Random Thoughts from a Restless Mind

“The grains of sand that pass through the funnel of life’s hourglass are only dry and colorless if they are observed from afar; up close each one is as colorful as any rainbow, as full of energy as any thunderstorm. Poetry is there for the asking.” DEW 1/16/2017.

While everyone isn’t necessarily “A” somebody, everyone is somebody who matters. My Dad was heroic in this regard. He remembered everyone. The lower on the economic food chain someone may have been, the more he remembered them. Janitors, waitresses/waiters, maintenance workers…he knew all of their names. He’d ask you about your story, ask you to describe the grains of sand in your hourglass, and if you told him he remembered. Dad would be dumbfounded by the denigration of these and other physical jobs so prevalent on mainstream media and other outlets.

Dad had a way with frontline workers. It was natural, a gift for sure, but he obviously worked at it, too. Did you have a problem getting THAT gift this year? Turns out, that’s not a new phenomenon caused by “COVID-related supply chain issues.” My Dad had a coronary artery bypass graft surgery (CABG) in 1985 at the peak of the Cabbage Patch Doll craze. Somehow he found a Cabbage Patch Doll for every nurse in the Coronary ICU to thank them for their care.

So what’s the point? It shouldn’t take a pandemic that interrupts every aspect of everyday life for us to notice the folks who aren’t anywhere near the top of the economic food chain. CEO’s saved the world in the early parts of the pandemic (Sunday NYT)? Bullshit. Company X allowed the economy to survive because it made “stay at home” work possible? Yeah, that’s bullshit, too. The person who answers the phone in my office or the person driving the garbage trucks had just as much impact as that self-satisfied CEO who’s biggest sacrifice was skipping Davos this year.

There’s no such thing as a small life. Each life is full, vibrant, colorful, and important. Each little grain of sand flowing through the hourglass is as meaningful as the next.

It’s been years since my Dad died and yet I return to his lessons on a daily basis. I see him talking to the guy who swept the floors in the factory. There his is, sitting down to lunch with a banker. If I close my eyes and just listen to the personal banter it’s hard to figure out which is which. The sands of time that flowed for each looked the same to my Dad. He heard the poetry, saw the beauty. My Dad made every life he touched bigger.

Everyone was a somebody.

An imaginary letter to an imaginary advice columnist about something that may or may not have happened…

Dear Arthur,

Boy, does this feel strange. I’m the guy who folks of all ages, types and sizes come to for advice. My sole goal, the thing that approaches every conscious decision I make is to speak and listen, act and react from a place of kindness and, if possible, love. Yet here I am, silently frozen out of a friendship more than 20 years in the making for a presumed act of disloyalty. I got caught in a picture that I tried very hard to avoid being caught in, and before I could untag myself my friend caught sight of it on some social media thing or another.

Even the mailman was puzzled by the stamp on my returned Christmas card: “Delivery Refused”.

My sin was to do something kind for another friend entirely. I accepted their invitation to a gathering where I would know many people; my attendance would be very welcomed by everyone there, and the friend who invited me would likely garner some goodwill for having me there. One of the other guests who I once knew quite well but hadn’t really had contact with for more than 8 years had caused great harm to my out-of-town friend, someone who I try to be in touch with several times each year.

With the exception of the time I spent with my hosts, locals we try to hang out with, the gathering was rather awkward and uncomfortable for me. I left after a short stay; the only goodbyes I said were to my hosts. Still, just for being there it appears as if my long-time friend has decided to end our friendship over a picture on the internet. Our last interaction was a two sentence exchange on that social media site in which I explained the invitation.

Since I have enjoyed this friendship a part of me feels compelled to explain. At the same time the reaction to the picture seems so outsized I am left to wonder if doing so will matter.

Anonymous

Dear Anonymous,

What an odd world we live in! Once upon a time you had to almost work at it to offend someone face to face, or at least via a phone call or personal letter in order to get put in the eternal friendship penalty box. Now? Apparently all you have to do is show up in a random picture somewhere online without any context. Rough place, that internet.

I get it, though. Judging by your somewhat cryptic letter something really lousy must have happened to your out-or-town friend at the hands of the other invited guest. You accepted the invitation from your local friends because, well, they’re your friends, too. You seem to have made an effort to be electronically invisible but got photographed anyway. Perhaps you were momentarily distracted and didn’t want to cause discomfort for your hosts by more aggressively declining the photo. You say that you aim to be kind in your interactions. It is understandable that the “here and now” of the gathering was the stronger influence.

So what now? You feel badly. Your out-of-town friendship must be very meaningful. I mean, you and your mailman looked carefully enough at the returned letter to see the “why” on the envelope. As I see it there are two ways you can look at this. You can paraphrase the American philosopher Elbert Bubbard: “Never explain. Your friends do not need it, and [everyone else] will not believe it.” Do you think a more in-depth explanation than your quick SM interchange will make a difference?

Or we can channel another Philosopher, Reinhold Niebuhr: “No virtuous act is quite as virtuous from the standpoint of our friend or foe as it is from our standpoint. Therefore we must be saved by the final form of love, which is forgiveness.” Perhaps, upon reflection your friend will realize the value of your friendship, and upon doing so will recall your basic nature. Your tendency to kindness. And having done so will forgive you for the pain you unintentionally and unknowingly caused.

To each other.

With best wishes, Arthur

I’ll see you next week…

[Post below was originally the 5th bullet point in “Sunday musings…” 1/16/2022″. After engaging a bit with Mr. Cuban (who is very accessible for a man as famous as he is) about drug costs and generics I wrote and posted this in the hope that Mark would put his considerable intellect and influence to the task of drug costs as a whole. To start a front to attack all of the financially malignant players (health insurers, PBM’s, bloated government regulations etc.) that stand between patients and the care they need and deserve. Mark recently did just this on X.com and elsewhere.]

Mark Cuban has launched a website/business called “Cost Plus Drugs” (costplusdrugs.com) to much fanfare, especially on Social Media of all sorts (Cuban is a plays SM like Yo Yo Ma plays cello). The concept is quite simple: buy generic drugs at wholesale cost, mark ’em up 15%, add a handling fee of $5 and ship ’em off to a waiting patient. The fanfare part comes in the marketing on the website. Each drug is compared with the retail price of the branded drug from which it was spawned. For example, $41 for a chemo drug compared with $9,600 for the brand. Brilliant, right?

Meh…not so much. First of all, if a super expensive drug is off-patent and there is now a generic equivalent on the market, essentially no one prescribes the branded drug anymore (caveat: equivalent in potency, side effects, etc.). Secondly, there are several options out there already doing a very nice job of this, thank you very much, without the hullabaloo surrounding Mr. Cuban’s offering. GoodRx and Costco come to mind. There’s somebody out there, can’t remember who, offering hundreds of generics for $4.00 a month. To the extent that Cost Plus Drugs continues to pressure the pharmaceutical industry and its high prices I suppose Cuban’s entry is a net positive.

Let’s step back and look at the real issue here, though: groundbreaking, new treatments are too expensive. I’m not talking about the outlandish prices of these branded, patent-protected drugs that people like Mark Cuban bandy about to make the price of their generic look so virtuous. No, I’m talking about the amount of money that comes out of the pockets of the people who need the newer medications for which a generic equivalent is not available (or who for whatever reason cannot take a particular generic). For all of Cuban’s bluster and bravado, the bruises that he is getting from patting himself on the back are all for naught. With very few exceptions people aren’t struggling to pay for generic chemo drugs, they are breaking the bank on the newer, more effective drugs.

In general, new drugs come in one of two varieties: minimally changed versions of existing drugs/”me too” drugs from a competing company in order to be in the market space, or truly innovative and new drugs that are a measurable upgrade in all ways from existing treatments. Yes, to be sure, there are some newcomers into a therapeutic space that have a similar mechanism of action as legacy drugs but really do work better in that treatment pathway, but they are a small minority; most are the same drug with a slightly different concentration or secondary delivery ingredients, patented and priced as if they were groundbreaking, new developments.

Where we need someone of Mark Cuban’s intellect, entrepreneurial zeal and all-around chutzpah is when the very best treatments, standard of care treatments, are not available as generics. Here the unholy triumvirate of manufacturer/pharmacy benefit manager (PBM) and insurance company put profit before patient (and healthcare worker) welfare. New, innovative treatments are priced so that the manufacturer can give a handsome rebate (kickback) to the PBM. A patient is then charged a co-pay which is a percentage of that artificially elevated price. This co-pay reduces the financial obligation of the insurance company to pay for the medication. If you’ve ever wondered why a medicine which was priced at $100 ten years ago is now $1,000, this is it.

If the Mark Cubans of the world want to have a real impact on the healthcare costs that matter, the costs to the patient themself, let them turn their attention here. It does us no good to have another do-gooding middleman saving patients a few dollars on widely available generic medications. This is the equivalent of hitting a single when you’re down 10 runs in the ninth. In eye care we don’t need someone to shave off a couple of bucks from the cost of Avastin as the first-line treatment for the devastating, sight-stealing disease macular degeneration; it’s like $50, so patients drop 10 bucks in the bucket on the way out. At big places like the Cleveland Clinic they pay more to park.

No, what we need is someone to step in and figure out how regular folks can afford Eylea or Lucentis, the branded medications that a majority of these patients end up needing when the Avastin stops working (as it almost always does). At $2000 a pop that 20% co-pay can run into thousands of dollars each year for folks who need injections every few weeks, sometimes forever. Cancer treatments that cost $40,000 per dose or truly revolutionary, life-saving drugs like the hepatitis C drugs that came out a few years ago that are now “only” $10-15,000. 20% of that is meaningful to most folks. Step up to the plate and take a swing at these, Mr. Cuban. Figure out how people who have terrible diseases that aren’t really all that rare can afford their medicine. You’re not a singles hitter. Figuring this out is the equivalent of hitting a walk-off grand slam in the 7th game of the World Series.

You were made for this, Mark.

Here we are, almost 4 weeks into another new year. With the exception of a single resolution to endeavor to be more like some of my friends who I admire, to adopt one or two of the laudable traits that make up their character, I really didn’t make up a list of traditional “things I should do” in the new year. And here it is, almost February, and I’ve yet to sit down to ponder how I fared in the year just past. As a way to do this each year I return to a little thought experiment I discovered in the WSJ some 8 or so years ago that measures, at least for me, whatever declines I may have experienced, against those gains that I have (hopefully) made:

You are given the option of taking a pill that will halt the aging process. At what age would you decide that the balance of physical prowess, mental acuity, and age-begotten wisdom, was optimized? At what age do you take the pill?

After a certain point that is different for everyone, each human begins to experience an inexorable decline in their physicality. Strength, speed, endurance, balance. Pretty much all of our physical attributes will show a net decrease over time. My physical prowess probably peaked in medical school. My classmates and I somehow found time to play hours of pick-up basketball each week, and we organized countless squash round-robins in a school with 20 racquetball but only two squash courts. Beth and I had already discovered a shared love of strength training, and for wild reasons of all the wrong kind, a small group of us found joy in the back row of the aerobics classes then in vogue. Age 26 was my peak year in this domain.

In a similar way, we become less “sharp” mentally. We may still maintain possession of our memories, our internal hard drive if you will, but we begin to experience slower access to them. Our computational abilities decline as well. Now, to be sure, this is not a straight-line decline, not like an airliner on the glide path. It’s more like descending through a rolling hillside on the way to the valley below: both physical and mental prowess can be enhanced, at least temporarily, through purposeful action.

On the flip side of this we have what we would all understand as “wisdom”. Wisdom is something more than simply experience. It’s more like, I dunno, actionable experience I guess. It’s a kind of knowing, a confidence leavened by compassion, in the act of decision making. If you are fortunate your wisdom is a source of comfort for some of your people. Having you, and your wisdom, makes their lives better.

Along with this comes a deeper type of happiness that you hopefully gain by ever closer relationships with those same people. Family, for sure, but close, loyal friends as well. Another year has hopefully brought you deeper, more positive interpersonal relationships that result from your wisdom. Another year has brought you more joy as well as an ever greater ability to recognize and embrace that joy (read the latest findings from the famous Harvard study on happiness over a lifetime: The Good Life by Waldinger and Schulz).

One very important aspect of that age-begotten wisdom is the ability to take a gimlet-eyed view of the decline. Blake Crouch in “Upgrade”: “If we all had perfect memory, we would all grieve the older version of who we used to be, the way we grieve departed friends.” Grieve yes. Pine, no. To pine for that earlier version is to regret not figuratively taking that time-stop pill earlier. Our wisdom will hopefully allow us to take the occasional trip back in time for the pleasure of watching a less-wise but almost surely more exciting version of ourselves.

Physicality, mental acuity, and wisdom. As noted, physicality and mental acuity can be trained to a point. After discovering CrossFit in 2005, just before my 46th birthday, I enjoyed a kind of “mini-peak” in my physical fitness at age 48. For the first time in my life I got really serious about strength; I was likely as strong as I was as a 22 year old football player in college. Likewise, until a shoulder injury derailed me at 49, I was likely MORE fit from a cardiovascular standpoint than at any other time in my life. Still, I managed to stay within hailing distance of 49 for almost 10 years.

The failure and ultimate “departure” of my left hip in 2019 brought a rather rapid reversal of many of these mid-life gains. Alas, despite what looked like a promising road to retrieval of at least some of those gains was derailed by my right hip’s decision to follow suit. Adding injury to insult, months of post-op pain prevented me from returning to even my pre-op levels of physicality. Now, at 66, the fight is similar to swimming in one of those pools in which you try to stay still while you swim against, for me, a current set somewhere around age 61.

The last peak.

Like all doctors in my generation I probably contained more stored information in my brain at the time of my med school graduation at age 26. I was likely as smart as I would ever be, at least without the help of a Google search or guidance from Claude, one of my new best friends, when I graduated from my residency at age 30. Still, even with this in mind it is glaringly obvious that my overall mental acuity continued to expand and improve, not only in the ever finer prism of my professional acuity, but also as a thinking “machine” in general. I began to write in earnest some time around 2004 or 5, expanding the “fitness” of my language “muscle”. Looking back and reading my earlier stuff I got steadily better as a writer for many years, at least until 2019 or so when I “lost” my muse, CrossFit. I still write something pretty decent on occasion though, both here and in the tiny little “home” I’ve carved out in my professional spaces.

Has my mental acuity started to back up like my physicality? Man, that’s a really tough call to make from the “inside”, ya know? I find myself spending an extra heartbeat or two waiting for a name to arrive, and I admit to finding it easier to just Google-check myself for random factoids I might have just tossed out with confidence in years past. Still, from a functional intellect standpoint where one is tasked with evaluating the data on hand and coming to a conclusion or making a decision, I’ve probably been sitting on my peak for quite a few years.

Likely still sitting on a rather high altitude mesa, a long-lived peak.

Which leaves wisdom. There’s a lot that’s packed into wisdom, especially if we want to continue to think of this thought experiment as a three-legged koan without adding smaller, however meaningful subcategories. If we include things like the ability to discover and experience joy, or as I wrote in an earlier year the capacity to both extend and accept empathy under the umbrella of wisdom, we can make it work.

In the last couple of years I have learned that increasing wisdom is harder and involves more pain than what it took to gain greater physical prowess or mental acuity, or the tribulation inherent in fighting off the inexorable and inevitable decline in both. Wisdom is certainly there to be gained in joyful experiences like the Mulligan we get if we are lucky enough to have grandchildren and to relive childhood years without the pressure of parenthood. It is there to be found in witnessing joy in those we care about. Hopefully our wisdom can be put to use in the pursuit of joy in ourselves and in others.

But wisdom seems to be a bit of a double-edged sword, I think. It seems that a meaningful amount of one’s wisdom comes about from times of hardship, or pain, or loss. I’ve written that the months of pain I experienced after my second hip surgery changed me. I am so very grateful that the pain stopped; I find it easier to come to situations with a grateful mindset, a subtype of wisdom. Each episode of lost innocence when expectations are unmet, especially by those closest to us. Lost parents. Lost or misplaced friends or, Heaven forbid, children. Any or all of this seems to impart the kind of wisdom which, when imparted either to others or simply within, is gained.

Wisdom, and the growth of wisdom within me, is the greatest reason I have turned down “the pill” in our little thought experiment. Looking back, even way back, it is the reason why I wouldn’t have taken the pill if someone had given the option at my physical peaks at 26 or 48, or the last peak at 59. Why I would not have stopped the clock at 30 or 40 or 50, or even this lovely high plateau as my intellectual gains began to slow. This type of knowing, of knowing joy and empathy, of knowing that I can still find gains in the most elemental essence of those closest to me, to experience growth DESPITE what are the inevitable declines in physicality and acuity, seems too precious a possibility to decline.

And so once again, at 66, I will gaze upon the pillbox and wonder, as I slowly close its cover and store it for another year. Will I ever make the call? Will the unescapable slide in physical and mental prowess eventually outpace the growth of wisdom? Ah, how could one know? Maybe the best I can do is to have a little hope, perhaps make a tiny wish that I am granted a bit more wisdom, at least for a little while, with only a little bit of the pain or the loss to pay.

Maybe, if I may, only a tiny bit to pay.

I’ll see you next week…

“Eating healthy is too expensive.” How often have you heard some version of that phrase. Whether it be Zone, Paleo, Whole 30, or just “stay out of the middle of the grocery store”, this is uttered with some degree of exasperation and oppression with a kind of mind-numbing, self-fulfilling frequency.

How so? Per the folks at Whole Foods, regularly skewered for being too expensive (seriously, they sell fancy potatoes), on average we in America spend 7% of our disposable personal income–that’s SEVEN–on food. 50 years ago that number was 16%. We now spend less than 1/2 of our after-tax income on food compared with what we spent 50 years ago.

And eating well is too expensive.

If we dig deeper into that stat alone we see that modern food production has decreased the cost of food relative to both income and inflation. The cost of producing food of all kinds has risen much more slowly than income. Why? Partly because junk carb-laden food is cheap. High-fructose corn syrup costs a fraction of grain sugar. Corn-fed protein with or without pharmaceuticals is grown faster and cheaper than grass-fed. Stuff like that. Less expensive to produce/incomes risen at a greater rate across the entire spectrum, top to bottom.

How then is it too expensive to eat a more healthy diet. We have 9% of our after-tax income to play with, right? Is some other necessity (shelter, transportation, medical care, etc) eating that up? What are we doing with that 9% that we can’t find some of it to eat better? Ah, Grasshopper, now we begin to see. It’s a ‘Nando thing, superficial. It’s not how healthy you are, it’s how you look, or something like that.

Some stuff might be more expensive, but the seemingly obvious culprits are actually false targets (eg. healthcare which for this audience represents only a tiny % of new cost c/w 50 years ago because of insurance, govt. programs, etc.). Nope, it’s how we CHOOSE to spend that freed-up 9% .

Think about that household in the 1960’s or even the 70’s. One car. One TV. One radio. Once purchased all data was free. A pair of shoes and a pair of boots. Sneaks if you were a jock. You didn’t get your hair done if you were a guy, you got a haircut. You didn’t get your acrylics touched up every 2 weeks; if you wanted long nails you grew ’em. Stuff like that.

Fast forward to today and think about the stuff you’ve acquired, stuff you are convinced you can’t live without, stuff that costs money that you choose to spend every single day. The ratio of drivers to cars in a household is seldom less than 1.5/1. The ratio phones to people over the age of 10 is seldom less than 1/1. It’s not enough to have a phone, or even a phone with an unlimited text plan, nope, it’s gotta be a phone that will let you post your thoughts on today’s weather in Bimini to FB. Right now, from anywhere. If you don’t have Netflix available on each of the 4 flat-screen TV’s in the house you are considered a Luddite.

Listen, I certainly am not saying that all that stuff isn’t great, that it’s not a ton of fun and really convenient (as I type on one of the Apple products that literally litter our household, through my WiFi network, in front of my LightBright lamp), or anything like that. What I most certainly AM saying, though, is that people who whine about how hard it is to afford to eat better almost always do so via a FB post from their iPhone 5 while sitting in the salon having their hair done, hungover from too much Bellevedere they consumed last night while noshing on Doritos smothered in Cheez-Wiz.

9 %. The stark reality is that we have let our things become more important than ourselves.

1) Seagull. Why don’t seagulls walking around on the ice get cold feet?

My hands turn white just looking at them walking around on the ice.

2) Thanatophobia. Fear of death. William Shatner of all people thinks about death all the time. I mean, he’s certainly old enough to have it on his mind, of course. To be honest I’m not sure he’s really truly afraid, just reluctant.

“i’m surrounded by love. My life is fertile. I don’t want to go. Thoughts of leaving leave me sad. I just don’t want to leave.”

I get every bit of that.

3) Wealth. There are many types of wealth. All of them capable of eliciting envy. According to Sahil Bloom the important ones are financial, time, social, mental, and physical.

We all know what it means to be financially wealthy, and to at least some degree what it takes to become financially wealthy. The other four respond to investment as well, and investments in all produce measurable returns that are more likely to be measured in happiness than financial wealth alone.

What’s your investment plan?

4) Mattering. Lots of folks around me thinking about retiring. A bunch of my doctor friends. Folks of all ages I know who are in the military. I brought a “welcome home” gift to friends who lost their house to a storm disaster and had to re-build. Pretty much the same age we spent an hour or so talking about our plans for our next, likely last acts. Like me, my friend Frank has given a lot of thought to not only the “when” but also to the “what comes after” part of the decision. We both get the keep busy part, and we are both committed to being busy in the company of friends and family.

Yesterday’s WSJ added a bit of a twist to the conversation, at least for me. One of the things I have really enjoyed about my job is the opportunity I have had over the last couple of decades to interact with folks at all levels of the org charts in the industry that exists alongside the “caring” part of healthcare. These are the people who work for companies that make the drugs and devices that doctors and their teammates use to preserve and restore health. In this role my job has been to bring the realities of life at the exact point of healthcare delivery to industry execs, and bring back to my clinical colleagues a sense of what a company can do to help.

I’d kinda like to keep doing this for a while, at least as long as those executives think whatever I have to bring to the table remains relevant.

When you have a job or some type of calling you begin each day with a very particular incentive: you show up because doing so matters. You’ve likely been doing something that matters for many years. A job, for sure, but there are any number of other things that might have gotten you out of the door that wouldn’t be considered employment. Perhaps you were the primary parent running a household and raising a family. Or on the other end of the timeline you spent years as the primary caregiver for a parent or older family member. Any number of volunteer positions certainly fit.

When you retire it’s natural to wonder if you matter anymore.

Jennifer Breheny Wallace, the author of the article and a soon to be book on the subject, posits that mattering has four main components: feeling significant (seen and essential), appreciated (valued for your contributions), invested in (supported and cared for), and depended on (needed by others), encapsulated as “SAID”. As I think about it this is a very helpful corollary to the things that I have been examining as think about how it is that I will spend my time in retirement. I have been using the term “relevant”, but I now think that this is simply a “clock” or duration issue. In a small sliver of what I hope to do when I retire what I am really saying is I’d like to keep my little place at the intersection between commerce and care for as long as I matter.

Like everyone I know who is thinking about retirement I have endeavored to ensure that I have enough financial wealth to not run out of money before I “leave”. I have spent my working life in the company of retired people many years my senior and I believe they only come in two varieties, those who relax into the free time bounty they have graduated to, and those who are so busy they can’t figure out how they ever had enough time to hold a job. Kinda hoping that’s me! I’ve invested time and effort to build my physical and mental “bank accounts” in the hope that here, too, I will have enough wealth to avoid impoverishment for as long as possible.

Mattering speaks to social wealth, at least in part. Happiness is well-known to be highly dependent on having close personal connections, especially as you get further away whatever it was you retired from. That still feels like investment job number one as you build your retirement. To feel needed and wanted, significant and appreciated, to find that place where you matter seems like an awfully good investment strategy.

I guess I’ll keep doing all this as long as it matters, and as long as it does I’ll see you next week…

Lake Wobegone, where every child is above average. Remember that? It’s a joke, of course, but it’s funnier if you have even the tiniest bit of comfort with numbers, statistics, and probabilities. Every parent wishes for that, right? To have raised a child who rose even just a little bit above.

What does it mean to be average? It begins with the cohort, the population you are evaluating, and the particular variable that is to be measured. The average Division 3 cornerback is a decidedly different specimen than the average guy playing on Sunday. The average working vocabulary in a room filled with Pulitzer Prize winners is quite a bit different than that of, say, the Green Bay Packers booster club luncheon yesterday. On the other hand, the average VO2 max in those latter two groups is likely pretty similar.

Along with average comes a range in any curve. Some groups are tightly bunched around the mean, the average; being average is an expectation. On the line at Ford your performance has to be average at worst. If you are above or below the average in any other group it probably is helpful to know how big the range of differences is in that group. For example, if we are measuring 400M run times at the Olympics there’s a pretty skinny range beyond which below or above average makes you stick out, good and bad.

Average does not necessarily mean mediocre.

I got to thinking about this yesterday when I heard from a bunch of my college buddies sending along birthday wishes. In my life there have been two places where I’ve been average: Williams College and CrossFit. Both here in the CrossFit world and in my college years at Williams it has taken everything that I have just to be in the middle of the pack. This is a double-edged sword. It’s humbling to have to literally give it your all just to hit the mean. However, placed into a group or given a task in which you have the potential to excel, to bust the curve if you will, the experience of having to work so hard just to be middling should drive you to do the same when you have a chance to be the best.

My Mom and Dad did, indeed, raise kids who were above average. It appears that Mrs. bingo and I may have done so, too. If we are lucky, the Man Cub and his cousins will follow suit. The only way I will know is because I had the privilege of struggling to be average in the company of two very extraordinary groups of people.

My classmates and teammates at Williams and my fellow CrossFitters.

1) Saddle. As in “back in the saddle” this week. For Beth, to be taken quite literally as she has been astride her horse “Hero” almost every day, riding for fun, fame, and glory. For me? Well, it was back to work, each day astride my trusty stool as I steer through a microscope.

Riding for everyone who came in.

2. Edwin’s. Beth and I joined close friends to celebrate my 66th birthday at a rather unique restaurant named “Edwin’s”. I’m afraid I can’t remember why “Edwin’s” but the story behind the restaurant’s concept I do remember. Once upon a time when BC the owner of the restaurant was a teenager he ran afoul of the law in some way or another. Again, I don’t remember the exact details of this part of the story (it’s findable online as BC is quite transparent about his youth), but I do remember that it was a nonviolent mistake.

When brought before the judge BC was quite contrite. The judge, exhibiting astute powers of character assessment, realized that BC was hardly on a course toward a life of crime. He admonished the youth to stick to the straight and narrow, and warned him that he, the judge, would be watching over him, lest his character assessment be inaccurate. Should he break the law again the judge assured BC that he would face a maximum sentence for both the original and subsequent crimes.

As it turns out, not only was the judge correct in his assessment, but BC silently vowed on the spot that he would find some way to repay the judge. How? After a decade or so managing prestigious restaurants BC left the world of the employed and opened a restaurant almost entirely staffed by the formerly incarcerated. Chefs, waitstaff, hostesses and bartenders, all with time spent behind bars. So, too, the bartenders, valets, and bussers. (See below)

A huge hat tip and “good on ya” to BC, who we know casually, on paying back a man who gave him a mulligan. It was a privilege to dine at Edwin’s.

3) Service. As I get older, and reflect that I have spent my entire working life in the service of others, I find it more and more difficult to tolerate poor service when I am on the receiving end of the continuum. I once wrote an essay in which I stated that every doctor should spend 6 months learning what it means to provide service by working as either a caddy, waitstaff in a breakfast joint, or selling shoes. To understand the serving side of the continuum you should spend time in the act of one-on-one service. It’s harder and harder not to call attention to poor service when I am the one paying for the service.

Of course, how we perceive the quality of the service we receive is dependent on our expectations in any given situation, or at least it should be. For example, if I am buying shoes in person I have an entirely different expectation of what my service experience will be if I am shopping at a DSW outlet vs. Nordstroms. One should make it a point to know the “story” about any place you might seek service so that you are prepared.

There is often a financial correlation between the experience extremes, dismissive to flawless, and we quite naturally expect a level of service that is closer to flawless if we are paying a premium. Many’s the time that you can accurately assume what to expect simply by looking at the “menu”. A “destination” restaurant that specializes in classic French cuisine typically has prices that will curl your hair. Naturally you expect a dining experience commensurate with the quality of the food, and in the overwhelming majority of cases this is precisely what you will get. Dismissive or inattentive service would be unacceptable.

Edwin’s is a case in point where one must do a little bit of research before making a reservation. While the food is, indeed, outstanding, and the prices are full-on fancy French restaurant prices, there are parts of the dining experience that are entirely expected given the main mission of the restaurant, to provide training and employment in an unexpected arena to an unexpected cohort of employees. Here the expectation is about effort and attitude. Or it should be. Ten minutes to take dinners orders at a four-top? You could just see how hard the waiter was trying not to make a mistake. Tiny little white wine glasses for the massive Bordeaux? The guy fairly sprinted to the bar for replacements. We waited a long time for our dinners to arrive.

No way was Chef sending out a plate that was less than perfect. We tipped big.

Healthcare is a more complex experience than buying a pair of shoes or sitting down to a dish of Cocque aux Vin. Much of what is dispensed in the U.S. is done so in the absence of local pricing power: insurance companies and the government effectively set the “price” of care for the vast majority of Americans. Interestingly, the larger the healthcare organization the more likely it is that it is paid MORE for the care provided (a result of the Affordable Care Act), all the while providing a care experience that is typically closer to, say, an Au Bon Pain chain restaurant than The French Laundry, despite receiving French Laundry “fees”.

There are segments of American healthcare that behave more like other retail service spaces like the above-mentioned shoe shopping and dining. Cosmetic plastic surgery, refractive surgery, and veterinary medicine are all cash-pay businesses that must justify the prices on their “menu” by achieving excellent outcomes and a flawless experience. A plastic surgeon will struggle to survive in a market if they do not have excellent results, and those who have excellent results but do not provide a French Laundry experience will find it difficult to charge top of the market fees.

I have spent my entire professional career as a refractive cataract and laser surgeon. Some of what I do is largely or entirely paid for by insurance of some sort or another. However, there are some things that I do that are not recognized by health insurance policies as medically necessary, however desirable a patient might find them. In my case the most common of these are refractive surgeries like LASIK, the intraocular contact lens, and specialized lens implants to reduce or eliminate the need to wear glasses after cataract surgery. These are “cash pay” procedures just like cosmetic plastic surgery procedures, and because of this people expect not only an extraordinary outcome but also flawless “service” along the way.

A refractive cataract and laser practice that does not achieve excellent results or does not treat its patients like visitors to a fine restaurant may very well struggle to justify its prices.

This long-winded dissertation is a prelude to our family experience with a 100% cash-pay medical experience that was very disappointing to say the least. Do you have a pet? If you do you then know that, with few exceptions, veterinary medicine is a cash-pay business. Ever have a pet with an emergency? Man, then you REALLY know that vets are in the cash-pay business. It doesn’t matter how long your family has been seeing a particular veterinary practice (for us it’s been 13 years), or how busy the doctors happen to be on the day your pet has an emergency (lots of open slots in the schedule in our case) you are writing a hella big check just to have them seen in an emergency-prompt fashion.

You are probably looking for me to exclaim that these “enhanced” fees should come along with some sort of enhanced services. After all, they will do the same exact stuff they would do on a scheduled visit, just with a premium added to the bill because your pet couldn’t wait for the next available visit to be seen after they got hit by a car, or bitten by a snake, or whatever. For any resentment at a business model that takes advantage of the emotional trauma suffered by the pet owner I might have, I am actually jealous of their ability to charge for their availability. So nope. What I find unbelievable, bordering (as a fellow healthcare worker) on amoral, is care that falls below the basic level of expectations that every patient or patient-equivalent has a right to expect when seeking and obtaining care on a regular basis. Care that is universally provided whether it is covered by insurance or cash, whether the office is a tiny boutique private practice or a massive medical institution.

Whether doing a facelift, selling a pair of shoes, preparing and serving food, doing cataract surgery, or caring for a dog with an injury, there are basic levels of service that must be provided. Operate in a sterile setting, disinfect a shoe that has been tried on previously, be mindful of food allergies, do everything to ensure the proper implant is inserted. Things so basic that they are “table stakes”, the ante you put up just to be in the game. Even more basic than that is to communicate clearly and accurately with your patient, and to provide ongoing communication if the care is ongoing.

Yup, I’m on the receiving end of the service continuum on this one. There’s no backstory, no feel good story here to explain why our family and our dog have received bad service. Which has resulted in substandard medical care. No apology or explanation. We have a long history with this practice and I was led all along to believe that I was in the equivalent of a fine dining restaurant, and I was charged accordingly. I expected to be treated accordingly. I certainly expected to receive the most basic care and feeding, to be informed of a diagnosis and a plan, not to be gaslit that we had, indeed, been contacted and informed. Table stakes, all. Hardly the stuff of fine French dining.

The older I get the harder it is for me to stomach poor quality service when I am on the receiving end of the service continuum. I was a caddy as a kid. Even as a young man I understood the concept of basic standards of service. Table stakes. It’s been almost 5 days and I don’t feel one bit better about what we experienced at the vet. It’s harder and harder not to call attention to inexplicable bad service when I am paying for the service. Especially when someone stiffs me on a table stake.

It’s becoming less and less likely that I will be able to keep myself from picking up the phone.

I’ll see you next week…

1) Magi. As in the O. Henry short story “The Gift of the Magi.” You remember it, right? A young couple so in love they each sell their most priceless possessions in order that they may afford to buy each other a most personal, meaningful gift. Della cuts her hair and sells it so that she can buy a chain for Jim’s treasured pocket watch. Jim, of course, sells the watch to buy beautiful combs for Della’s exquisite hair.

All at once rendering their gifts useless, and yet as priceless as the sacrifices they made to obtain them.

2) Seeing. Remember the story I told last week when I was re-telling the tale of Beth explaining how Santa is, was, and always will be real? About the Dad who taught his son the true meaning of giving a gift? The son was tasked with thinking deeply about someone who would be lifted by a gift that was given from someone who had done just that, thought deeply about the recipient.

To give a truly meaningful gift does not necessarily need to involve sacrifice, like Della and Jim, nor does it require anonymity as the father insisted in order that his son become a true Santa. What it does need is the kind of deep knowledge about the recipient of your gift in such a way that they feel seen. Known. Understood.

Such a gift need not be practical in a way that it fulfills a need, nor does it necessarily need to be impractical in a way that it fulfills only a want. It could, of course, do both, like a hair comb or a watch chain, but my conjecture is that it is the transmission that you know, really know the recipient that is the truer essence of the giving.

This past week I have been on the receiving end of many, many gifts. Each one, however small (thin peds to fit into stylish new beach shoes) or large (IYKYK!) sent the message loud and clear: “I see you!”

3) Loved. If you celebrate Christmas (or Hanukah for that matter) you probably did a bit of gift giving recently. Sure, some of it probably felt kinda like an obligation, but at least of bit of that gift giving was really more about the expression of love behind the gift. That’s the easy part, at least for me, expressing love. I spent so much time thinking about the people who would be receiving my gifts. Once I gave myself permission to freely express love it really became pretty easy.

And it was fun, too!

The receiving end of the gift thing is a lot of fun, too, of course. I mean–come on–who doesn’t like opening up gifts?! One in particular left me standing and staring and just repeating “holy shit” over and over again! The video is hilarious. Lots of funny stuff around getting a gift, too. Think of all the funny “re-gifting” stories you have, or the last “White Elephant” party you attended. In the White house the philosophy of “it’s OK to say you probably won’t use that gift” became “REJECT THAT GIFT”! Seriously, toss it back under the tree right in front of the gift giver reject it. That got to be quite funny. We still talk about my sister Kerstin and her multi-year streak of having her gifts rejected, and the year of redemption where each of her gifts was everyone’s highlight of the year.

In reality, accepting a gift is really rather easy. It’s accepting the love behind the gift, accepting another’s love that’s a little more complex. Maybe you didn’t know. Maybe you are worried it’s conditional, with strings attached. More often, though, the problem is that you aren’t really sure HOW to accept the love, or even if you are deserving of such a thing. That’s it, isn’t it? That’s really what you’re thinking. “They can’t possibly love me, love me that much. If they only knew the truth.” Or something like that.

Here’s the truth: they really DO know. Know you. And because of that they really, actually, truly DO love you. Most importantly there’s not even a little bit of a mistake here, and more than likely there’s not even the tiniest thread of a string attached. Not only are you loved, not only has someone in some way told you that, you deserve every little bit of that love. Carry that thought into the New Year. That you really are loved. That you deserve that love. Resolve this year to believe that. Resolve in 2026 to be openly thankful for that love, just like you are for that beautifully gift-wrapped present under the tree or the Menorah.

Resolve to let yourself be loved this year.

I’ll see you, well, next year…

Once again on this day of days I offer this verse from “An Olde City Bar” by the Trans Siberian Orchestra.

“If you want to arrange it

this world, you can change it.

If we could just make

this whole Christmas thing

last.

By helping a neighbor,

or even a stranger.

To know who needs help

you need only just

ask.”

Merry Christmas my friends. May the Eastern Star light your life today, and every day.

I’ll see you on Sunday…