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Archive for January, 2020

Thoughts on Inequality

“Life’s not fair.” –Scar

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

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

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

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

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

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

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

Enduring Friendship: Sunday musings…1/26/19

Sunday musings…

1)  Capitalism. “Capitalism is the worst economic system, except for all of the rest of them.” Winston Churchill

2) Randy Newman. While I was surfing around Facebook the other day I came across a page where Three Dog Night was singing their hit song “Mama Told Me Not to Come”. It turns out the song was written by Randy Newman.

Of course it was.

3) Friendship. I have been asked many times over the years when it is that I actually write “Sunday musings…” That question has always puzzled, and frankly amused me. I mean, it is called SUNDAY musings, right? I sit down on a Sunday morning and think back over the week just past and pull out the things that were interesting to me. Or things that made me think. Or things that I hadn’t quite figured out yet. But I really do sit down on a Sunday and put down my thoughts on that day.

This week I was planning on writing about CrossFit, and where CrossFit finds itself as a movement in the year 2020. I also stumbled across an article on the dangers of early specialization in young athletes. Poor Zion Williams looks like he is the most recent victim of this phenomenon, having experienced a knee injury at the tender age of 19, suffered in the act of plying his trade. Now for sure I will eventually take up both of these topics, but as is so often the case something is a little bit more important, or at least high enough on my priority list that it will bump everything else and become this week’s “Sunday musings…”

Friendship is once again foremost in my mind this morning.

Last night Beth and I hosted a group of couples we first met when our family moved to Bay Village Ohio in 1992. Bay Village is a pretty interesting place. People are born there, go to school there, return, and raise families. It’s not unusual for Cleveland natives to live in a social circle which was formed in kindergarten. This is not only particular of Bay Village, but seems to be a thing across the entire Northeast Ohio region. I have friends who went to Catholic elementary school, junior high school, high school, and then college, who will see their best friend from age 5 on a weekly basis for a beer. The particular group we had dinner with last night is not like that at all. We were all transplants from somewhere else raising our families in Bay.

Beth and I have watched this phenomenon now for several generations, as parents ourselves watching our children, but also watching some of my younger colleagues in the healthcare community. The preschool PTA group we hosted for dinner last night all had children within a year or two of one or several of our three. Most of the moms were stay-at-home mothers, a surprisingly common state that women in our generation found themselves in during the early 1990s. As an aside, the death of the stay-at-home mom was proclaimed quite prematurely, at least in the greater Cleveland area. As is so often the case the men involved became friendly as a side effect of the lives that our wives were living while they were raising children.

For the seven couples arranged around our table last night it has been at least a 25 year journey in friendship. Support given and received during the tumultuous years of raising children has evolved into the kind of friendships where trust is a given. It’s funny how these friendships built through our children are the friendships of our adult years. I have often noted that men are very bad at the game of making friends after we leave school. Particularly after the age of 30 men don’t do a very good job at making friends. Women tend to make friends by sharing experiences, sharing emotions. This can actually be done over the phone, by FaceTime, even through texting and messaging. Of course, it’s always better when done face-to-face. Men, on the other hand, are well known to make friends standing shoulder to shoulder. Our friendships are typically based on shared experiences.

Our particular group of men has bonded over the game of golf. I was really the only real golfer in the group when we started. As I have written before my dad gifted the game of golf to my brother and me when we were very young. All of the other men in our group took up golf later in life. Sessions at the driving range and rounds played at public courses all over Ohio and on trips to the South were as much about time spent together as they were about time spent playing golf. My sides and my stomach ache this morning from all of the laughter we shared last night retelling the same stories we’ve been telling now for 25 years about adventures on and around golf courses; adventures in friendship more than really adventures in golf.

What’s the point, you ask? Well, I think the point is really most about the value of these long tenured friendships. Tending to these friendships like one would tend to an ancient garden. You know in your heart that the garden will still be there if you happen to travel, to spend time away from it. And yet time spent in the garden, tending the flowers, judiciously weeding out anything that might harm the garden makes it so much better. The effort to do so really doesn’t feel like work at all, does it? The joy one gets from being in the garden is so great that the work it takes to tend to the garden just doesn’t feel like work at all. Friendships like that are a gift.

Last night we ate too much, consumed at least enough wine, and left no dessert behind. We listened, we laughed, and we loved. I guess “Sunday musings…” today is really just a long and rambling “thank you” to our friends for, well, being our friends. I always wake up every morning thinking how lucky I am. Over the course of this weekend at dinner on both Friday and Saturday nights Beth and I were embraced by our friends.

This morning I woke up feeling just a little bit luckier.

I’ll see you next week…

Sunday musings…1/19/20

Sunday musings…

1) Hiatus. Been a couple of weeks. Miss me? Lots to catch up on.

2) Spotify. I love Spotify.

That is all.

3) Dragon. At the moment I am awaiting the delivery of a new laptop that will allow me to “talk” my writing. I have long known that I am much more creative when I speak than when I type (my fingers can’t keep up with my brain, especially with this gawd awful new Mac keyboard).

With the likely exception of travel this may be the last “musings…” I type.

4) Wax. To increase or grow. To thrive

Wane. To decline or shrink. To wither.

Admit it, you always have to pause for just a moment to remember which is which. You’re welcome.

5) Narrative. Pretty much just means story. Like “my story” instead of “my narrative” except that narrative has been adopted by the precious consulting/media class to upgrade the seriousness of whatever they may be discussing. It’s all so very pretentious if you ask me. “Narrative correction” is simply changing the story, usually to one that makes the changer look better or gives them some sort of edge. For some reason it just seems more acceptable, rational, and proper if you are changing the “narrative” rather than your “story”.

Remember, the folks who insist on using “narrative” are the same folks who have so brutally abused the word “so” through such massively unthinking overuse that it makes “Um” look like a comparative slacker in public speaking. I still wonder why every declarative sentence uttered when changing the narrative ends in an uptick, a verbal question mark.

If you have questions about every sentence in your narrative why should I believe your story?

6) Judy. For the life of me I don’t know why I suggested that Beth and I watch the new Renee Zellwinger movie about the late singer Judy Garland. Man, it was 2 hours of relentless beat down of both Ms. Garland and anyone watching. What a sad story. Judy was psychologically abused from her earliest teen years, emotionally abandoned by her parents and apparently physically abused by power figures (read: men) in the studio system that made her a star. Dead at 47 but by the looks of it without living for many, many years prior to that.

Ms. Zellwinger is a revelation in the title role. If you are a movie buff (and I admit, I am starting to enjoy the exploration of movies as I enter my last 3 innings) her performance is riveting. If not this is probably one to steer clear of.

The end was a relief.

7) Trifle. My day job is one that has one of the highest suicide rates of any jobs in the U.S. Physician, that is. Don’t worry, this is not any kind of plea for help as I do not suffer from what is commonly known as “physician burnout”, the umbrella term for the myriad psychological stresses felt by practicing doctors that leads to the kind of beat down felt above by Ms. Garland. (As an aside a recurring theme around Judy Garland was a kind of incredulity by people with whom she worked that anyone like Ms. Garland could have any reason to be unhappy, let alone depressed). In fact I recently gave a speech about the quest for happiness in doctors in which I state early and often that I am actually quite happy.

But as I look around at my colleagues I see so many of them succumbing to the continual micro-assaults they suffer in silence until eventually the cumulative wounds add up to a hemorrhage of the spirit that is as unstoppable as a single slash to their emotional carotid artery. As is my wont I have been searching for some vocabulary help, some phrasing, a metaphor to use that would help me to both understand and explain what I see. Reading “The Ethicist” in this morning’s Sunday Times I came across this gem:

“De minimus non curat lex.” The Law does not care about trifles.

Eureka. Every doctor is taught that nothing is a trifle when it comes to the health of their patients. Especially the patient sitting in front of them. And yet 90+% of the changes in the provision of medicine over the last 2 decades have been precisely that, the introduction and proliferation of trifles into the sacred space between doctor and patient. “Non-combatant” narrative correctors have piled trifle upon trifle into the life of your doctors. Things that have no meaningful positive impact on your health. These, in turn, have bled much of the joy from the exam room for those same doctors. Making matters worse is the fact that more and more power has been vested in those OUTSIDE the exam room, OUTSIDE the operating room. Think administrators, government functionaries, insurance and pharma executives.Those who brought you the abuse of “so”, the question mark at the end of declarative sentences, and “narrative” want your doctor to be accountable to them, not to you and your individual health.

Fidelity to HIPPA rather than the Hippocratic Oath.

Despair over the injuries of a thousand pin pricks can be hidden until the psychological blood loss is the equivalent of a head on car crash. Judy Garland was “Judy Garland” on opening night in London. No one in that audience could see the scars from her years of abuse. No one knew how much “blood” had been lost until her injuries added up to a stumbling, bumbling and mumbling catastrophe on stage. Doctors, like Judy Garland, are looked upon as pampered creatures of privilege. Generally well-paid and with at least the veneer of social prominence and deference, it is inconceivable that they could be suffering from the very thing that has given them their station. To complain, nay even to offer the observation that such a thing could be, is met with at best incredulity, at least as often with scorn and ridicule. It’s just a trifle; what’s your problem?

Each trifle is in itself trivial. Yet trifle upon trifle leads to discouragement. It is discouragement that leads to despair, despair that can lead to death. To be damaged by being buried under a ton of pebbles is no different than the damage that occurs from the strike of a a single, massive boulder.

Just this morning the solution came to me thanks to The Ethicist and my new vocabulary word, “trifle”. We physicians are more important to our audience than Judy Garland was to hers because we possess the ability to prolong life, to cure, to make well. And like Ms. Garland who could not resist the stage, we desperately want to to this, to prolong life, to cure, to make well. During a brief conversation with my colleague Barry this morning it became apparent to me that our “narrative” has been stolen, or at least our right to own and tell our narrative, and with it I fear our ability to save ourselves is gone as well.

Think about this a little bit, won’t you? My epiphany this morning was equal parts simple, straight forward, and stunning. That part of our healthcare system that that most deserves saving is the part where a doctor sits with a patient with the sole responsibility and goal of making them healthy; call it the Hippocratic Space. Saving that sacred space won’t  come from us, your doctors. This morning it became clear to me that saving that space, and along with it saving doctors, will be done by patients. All of us are patients, and it is as patients that we have the most to lose if the avalanche of trifles drives doctors as we’ve known them off the mountain.

8) Dragon 2. If I had dictated “Sunday musings…” today I would not only have been done long ago, but at the time I type these last words I would also be done with my workout, taken a shower, and finished the laundry.

I’ll see you next week…

The Slow, Easy Curve at Mile Marker 59

Turning 50 was awful. I stunk at turning 50. From the minute my 49th birthday was over I began turning 50 and I was simply terrible at it. In short I had popped off in my early 40’s about all of the magnificent stuff I was gonna do when I turned 50–climb Kilimanjaro, teach cataract surgery in Nepal–but when push came to shove my life was crammed with stuff happening right here at home. And I was broke. I spent almost the whole year in a tight little angst bubble until one of my patients tipped me off to the problem as we discussed her upcoming 60th. You can read about the details in “The Hard Turn at Mile Marker 49” if you wish (as it happens it’s actually one of my better pieces. Go figure.).

My birthday is in two days and I will be 60. What’s it been like this past year, turning 60? Funny you should ask. In truth it’s been a tumultuous year of change, challenge, and loss. It should have been a real trial, to be honest. In fact it’s turned out to be kinda easy. Like it was just another year. Just another meaningless romp around the sun. If it wasn’t for all of the folks asking me about it I probably would have had it sneak up on me and all of a sudden appear in the windshield..

How come?

This year should have been the one filled with angst. Seriously, there was so much illness and loss I should have been buried. Every positive milestone, whether it be personal or professional, was paired with some sort of emotional speed bump. When I was turning 50 any one of those speed bumps might have launched me over the edge of the highway, but this year they were strangely tolerable. We lost my mother-in-law Sandy just before my 59th, and Beth and her sisters spent months cleaning up the estate. Both of Sandy’s brothers passed as well, in 13 months wiping out the entire generation of Schaefer’s. My Mom had one medical challenge after another, in and out of ER’s and hospitals and finally out of our family home and into an apartment nearby. Sadly, even though her living situation is much safer, much more appropriate to her life stage, the medical itinerary didn’t change all that much. Maybe it’s just that we’ve all had so much practice at handling the challenges of the generation before us (as opposed to those of the generation that follows us when I was turning 50), but it all passed in a rather matter-of-fact fashion.

More than that, the speed bumps didn’t take away from the joys that found us this year. What would have totally derailed me, and stolen all of the sweetness of whatever lovely stuff was happening, just kinda rolled by in a “handled mode”. Now I will admit that stuff that was happening with my grandchildren still made me anxious, and there was plenty of that. Still, the good things were really good, and I felt that goodness while it was happening. I needed a new hip (not so good), but it went off without a hitch thanks to a great surgeon and the fact that I still control every bit of my schedule. Coming back to the office was a breeze, even though we ended up being crazy busy out of the gate. Instead of pushing back against the extra work my entire team reveled in the fact that we were doing great and stepped up big time. So did I! All of my Dad’s (and Gramp’s) genetics caught up with me this year; my doctor friends all insisted that my CrossFitty lifestyle needed a little boost from modern medicine. Even this passed with little more than a tiny shrug since all three of them, dear friends, softened the blows with heartfelt hugs.

Why so much better at 59 than 49? It all kinda made sense. Middle-aged guy medical stuff? Of course there was. I think it was also about expectations. I don’t think I really had them this time, which left me free to not only see all of the roses blooming along the path to 60, but step off the road to smell them, hang out awhile among them. Seriously, I have no idea why all of the indignities of getting older were little more than a passing cloud in otherwise blue skies.

Actually, yes I do. I am openly grateful for each of the good things in and around me. Those surprises that shocked me at 49 are almost all really nice surprises this time. Seriously, is there anything better than the sound of a grandchild’s excitement when they realize you are home?The warmth of a child’s embrace as if it’s been a month of Sundays since you were last together, and it’s been less than an hour? Without conscious effort I have begun to stop and take a moment each time something is good, someone is nice, things look up, and just enjoy it. Enjoy it and be glad for it. These things are mostly small, almost insignificant (the first time I deadlifted after my hip surgery; my Man Cub writing his name for the first time in my notebook), but some of them were, in retrospect, kinda big (gonna have to trust me on these). But large or small, this time I am openly happy for the happening and grateful for that happiness.

Whereas turning 50 seemed like coming upon a hard turn while speeding along the highway, turning 60 was a nice easy cruise with my darling Beth along a gently winding road with mostly killer views. I was terrible at turning 50 but pretty darned good at actually being 50. Will I be as good at being 60? Who knows, but I have a good feeling about 60, just like I ended up having a good feeling about 50. It’s great to be here, great to have so many of my loved ones still here, so many living so close to me, those not closer wishing they were, so many genuinely happy to be with me. I have what I need and I want what I have; it’s been like that for a really long time and turning 50 seems to have awakened me to that fact.

I’m rounding an easy curve at mile marker 59, arriving at 60 in two days, and I’m very grateful for the ride.


2020? the Kid’s Alright: “New Year’s musings…”

On the surface there seem to be so many similarities. Between 1920 and 2020 that is. A soaring stock market. Companies setting profit records every quarter. Essentially full employment across all industries and economic strata. Technology coming on board that promises to continue to move all of these needles forward. Americans were generally not just positive about the economy and the state of all things American, their bullishness knew few bounds. Of course, there was the little, pebble-in-the-shoe issue of a growing chasm between the “common man” and the ultra-wealthy, a tiny gnawing ache in the soul of the country. Still, there was so much positive stuff, so much momentum.

What’s it gonna be in the 2020’s?

Now the cynical, the naysayers and the glass half-empties would look at our world today and say that there is a fundamental difference between then and now brought on by a single man in power. More contemplative members of this camp are a bit more sanguine about the provenance of this feeling; they would say that it was there for quite some time, perhaps as far back as our last Democratic President, and the latest ass to occupy that particular seat is simply the personification of a movement long present in our midst. No matter. If one were to look back at the 1920’s and peer just barely below the surface one would see a seething caldron of conflict between classes (and races) that would erupt soon enough. After all, the abuse heaped upon the working classes by the ownership class resulted in the great wave of the original labor movements, right? From farm to factory to union hall, and now to Twitter. The times, they don’t feel all that different when looked at through that particular lens, do they?

It could be argued that what made the 1920’s a time of explosive growth is precisely what is happening now. Cheap money available to those who are already moneyed, coupled with an economy based on influence peddling and self-dealing not available below the most rarefied levels of the economic food chain are the common links. Where once we had Big Oil with an outsized finger on our economies we now have internet information platforms without which commerce seems impossible. Banking monopolies, real and virtual, are now represented by the likes of Amazon, without which commerce now seems impossible. And the fortunes! The rich are as idolized and romanticized today as they were in the days of Gatsby.

Where are we in the cycle? Are there 9 years left and then a crash? Or is the apocalypse nigh, right around the corner, ready to take society with it again? Man, who even knows? For sure I don’t. Nor do I have any intention of pretending to know. For whatever it’s worth I do have a couple of thoughts about how to be thinking about it, though. You know those disclaimers in the ads for mutual finds that say stuff like “past performance is not indicative of future gains”? That. There were plenty of the same macroeconomic factors at play just before and after the tech stock meltdown of 2000 and the real estate driven Great Recession of 2008-10. Indeed, we had a leader who was reviled by a majority of not only the national intelligentsia but the non-elected careerists in our government. And yet, no societal collapse.

The second thing is one of attitude. Point of view. What one chooses to look at or emphasize when one analyzes the landscape, so to speak. Last night we listened to a young singer who is best described as nihilistic in her worldview. Everything is so terrible, so riddled with dysfunction and despair, that to make even a perfunctory effort to address the future is a hopeless, worthless gesture. Stephen Pinker, the noted societal observer and philosopher, vigorously disagrees. He has written a book called “Enlightenment Now” in which he makes the case that the world is by far and away better now than it has ever been at any time in history. In almost all ways, every aspect of life is better for pretty much anyone at any level of society today in comparison to any other era we might consider. Because of this every day is, or should be filled with boundless hope. If not for better than at least for more of the same.

So who is right? The 20-something who is not a progressive dreamer committing herself to changing the world but a fatalist who sees nothing worth fighting for? Or the philosopher who sees not a glass full world but one in which the glass continues to be so full that we need to build ever larger glasses to contain society’s bounty? Well, anyone who has read any of my drivel knows right away that, if forced to choose between the extremes I will choose Pinker every time. Our daily existence may or may not be as good as Mr. Pinker describes (although an objective view of the data surely looks like he is on point), but a 20-something living a 2020 version of the bohemian 20-something of the 1960’s barnstorming the Pacific Northwest in pursuit of musical fame and fortune who espouses an existentialism that would make Sartre blush is surely missing not just the point, but a heckuva life to boot.

Only time will tell if we experience yet another come-down from an over-the-top Roaring 20’s peak. In the meantime I, for one, will continue to find comfort as well as encouragement in the oft-expressed sentiment shared by Warren Buffet when the question of how best to prepare for whatever hangover might be on the way: never bet against the United States of America.

I’m betting it’s gonna be a Happy New Year.

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