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Archive for October, 2021

A Father’s Gift: Sunday musings…10/24/2021

My in-laws loved to travel. Each was bitten by the travel bug early in life, and both reveled in everything there is about travel in their 50+ year marriage. I confess that the backstory to Sandy’s wanderlust is not one I know very well. Bob, on the other hand, has a story oft told about young men in his generation. Born and raised in semi-rural PA and without a family heritage that included a college degree, he joined the Navy out of high school. As a member of the Navy Band his tours during Vietnam took him through much of Europe. His time spent in the Med near a tiny town called Cap Verat was particularly influential.

Bob and Sandy were both educators, he at the college level, and Sandy as Headmistress of an alternative school called Upattinas. I’ve written about Upattinas before. Part of the curriculum there for the upper school was spending a month on the road somewhere in the U.S., usually in the West or Southwest. Bob would occasionally accompany if a daughter or two were on board. Not content with this degree of exposure to the world my in-laws coordinated a yearlong sabbatical and took to the road, 3 daughters in tow. 6 months traveling by car in the U.S. hitting some 40 states followed by 6 months living in Cap Verat in the south of France.

Beth and her sisters were well-traveled, to say the least!

Fast forward a couple of decades. Bob and Sandy have fallen in love with Mexico. It is their fervent hope that their daughters will continue to make travel a meaningful part of their lives as the girls move through and past their child-raising years. To facilitate this Bob begins to buy, and then upgrade, three timeshare properties, one for each girl. His plan was to bequeath one to each of his daughters. “I have given you a bed in Mexico to sleep in; what you do when you are not sleeping is up to you.”

Now if you have any familiarity with the timeshare industry circa 1990 you know that investing in a timeshare was not a wise financial move. The girls and their boys were not really all that aware of that in the beginning. Nope, we were just dazzled by how exotic Mexico was, and grateful for the generosity that Bob and Sandy showed to us and our families. The highlight for all of us was an epic trip for the whole fam damly (+ significant others) for a week together in Nuevo Vallarta, complete with the lifelong memory of Grampa leading the way on a jungle zip line excursion.

Eventually the reality of timeshare economics barged into Bob’s lovely gesture. Did you know that many timeshare contracts have a clause obligating the owners to pay an annual fee over which they have no say for 99 years? For sure none of us did, including Bob. Still, this gift was so special that the three daughters decided to fight for something that they could have, to make Bob’s sentiment real, without saddling his children’s children’s children with this annual burden. Beth, Lisa, and Amy consolidated their assets, gained a bit of leverage, and essentially bought out 90 years of the contract.

Leaving us with 10 years of a bed in Mexico from which we could do anything we wanted.

And so it is that Peter, Gene, and I find ourselves once again together with our girls in a spectacular property on the ocean in Mexico. Since our very first trips with Bob and Sandy when we went solo with them, we three couples have never been to this property alone. Sure, we talk a big game about how one or the other of us will head down for a long weekend, or take some part of our own families away to that “free bed in Mexico”, but none of us has pulled that trigger. This trip is about the Hurst family. Like Cape Week for the Whites, our trip to Mexico is about being Hursts.

In the end my father-in-law got his wish. Like butterflies to Capistrano, his daughters return each (non-pandemic) year to his beloved Mexico. They bring their husbands to walk hand in hand on the beaches and through the markets he and Sandy so loved at the same stage in life. It was a massive gift in all ways, the tribulations it took to liberate it from the mercenaries notwithstanding. The boy who grew up in the farm country of Pennsylvania gifted his girls Mexico. When Lisa and Gene get here we will raise our glasses to Bob and Sandy in thanks for this gift.

A gift of family.

I’ll see you next week…

Cost, Convenience, Quality: Paying for Healthcare in the U.S.

At the moment I am sitting in a hotel in mid-town Manhattan, between speaker slots at a convention and wishing I’d accepted a less ambitious schedule. Typical of me when away alone, I’m trying mightily not to get on an early flight home. Still, as predictably homesick as I may be, it is good to once again be out “in the wild” among my tribe of eye peeps as we seek more and better ways to stamp out all manner of blinding disease.

While we rail against the vagaries and insults rained upon both patient and doctor by the healthcare payment “system” that exists in the U.S.

Last night I had a very illuminating conversation about some of the maddening nuances that exist in the endless games played by the government and health insurance companies as they plot to thwart the makers of pharmaceuticals and devices from being paid for the use of their products. These producers of products respond with gamesmanship of their own. This, in turn, creates vast inequities in access to both drugs and devices for patient that need them. Safe Harbors compete against Most Favored Nation clauses while middlemen called PBM’s extract a toll at every juncture of the process. Doctors (and their staffs) bend under the weight of misdirected blame and bile for treatment roadblocks they neither built nor can they demolish. Frustration rules the day.

A while ago 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 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 both the baseline or floor level, as well as any level that might be considered “luxury”. 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. The cost of achieving that baseline universal outcome is covered, the “what you experience” in doing so is not. Our family experienced a bit of this with Beth’s Mom. She was living in a setting that provided excellent care at a reasonable cost, but in a setting that did not provide any extras; it was old, not very pretty, and had we not moved her she would have had a roommate. Her (and her daughters’) experience, what we might call “convenience” in our formula, was found to be lacking.

Therein lies the problem with any discussion about literally anything that we might discuss as a “right”. If we examine food, something we are very conscious of in the White house (Beth and I stopped eating meat 1 1/2 years ago) 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 food experience. Not even a little bit. Even the most extreme in the “equality” set do not assert that EVERYONE gets swordfish if ANYONE gets swordfish; it’s the protein that matters and you can get that from a can of tuna. No, quite the contrary, all that is discussed is cost and convenience (access).

Now, of course, in my old CrossFit world (and to a degree in the medical world) it is argued 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. While this is accurate and proper we can reasonably define adequate nutrition as consisting of comparable protein, complex carbohydrates and beneficial fat and keep it separate from other needs, at least for the purpose of our discussion. “Quality” here would be more accurately be called the food “experience”.

How about medications? After all my conversation was with a team from a pharmaceutical company. A complete description of the morass that prescription coverage has become is way beyond the scope of this essay. Hewing closely to Beth’s proposition, each individual should have the right to obtain a medication (or device) that works. Consistent with my further interpretation of the three components of value, the floor of the care continuum is just that, the medicine that works. One should expect to shoulder the cost of more convenient forms of treatment. A 4 time per day pill versus once daily, for example.

The interplay between cost, quality, and convenience holds true in nutrition/food on a global, grand policy making level: From the value components quality, cost, and convenience, you can pick any two, but only two, when you are declaring what is the minimally acceptable level. As Beth intuits, this is similar in healthcare.

My formulaic approach to the coverage of healthcare 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. The law of diminishing returns arrives in the form of asymptote as quality rises. For example, there is little statistical difference between 0.03% and 0.035% when we discuss the risk of a surgical intervention; it becomes similar to chance.

On the other hand, cost and convenience are unbound and can rise almost infinitely. Using an example which is more dramatic than my swordfish/canned tuna offering, alcohol in moderation is consistently shown to reduce mortality. Note that 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 baseline cost are addressed and everyone is left to make their own call on convenience/experience (e.g. private or shared convalescent care room, filet mignon or a burger)? 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, work to pick up the check for the true needs of each: equal outcomes at a universally affordable cost. “Want”, on the other hand, is the proverbial “free lunch”. I’m all for “a chicken in every pot” , but if you want yours to be Coq au Vin, you gotta buy your own wine.

There ain’t no such thing as a free lunch.

I’ll see you next week…

The Cardboard in the Shoes Kid

A reprise and an update on the weekend of my Dad’s passing 6 years ago.

My Dad would have been 90 this year. The “cardboard in the shoes kid” who grew up poor during the Depression and became the embodiment of the American Dream. We lost him six years ago yesterday, 10/9/2015, at 8:30 in the evening. He slipped away slowly and peacefully with my Mom and my sister Tracey present. Dad was something of a medical miracle. He survived a 4-jump bypass at age 54, lost a kidney to some weird cancer undoubtedly caused by his experience as a nuclear test “observer” in the army in the ’50’s, and lived pretty well for a couple of decades while ignoring his diabetes. His active life slowly eroded due to terrible pain caused by spinal stenosis.

His life was effectively ended when he suffered the “never event” of a spinal infection from a pain injection.

Even though he didn’t actually die for almost 3 years, we lost the Dad we knew in the ER when he was given medication which turbocharged his otherwise very mild dementia. 3 months of hospitalization later the smart, funny, kind man with back pain who entered the ER was replaced with a fearful, angst-riddled guy who couldn’t remember if he’d had breakfast 15 minutes after getting up from the table. The sole consolation in the entire endeavor was that he not only was pain free from the surgery that cured his infection, but his dementia was such that he had no memory of ever having it.

We had two and a half years to prepare, a kind of “pre-mourning” if you will. Don’t believe it. There’s no such thing. Staring at the specter of a slow, tortuous decline with all of the indignities associated with it, I was still wholly unprepared for what turned out to be an unexpected and surprisingly quick demise. Nothing of these 2+ years of knowing left me the least bit prepared.

Some time ago I attended a talk on end of life care, the first in a lecture series honoring a friend I lost to cancer a few years ago. The talk was surprisingly moving, not only because it brought back memories of Ken but also because while attending it I knew I would likely lose my Dad in the not too far future, and I thought of my folks throughout the talk. What the speaker discussed as end of life care and end of life preparations also offered a very important take-away that I tried try to apply every day since, especially with my parents.

The speaker’s thesis is that one should say 4 things often and with ease, not only in the course of completing a life’s work or concluding a life’s relationships, but in the course of living a life.

Please forgive me. I forgive you. Thank you. I love you.

Sounds simple, huh? Maybe even a little trite. I’ve now spent several years thinking about those 4 essential things and about how they fit in a life that is not necessarily concluding (at least I hope not!). We are, each of us, part of a tiny little ecosystem; thinking about using these phrases encourages us to look outward and see the others in our own worlds whether we are approaching the conclusion of a life, or smack dab in the middle.

Actually, without really knowing it I’ve been on this path for some years now, probably guided by Beth and her inherent goodness. Friends come and go; either way I’ll likely feel a sense of completeness in any relationship if I remember these 4 things. Patients and staff do, too. I think I’m a pretty good boss and pretty user-friendly for patients as far as specialists go. Bet I’ll be better at both if I’m thinking about these, even just a little bit, even now.

Please forgive me. I forgive you. Thank you. I love you.

I hope, sweet God do I hope that I remembered enough, said these enough. I pray that I remembered to say them to my Dad before he lost the ability to remember that I said them. Don’t wait as the end of someone’s life approaches to say these four things. Don’t wait for the conclusion of your life before you think about these.

Richard E. “Dick” White 6/21/31-10/9/15.

I really loved my Dad.

Happiness is the Ultimate Non-Zero Sum: Sunday Musings…10/3/2021

1 Anorak. Greek for geek or nerd. You thought it was just a pullover too, didn’t you…

2 Ryder Cup. I always miss my Dad the most when stuff like the Ryder Cup is being played. An event that brings back memories of a special time I got to spend with him doing something he loved. This particular one was also shared with my brother and one of my brothers-in-law when we spent a weekend together at Oak Hill in the fall of 1990.

I want to talk to him every day. Hear his voice. See his smile. All the more so on a day like Ryder Cup Sunday when we would have watched this year’s matches together and reminisced. It’s days like this that make it hard.

I miss my Dad.

3 Happiness. “We should allow others to expand and contract without taking it personally.” –Kasey Musgrave

Life, liberty, and the pursuit of happiness. The three pillars upon which our country was built. It bears repeating that we are only guaranteed the right to PURSUE happiness; we are not guaranteed the happiness itself. The great conservative writer George F. Will posits that the pursuit of happiness actually IS happiness, though I doubt he’d get much uptake on that from the masses.

At the moment I am sitting in an airport with the love of my life, on the way home from visiting our daughter and son-in-law. I am quite happy. Belly filled with something called a “womelette” (an omelet poured into a waffle iron), couple of newspapers nearby, TSA successfully transited. We checked in on our new “toehold” here in the low-country, a small condo about 20 minutes from Megan and Ryan. Nothing special, just a place to call our own when the time comes that we can travel for more than a week at a time. Seeing it for the first time made us happy. Taking the 10 minute walk to the beach (and dreaming about an electric beach caddy) made us happy.

Our happiness does nothing to detract from anybody else’s pursuit of happiness.

In my travels, and those of my oldest friends and acquaintances, I have come across scores of people who are truly happy. Capable of feeling and giving in to joy. It’s such a special thing to see, and even better to in some way feel a part of that joy, wherever it may be from and whatever may have brought it to life. It’s out there, you know. Sometimes it’s subtle, as gentle and quiet as the proverbial footstep of a butterfly landing on a leaf. Other times it is raucous and riotous and simply blasts through your space like a runaway train.

We took in an R&B performance like that last night.

Sadly, there are others out there who resent the joy in others. Whether they are themselves happy or not so much, the happiness of another feels to them like losing. It’s more than envy in these unhappy people. For these folks it’s as if there is a finite about of happiness and joy in the world; no matter how much of either they may have at any one time they cannot see another’s joy without feeling as if it is somehow draining the reservoir from which they may drink some time in the future. Weird, huh? They sometimes seem more fixated on the blessings of others than on their own, so much so that their own joy slowly seeps away.

Happiness and joy are not limited resources. Quite the contrary. My happiness, my joy is not predicated on your unhappiness or your sorrow, and vice versa. Heavens, if one person’s happiness could come only from another’s despair we’d have long ago slipped into a rather dismal anarchy. No, joy is the ultimate non-zero sum measure. More than that, joy is an exponential multiplier. When you find or see joy in someone else and that vision makes you happy, the amount of happy you get is a full order of magnitude greater than it otherwise would be. If that joy and happiness should come to someone who has lately had little of either, well, that’s just that much better.

Life is pretty good around Casa Blanco right now; Beth and I are returning refreshed and renewed from our too quick trip. Beneath our masks (after all, we’re in an airport) we are smiling ear-to-ear. As much as I’d like to think that means it will always be thus, that’s not how life works. We will “expand and contract”, too. Regardless, if I should stumble upon you in the midst of something joyous, you can be sure that no matter what happens to be going on in my little world I’m surely not going to resent you or your joy. Quite the opposite.

Whether the skies be cloudy or eggshell blue, a glimpse of the sun always warms everyone there to see it.

I’ll see you next week…

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