlebury College in Vermont to get a sense of what this means. A (pseudo-) scholar was invited by a conservative student organization to speak. Mind you, this speaker’s ideas have been so roundly disparaged that even the members of that conservative club did not support them; they invited him in order to have an opportunity to debate the ideas. Alas, other members of the Middlebury community were offended by the mere presence of on campus of one who could hold ideas that are so antithetical to their own. This group declared that their grievance superseded any and all rights and privileges of every other individual or group, including the group that invited the speaker and whose members largely shared the opinion (but not the aggrievement) of the offended.

This small minority drove the speaker from the stage. They attempted to drone out an internet broadcast of his speech with repeated pulling of fire alarms. In the ultimate expression of their grievance they assaulted a faculty member who was driving the speaker out of town after the event, sending her to the hospital. It is particularly instructive that the group of the aggrieved chose this course because the speaker’s ideas and positions have been so roundly and completely debunked that it would probably have taken less effort and have been more effective to simply simply hoist him on his own petard on the stage and watch him swing.

I find myself in group 2 in my professional example (amused but somewhat astonished that experienced business people could be so tone deaf) and similar to the group that invited the faux-controversial speaker (contemptuous of pedagogy that cannot be supported with anything other than belief). Mr. Sowell is a true A-list man of ideas and letters, while I am a C-lister with B-list aspirations. Nonetheless I share with him his sorrow at this degeneration of American culture, this insistence that a difference of ideas begets a grievance that supersedes not only the rights of those who disagree, but also the very possibility that other ideas might exist. Replacing a culture of ideas and ideals with a culture a grievance is a step backward for society, perhaps for civilization.

The tyranny of the minority begins with a tyranny of ideas, waged with the weaponry of grievance.

 

Unshakable Belief Meets Unmovable Facts

This week I spent some time talking to a couple of folks who, unbeknownst to them, were talking about each other. Well, talking to them is not really accurate–they were having a discussion and I was having a listen. Both were talking about the effects of a particular happening on a particular person they both knew, effects that both could surely see if only they cared to remove their blinders and look.

They told wildly different stories. Their belief sets were so unshakable, so impervious to penetration by petty inconveniences like facts and reality, it was as if they wore not lenses to clarify but masks to obscure. The blind running from the blind, if you will. I’m fascinated when I see this; I see this almost every day when I am plying my trade as an eye surgeon. So much of what is “known” about medicine isn’t really known at all but “felt”. I constantly run up against an unshakable belief that is often expressed in a statement that begins “well, I think…” Indeed, I heard this from both folks telling me what was transpiring.

I’m fascinated and exasperated in equal parts by this because of how completely this unshakable belief nullifies the otherwise logical power of observable, measurable fact. If I step back and think a little more deeply about this phenomenon I am also terrified that I, too, may harbor similarly unshakable beliefs that blind me to the truths of a fact-based reality. This weekend brought me to a gathering of true experts in a particular field of my day job, one I was quite flattered to attend. There were a couple of points that I’m just convinced my colleagues got wrong, points of view it looks like I shared only with myself. Am I right? Is my insight so keen, my ability to analyze the data presented so much better, that I am just a full step ahead? Or is it rather that I am clinging to a point of view supported only by the virtual facts created by personal beliefs I am unable or unwilling to walk away from?

This simple awareness and acknowledgement–that I may suffer from “belief” bias–might be enough to inoculate me.  I certainly owe my patients (and my readers) an effort to investigate that.

Why Private Practice Survives

“I’m surprised these kind of places are still open.” –Physician employed by World Class Medical Center

“And yet, here you are, bringing your mother in for a visit.” Technician checking in mother.

In my day job I am an ophthalmologist, an eye doctor who takes care of medical and surgical diseases of the eye. Our practice, SkyVision Centers, is an independent practice, what is often referred to as a “private practice”. As such we are neither connected nor beholden to either of the large organizations here in Cleveland, both of which have large ophthalmology practices with offices near us. The mother in question was originally seen on a Sunday in my office through an ER call for a relatively minor (but admittedly irritating) problem that had been ongoing for at least a week.

That is not a typo; an ophthalmologist saw a non-acute problem on a Sunday.

Now Dr. Daughter swears that she tried to get her Mom in to see a doctor all the previous week. “She” even called our office (more in a moment) and was told all of the doctors were booked. Strictly speaking, the staff member who answered the phone was absolutely correct in noting that our schedules were full (actually they were quite over-booked in the pre-Holiday rush), and that we would not be able to see a patient who had never been to our office. Dr. Daughter works for a massive health system that advertises all over town–on billboards, in print, on the radio and online–that anyone can get a same-day appointment with any kind of doctor in the system, including an eye doctor. In fact, we saw several dozen existing patients that week for same-day requested ER or urgent visits with the urgency determined by the patient, not our triage staff.

What’s my point? Dr. Daughter never made a single phone call. She had one of her staff members call on behalf of her mother; neither I nor my staff is responsive to proxy calls from staff. I know Dr. Daughter and much of her extended family. Over 25 years practicing in the same geographic area and populating the same physician panels she has sent me barely a handful of patients, even though I care for a substantial majority of that extended family. Despite that my staff would have moved Heaven and earth to find a spot for Mrs. Mom if Dr. Daughter had called either my office or me personally.

I know what you’re thinking: Mrs. Mom would get in because her daughter is a doctor. Nope. Not the case. I may have taken Dr. Daughter’s phone call for that reason, sure, but Mrs. Mom gets an on-demand ER visit despite it being our busiest time of the year because she is the family member of other existing patients. We treat family members as if they are already SkyVision patients; we just haven’t officially met them yet.

Now you’re thinking “what does this have to do with private practice?” Without meaning to be either too snarky or self-congratulatory, this is precisely why private practice continues to not only survive, but in many cases thrive. We have the privilege of putting our patients first. Really doing it. Same day urgent visits? No need to put it up on a billboard; we just answer the phone and say ‘yes’. Lest you think we are simply filling empty slots, or that we have open ER slots we leave in the schedule just in case, let me assure you that this couldn’t be further from the truth. We. Are. Booked.

Well, it must be that we are so small that the personal touch is easy. Surely if we were huge we couldn’t get away with this. Sorry, wrong again. A bunch of my buddies are orthopedic surgeons in a massive private group on our side of town. Like 15 docs massive, with all of the staff you’d expect to go along with that many doctors. Got an orthopedic emergency? You’re in. You may not get the exact doctor you’ve seen before on that first visit, but you won’t be shunted to either an ER or an office an hour away, either. The staff members making appointments for a particular office are right there, sitting up front. The same goes for the enormous Retina practice that spans 4 counties here in Northeast Ohio. Ditto for the tiny little 3-man primary care practice up the street from me, lest you think only specialists do this.

The private practice of medicine survives because the doctors go to work for their patients, and they don’t leave until the work is done. Private practice docs bend their own rules on behalf of those patients. Every day and every night. You know what happens when private practices are acquired by massive medical groups like the two 800 lb. gorillas in Cleveland? All of those rules get made by people who don’t really take care of patients at all, and they never bend a single rule ever. Those former private practice doctors become shift workers beholden to an institution, no longer working for their patients at all.

That family doctor or specialist who was routinely asked on a daily basis if someone could be squeezed in is not only no longer asked, she doesn’t even know the question was there in the first place. Everything is handled by the institution’s call center, somewhere off in a lower rent district, with no sense of what is happening at that moment in the clinic. Your doctor might have a cancellation and a spot open to see your emergency. Indeed, if she’s been your doctor for a long time she would probably rather see you herself because that would make for better care.  But there are now someone else’s rules to follow, efficiencies to achieve so that they can be touted, and institutional numbers to hit.

“I’m surprised these kind of places are still open.”

“And yet, here you are, bringing your mother in for a visit.”

On her way out, after impatiently waiting while her mother thanked me profusely for seeing her when she was uncomfortable, Dr. Daughter extolled the virtues of her employer. Fixed hours. Minimal to no evening or weekend call duty. A magnificent pension plan that vests rather quickly. I should join up, she said. She was sure that World Class Medical Center would love to have me.

I smiled and wished her, her Mom, and the extended family a Happy Holiday Season. As I turned, shaking my head a bit, my technician put her hand on my arm.

“If you did that, who would take care of her Mom?”

Population Health v10.0

There is a certain arrogance in the academy, that vaunted group of professors who opine righteously from afar about pretty much anything they study. Add to that the well-known arrogance of youth with its inherent disregard for any and all history which transpired before the youthful reached the age of cognition and you have either a toxic combination of ignorance and impetuosity, or simply a laughably vacuous collection of paper thin pontification. Such is the case with a series of statements quoted yesterday morning from a lecture given by a young academic physician on the state of population or public health in America. He posits that there is a new movement toward moving healthcare from inpatient to outpatient. There is an equally new and heretofore unseen effort to make people healthy rather than treat them when they are not. This young doctor is calling his observations Population Health v1.0.

I’m calling it Bullshit.

The lecture in question was being live-Tweeted, but that is probably the only thing about the subject matter that can reasonably be v1.anything. Instantly available dissemination of medical information to a general audience is a truly new phenomenon. With it comes the danger of the wider audience simply accepting the information since it comes from an “expert”. However, along with the relatively naive broader audience we thankfully have a small subset that is either a) informed enough on the topic to offer a “con” opinion, or b) simply old enough to remember that there is a deep and meaningful history that predates what the young expert is proposing as new. Count me as able to check c) both of the above.

Population Health is simply a better term for what historically has been known as Public Health. While Public Health typically connotes some sort of governmental involvement, Population Health is a more inclusive, more powerful concept because it includes not only government programs but also private initiatives of all kinds. Public Health typically equates to top-down implementation of global governmental policy, whereas Population Health covers everything from large for-profit publicly traded companies to the tiniest solo-practice pediatrician. In fairness to the speaker (and in a kind of peace offering for what is to come) I do think his choice of a label is spot on. The rest of his thesis and its development? Not so much.

There is literally nothing new in the entire exposition. How can you call anything v1.0, the first iteration of something that is truly new, if everything that is used as an example is simply today’s version of yesterday’s news. Let’s start with his primary assertion, that there is a new move afoot in which healthcare is only now being provided in the outpatient, rather than the inpatient, setting. This can’t be a doctor who is taking care of any patients in the real world. It is long been the exception rather than the rule that a majority of surgeries take place in an outpatient setting. Heck, 99.9% of eye surgeries have occurred in this setting since the 1980′s. So, too, for invasive testing like colonoscopy, bronchoscopy and cardiac catheterizations of all kinds. It would be much more accurate to state that we are in the end game phase of this transition, v10.0 if you will. For crying out loud, this is such a mature part of the evolution of healthcare in America that any essence of patient-centered care that would require an admission to a hospital is dismissed outright, one more nail in the coffin of that now meaningless label.

How about the assertion that we are only now engaging in a concerted effort to improve the health of our population as opposed to simply treating various maladies? This one kills me. Really? All of a sudden the entire healthcare/government/industry axis is only now finally seeking to improve the general health of our people by preventing illness? Now, in 2016, we have population health v1.0?! That’s laughable. If our young scholar is anything like yours truly, the last stop he made before making his way to the lectern was the loo. HeLOOOoh. Indoor plumbing anyone? You can make a sincere argument that v1.0 of population health efforts occurred a hundred hears ago with the introduction of the kitchen sink and the toilet.

If we confine our discussion to matters more purely medical any reasonable view must acknowledge the tremendous life-saving effect of mass vaccinations for childhood illnesses. Smallpox, polio, and measles each killed hundreds of thousands every year before the advent of widespread vaccination programs. Even efforts which we would now condemn like the sequestration of TB patients in sanitariums must be considered a type of population health program. Despite our modern day fetish with privacy issues, the near elimination of syphilis  in the Western world through mandatory case reporting and contact notification cannot be forgotten or ignored.

When we talk of Population Health in this day and age we are typically talking about mitigating the effects of modern society. Indeed, in cases such as nutrition, we are actually talking about undoing the adverse effects of prior Population Health efforts. The U.S. government either simply got it wrong, or was led awry by a cynical effort by food producers who surreptitiously funded self-serving research. No matter. We are now in possession of a sedentary, overweight population susceptible to once less common diseases that now run rampant. There is little argument that the healthcare community should engage in the effort to keep people healthy as well as treat them when they are not. The notion that this is something truly new is a fanciful notion bred of what must be purposeful historical ignorance.

So, Population Health v1.0? Hardly. A process that arguably began with the invention of the flush toilet cannot be labeled new, no matter how good this makes a speaker, a system sound, or a concept sound. Those who fail to study history may be doomed to repeat it, though in this case there really is no need to do so. Acknowledge the past, make a sincere effort to place your idea in its appropriate slot in that history, and then make a case for your proposal. Have a little humility. There’s nothing wrong with being v10.0. Especially if it works.

 

 

 

 

 

Sunday musings 9/11/16

Sunday musings…

It was a Tuesday. For sure. Tuesday is an OR day for me, and I was with my work people on what looked to be a pretty vanilla Tuesday morning. That’s how you like it in the OR: vanilla. A good day is no memory of the operations whatsoever. A great day is one where you remember some interaction with your teammates, something good or funny or nice.

9/11 was definitely a Tuesday. What I remember is being with one group of my people.

Everything about the day was going just like every other Tuesday. Fast cases with great results. Stories flying back and forth between doc, nurses and patients. Just a joy to be doing my job. Until, that is, one of the nurses came into my room and said a plane had hit a tower. To a person our collective response was something like “huh…that’s weird. How tragic,” and then back to work. Back to normal until that very same nurse came back and said a second plane had hit the second tower. We all stopped after that case and headed to the family lounge, a TV and CNN.

I remember being in a similar place when the Challenger blew up, surrounded by colleagues, patients and families. That’s where I was when the first tower collapsed. After that nothing was normal about the day at all. There is literally nothin in my memory banks about the rest of the morning. I know we finished the cases, but then everything came to a full and complete stop. Clinic hours were cancelled, schools let out, and the wheels of American life ground to a halt. The rest of the day was spent in tracking down my brother (traveling now by car from Chicago to Connecticut), and best friend (stranded in Brazil). The skies were empty for days.

Our new normal had just kicked in.

My parents worried about an attack on our soil from Germany to the east (U-Boats off the coast of New England) or Japan from the west (a friend posted the story of a Japanese pilot who actually fire-bomb Oregon!). As a child our politics and our lives were spent worrying about the specter of a communist attack. As an adult, a father and a grandfather, it is now the fear of Jihad unleashed. The post-Reagan/post-Berlin Wall years of relative peace and security seem so very long ago now, don’t they?

The reality, of course, is that we are far safer than we think we are. Yet our own personal realities are driven by the same psychology that led our parents to fear a coastal invasion, for us to fear Russian bombers. We march on each day, as we must. We march on so that each day’s completion becomes one more tiny victory in yet another long war fought for us mostly between the ears, so much like the Cold War before it. We seek victory once again in the daily act of living our normal lives.

We remember, though. Like I remember that it was a Tuesday. We never forget, nor should we try to forget. It is in the remembering and carrying on despite the remembering that we do our tiny part to honor those who were lost. Today is a day to take a moment away from normal to remember.

I remember.

I’ll see you next week…

–bingo

Understanding is the Bridge to Empathy in Race Matters

Only twice in my life have I ever noticed that I was different. That I was, or could be identified, as “other”. Now to be sure, at neither time did this realization make me uncomfortable. That’s probably because I was in a relatively familiar setting, just among a rather homogenous group of people where I was the guy who stood out. Being the only person in church or on the basketball court who is NOT of color was for me, a non-large very white male, more a case of “huh, that’s different” than a case of ” be on guard”.

More than anything else, that is likely part of the core of what is meant when we hear talk of “white privilege”: I am only at risk if I actually do something wrong.

Sitting here in suburbia, in middle-age, it’s instructive to look back at how I’ve arrived at such a place. A place where I always feel like I could belong no matter where my place takes me. The town of my earliest youth is probably most responsible for this. Southbridge was a dying mill town in Central Massachusetts, although none of us kids new it was dying at the time. Settled initially by French-Canadien ex-pats, a second wave of migration from Puerto Rico occurred before I went to grade school. 10 or 15 percent of my classmates were children of Puerto Rican immigrants, but I knew them only as kids in school or teammates on the various fields of our youth. We fought side-by-side 100 times more often than we ever fought facing each other. Sure, they were different. Their grandparents spoke Spanish while most of ours spoke French.

Home since childhood has been driven more by economics than any other factor. Most of my life since then has been lived in worlds that roughly track the Southbridge of my youth, roughly 80% White/20% Black or Brown. People of color were either there when I arrived (and so belonged as much as I), or arrived the same way I did (and so belonged as much as I). At this point I should confess that I’ve never given too very much thought to the color mix of my surroundings. This may also constitute “white privilege” I suppose, the privilege of not needing to be aware of color at all. What makes that kind of funny is that until the very last major move of my life, each time I’ve moved to a new place, many people assumed that I was Black prior to my arrival. Darrell White the presumably Black football player arriving at a new high school or at college? Nope. Short, skinny white guy. Darrell White the first ever Black med student or Black resident at my respective schools? Sorry to disappoint. Still, short skinny white guy. Only my voice is 6’5″, and with no accent whatsoever it is colorless.

How about those two instances where I did feel different, in church and on the basketball court? In church it was mostly humorous since the other congregants made such a huge effort to make me feel welcome. Indeed, as the only White family among the churchgoers at the Black Baptist church one Christmas it was more than comical when the pastor, my friend the Rev. Mel Woodard, introduced us from the altar (over my gentle objection) to the congregation. “Please welcome The Whites!” With a twinkle in her eye “Lovely Daughter” leaned over to me in the pew: “Duh!” No, other than the obvious pointed out by Megan, in that setting the group made sure that only the most superficial differences existed for me in that room. I would only be “other” if I chose to be.

The basketball court just down the street from Wills Eye was a bit of a different matter, and because of that more instructive when examined through the  magnification of the retrospectometer. The rules of pick-up ball are clear, and they are largely consistent in every park in America. There’s a line-up of who has “next”, and if you are not a regular you just call “next”, wait at the end of the line, and hope that you can assemble enough talent on your team to last more than one game. Here, like in church with Mel, mine was almost the only White face, but here I was “other” in every sense of the word. My turn as “next” kept getting lost on the list, the wait for that one game almost 2 hours before one of the park leaders acknowledged the tiny injustice and put my team on the court simply by joining us as our fifth guy. The other White guy was on the team, of course, and he was a stud baller. A bit to the right of average for that park, that game was the first time in my life when I was more conscious of what my game looked like than how I was playing. Who do I pass to? Do I take the open shot?

We lost the game, of course. Not so much because of anything I did or didn’t do during the game as that the other team had a guy named “Jelly Bean”  and no one could stop him (pretty decent player; I think his son was somebody in the NBA or something). In the comfort of not needing to be the least bit introspective, of not needing to learn anything at all from that morning, all I got until this past week from my encounter with Philadelphia inner city hoops was pissed off that I only got a single run after waiting two hours for my “next”. It’s only now as I look back that I realize my sense of being scrutinized, of being conscious of how I looked while playing rather than just playing, needing to be much, much better than the other “average” ballers there that day because I was White.

The events–church, a pick-up basketball game–are trivial, but the fall-out, however long in coming, is not. The fact that it is now 30 years since my non-battle with Kobe’s dad and I am just now aware of how I felt may be part of what is called “White privilege”, but moments like this are to be encouraged however long they are in coming, don’t you think? My oldest friends of color, roommates and groomsmen, as well as friends of more recent vintage will likely welcome this sense with little more than a playful “what took you so long” wink, and begin the dialogue. The Rev. Woodard’s congregants didn’t even need the comfort and cover of friendship to offer a wink (and in their collective case, countless hugs), so aware were they of how it feels to be “other” until proven otherwise.

Sympathy, my friends, is not enough. Sympathy is situational and episodic, and is therefore also transient. After all, who among us but the most hardened bigots or the most unreachable psychopaths cannot find sympathy for the family of the man killed while instinctively reaching for his wallet, or the families of the officers gunned down while on duty? No, sympathy is not enough because it is only something that we feel, and not something that we are, or even choose to be. Empathy is the magic elixir because empathy cannot be set aside. Empathy is to feel with, not simply to feel for, because it is a part of who we are. But empathy is hard, and empathy takes time. No one would wish the loss of a loved one on another in order to feel “with”. Sometimes empathy is little more than a spark, and sometimes that spark is so small that it goes unnoticed or ignored.

There is a bridge, though, between sympathy and empathy, and it is understanding. Like a physical bridge one must look to the other side and seek to be there. Like any bridge one must have the faith that over the crest in the middle, beyond the road you can see, there lies ahead a clear path to the other side. The trip may be a difficult one, but as with all trips, it will pass much more easily if in the company of others who either seek to understand as well, or better yet others who already do. Like all those men and women who came up to me in church and hugged me after Mel’s introduction. Like the guy at the park who joined my team, made sure I got “next”, and told me to come back for a run the next Saturday.

Like Sheldon and Steve, Rasesh and Mel who will hold my hand and guide me  as I climb the bridge myself.

 

Customer Service: The Ohio DMV vs. Your Eye Doctor

It was the smile Ms. DMV Lady. No question, the smile told me that you chose to ruin my day when you had a lay-up chance to make my whole weekend, that you did it on purpose, and that it made you incredibly happy. In any other circumstances I’m sure I would have smiled back at you; that’s what other human beings tend to do when they see such unbridled joy on someone else’s face.

That trip back was my third one to the DMV, but there was no way for you to know that. You did see me on the second one, though, and you clearly remembered me. I forgot my license at home so I couldn’t do what I needed to do to transfer the title for my tiny little beater of a boat. Not only that, but there was nothing you could do to help me at that point, and I totally understood that. It was my fault entirely, so I didn’t ask anything of you on that visit because I knew that there was no way that you could help me, no matter how much you might have wanted to on that particular visit. I was really frustrated for sure, but I didn’t direct any of that at you, or anyone in the DMV.

Nope, it was the return visit where you could have made my day. My wife and I hurried home, got my ID and then hustled back. Did you notice that? Did you notice that we were both there? It’s really hard to free up two people who work full-time during your hours of operation. Definitely not your fault, that. We’d already tried to pull this off the week before and been thwarted, and here we were back for a second time with you, third time total. Now was your chance. We approached the desk with obvious relief on our faces. If we were successful this time we would still have to visit the DMV one more time (you only do titles; another location would do the license), but at least only one of us would need to take off work. You took the title transfer again–you looked at it in detail the first time and couldn’t possibly have missed this–and told us that the previous owner had filled it out incorrectly. He signed it in his name alone, instead of his name as “trustee”. That’s it; he forgot to put “trustee”.  You could have tipped us off before we went home for the license. You could have just noted it and let it pass. Nope. You said that we would have to bring it to him to fix before you could transfer the title.

We were equal parts dumbfounded and devastated, and it showed clearly on our faces. Here it was again, your chance to make our day. There was nothing nefarious about the prior owner’s mistake; it was a simple oversight in how he described the ownership. God, it was such an easy fix. It was right there, right in front of you for the taking. I held out my hands and pleaded softly and quietly for mercy. No disrespect toward you or your staff or your department, and no sense of entitlement or demand for action. A very simple request and a very quiet plea that we had acted in good faith. Your response? “You forgot your ID the first time, Sir.” I simply held out my ID and very softly said “but I went home and got it without saying anything, and here I am. Please, we’re really trying hard here and really could’t know.”

It’s a legal document was all you said. You had a duty to protect the State of Ohio, you said. It was then that I responded, still quite quietly mind you. I shared that the couple you had just chosen not to help were a doctor and a nurse. That we routinely put our family second as we care for patients in need. Nights, weekends…no matter. I asked if I could fill out your customer service survey, either on paper or online, explaining that I am evaluated on the care I provide and the experience that my patients have under my care. Oh my…the look on your face was priceless. Utter shock. Not once in your life, it seemed, had it ever occurred to you that it would be possible that you would be accountable to your customers. “We don’t have anything like that, Sir.”

Then came the smile.

Seldom have I witnessed such a pure, unadulterated expression of joy. You had chosen to ruin my day, and having succeeded you were not just pleased, you were infused with a visceral joy. It started in your eyes as realization crept in, and then it spread to every muscle in your face. Like I said above, it was the kind of smile that is almost always returned by another human being; we are wired to share such joy, after all. Alas, ’twas not to be for you and me. It was all I could do not to vomit on your threshold when you somehow found the strength to break through the grip of your ecstasy to wish me a nice day.

You will see me again, Ms. DMV Lady. Three times we’ve tried to get our little 1971 boat licensed, and it looks like we will need to make two more stops to accomplish that. It most certainly won’t be at your particular DMV location, though. Just thinking about that makes me nauseous all over again. No, you will see me again on my turf, as a patient. Karma, if nothing else, is imbued with a keen understanding of irony, a truly wicked sense of humor. In all likelihood it won’t really be me, personally. Even karma would find that too outlandish, an irony simply too delicious to believe. In reality you will need someone who does what I do, and you will need them in a manner and a sense that is identical to how I needed you.

I noticed that you are very nearsighted, and you have an inflammatory disease of your eyelids called blepharitis that often causes an acute type of particularly unsightly pinkeye (you are not my patient; this is not a HIPPA violation). Perhaps your son is getting married this weekend like mine. You didn’t know that, did you?  No, of course not. You broke your 3 year old glasses. Your prescription is out of date and you can’t just walk in to Lenscrafters and get a new pair, and your vision insurance only covers me. It would be a shame to have to wear broken glasses to enjoy this wonderful day. Or maybe that ugly, uncomfortable pinkeye bubbled up and there you are all red and gooey, two days before the whole fam damly shows up for the wedding. Nether one is truly an emergency, and failing to take care of either one right away will not cause you any harm whatsoever.

Let’s make it even more realistic. You know, like my return trip to your office. Let’s say it’s just before closing time, and the only way to get your glasses or your medicine is if a doctor gives the OK to see you right away. No matter what you see on the billboard, you won’t get an appointment at the Cleveland Clinic or UH. No, it will be a private doc like me. We always try to help. The Doc will know your story. How? Well, through our staff we always know the story because it always makes a difference. Would it have mattered to you that the reason I so desperately wanted that boat licensed was so that my son–the one getting married–could take his cousins and his friends out on his wedding weekend? We’ll never know; you didn’t ask.

There you will sit with your non-emergent problem that is only barely even urgent except for how much it means to you personally. Do you have any idea how easily the doctor and staff can slow-roll this even now, after you are in the office? They can follow protocols to the letter, check every preferred practice pattern box and follow every single insurance billing protocol, your chart and super bill as clean and proper as the illustration of a perfect boat title as you wait for your insurance to authorize your vision care visit, or pre-approve your expensive branded medication, and ruin your weekend.

In short, they could be you, ignoring the very real person with the very real need who stands before them asking for help. Or they can see you, hear you, and so easily choose to help you. Which, of course, is exactly what they would do. They will call the insurance company to get your Rx authorized, or they will give you samples of the medicine to carry you until you get pre-approval. Because you see, Ms. DMV Lady, that’s what every single one of us is supposed to do when we are on the other side of the desk from someone who needs our help and we are truly, safely, and easily in the position to choose to help them. It’s the decent thing that decent people do for others. When they can either make your day or ruin your day, it never crosses their mind that they even have a choice. It’s funny, when they know a little more about how meaningful it is to you that they helped, they really feel good about that.

Which is why after you have been helped, after you get what not only what you need but what you really want, you will be surrounded by people with the huge smiles of joy that come from doing the right thing. You’ll undoubtedly smile back.

Will you know why?

 

 

 

 

Sunday musings 3/27/16

Sunday musings…

1) Crenellate. Create multiple indentations on an otherwise smooth edge.

No reason. Just a cool word.

2) Eyelash. The normal lifespan of a normal eyelash is approximately 5 months.

Nope. I didn’t know that, either.

3) 16.6. Recovering from surgery from a non-CrossFit condition, I sorta kinda did a couple of the 2016 Open WODs. At some point over the rest of the year I will eventually do them (hopefully Master’s Rx), but for now I’m about to embark on CrossFit Open 16.6: constantly varied functional movements performed at relatively high intensity, with the intension of improving my work capacity across broad time and modal domains.

The CrossFit Games Open 2016 is an interesting and fun diversion, one that gives us a common experience across time zones and geographic variance. For me, though, the real magic happens in the other 47 weeks, the 47 week experience that you could call “16.6″ and heading into “17.0″.

That’s why I’m here.

4) Easter. Does it strike anyone else as odd, or something like odd, that it is only the two major Christian holidays (Christmas and Easter) that have superimposed, widely followed non-religious traditions? Try as I might I find no such superimposition on such equally important annual religious observations like, say, Ramadan or Yom Kippur . More so, if you do a little digging into the Easter Bunny’s origin you find that in his original incarnation he, like Santa Claus, kept a ledger of “good and bad”, with the good receiving eggs/candy/gifts. While I have no insight into why this might be, I find it odd.

In the Christian world there is no more important celebration that Easter. Indeed, the very concept of Easter is as difficult and complex as that of the Trinity. Judaism and Christianity share the Old Testament, and presumably therefore share a belief in the same Deity. It is in the interpretation of the Messiah that most people understand the difference between the religions (interestingly, the Koran recognizes J.C. as a significant prophet), but the more profound difference between Christianity and all other religions as far as I can see is the chasm that faith must leap to accept both the Trinity and Easter miracle.

While I am best described as having faith in a deeper, greater Presence, I am not a very religious person any longer (this makes Grambingo very sad). However, not unlike the CrossFit we all practice here, it is instructive to note the secular attempts to nullify the religious aspects of both Easter and Christmas, while noting how hard it is to hold tight the two beliefs that are the crux of Christianity.

For those who do the hard work of Christianity I offer a heartfelt and sincere Happy Easter.

I’ll see you next week…

–bingo