Random Thoughts from a Restless Mind

Berth 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 20 years in healthcare administration, her idea of what constitutes the sum of cost, quality, and convenience naturally overweights the integers for cost and quality: outcomes should be essentially equal across the board at the baseline or floor level, and the costs of achieving that should be in some way equitably shouldered by something we could describe as “society”. Very practical. A strategy that lends itself to being observable and measurable.

What’s the rub? Well, only two of the three elements that make up value are covered. To obtain an agreed upon level of medical outcomes (mortality, morbidity, longevity, etc.) the cost is covered. Ah, but HOW you obtain those outcomes is still a variable. It is the FLOOR of value that is guaranteed. Our family is experiencing a bit of this right now with Beth’s Mom. She is living in a setting that is providing excellent care at a reasonable cost, but it is a setting that does not provide any extras; it’s old, not very pretty, and she will soon have a roommate. Her (and her daughters’) experience, what we might call “convenience” in our formula, has been found to be lacking.

Therein lies the problem with any discussion about literally anything that we might discuss as a “inalienable right”.

If we examine food, something we are very conscious of in the CrossFit world, we find something quite similar. No one among us would say that X Million people should go without food. Indeed, we don’t even really talk about true hunger in the U.S. anymore, we talk about “food insecurity”, the concern that we may become hungry. By the same token, though, no one asserts that everyone is entitled to the same quality of food. Not even a little bit. No, quite the contrary, all that is discussed is cost and convenience (access).

Now, of course, we in the CrossFit world (and to a degree in the medical world) argue that quality is an ineluctable part of nutrition, that one must extend the equation outside of food alone so that an explicit choice is made that prioritizes quality calories over other purchases. While this is accurate and proper we can reasonably quarantine nutrition and keep it separate from other needs I believe, at least for the purpose of our discussion. The universal concept of the interplay between cost, quality, and convenience holds true in nutrition/food on a global, grand policy making level:

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

My formulaic approach to the coverage of needs has a little wrinkle that should be mentioned: quality cannot be increased ad infinitum. In all examples we might evaluate there is a practical limit to the ability to improve quality. The law of diminishing returns arrives in the form of asymptote as quality rises. On the other hand, cost and convenience are unbound and can rise almost infinitely. If there is one, it is the alcohol in a drink that confers the health benefit, or in the excess, the adverse effect; 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. The same is true for food: the protein content is the same in Salisbury Steak as it is in Steak au Poivre.

You get the picture.

What will become of our conversations about issues such as healthcare? Will we arrive at a similar juncture to the one we have now in food, clothing, and shelter? Where quality (outcomes) and cost issues are addressed and everyone is left to make their own call on convenience/experience? Beth can’t see how it can be any other way. Me? I’m much less optimistic. That old “want vs. need” thing just keeps popping up. Confusion arises when a truly generous people confuse what people want with what they need. Need is measurable and therefore finite, whereas want is neither. We can, and should, all work to pick up the check for the needs of each of our brothers and sisters. “Want”, on the other hand, is the proverbial “free lunch”.

TANSTAAFL.

1) Lego. While pursuing my interest in Healthspan, the combination of not only a longer life but a longer span of health, I stumbled upon a magazine in an airport shop featuring some newer takes on the topic. Particularly intriguing was an article on spurring continued mental acuity by learning things outside those that have already taken up residence in your greying matter.

This one touted complex Lego models.

Being the Papi to two Lego-obsessed boys it made all the sense in the world to give this a try. I picked up one of the Lego Botanicals collection, the Japanese Red Maple Bonsai, and planned to give it a go. When my Mancub saw the box he offered to help. This, of course, started off as us doing it together with Landon giving Papi instructions. Which led to us physically taking turns adding pieces. And ended up with “OK Papi, turn to the next page” of the instructions as he flew through the construction.

Unlike “gym as third space”, training your brain muscle looks like it needs to happen without a “personal trainer”.

2) Arquette. Patricia Arquette is interviewed in both the WSJ weekend edition and the Sunday NYT. Seems she is in a new mini-series (do we even call them that anymore?) about a rather tawdry, years-long family tragedy in the Low Country of South Carolina. One my SIL Ryan was mildly obsessed with a few years ago as it reached its climax. It’s likely to be a rather interesting thing to watch; Ms. Arquette is by all accounts pretty good as the doomed wife.

Still, for all of the falderal about the massive gulf that exists between the political poles of mainstream media represented by these two august publications, don’t you find it a bit strange that they can’t find two people to highlight on any given Sunday? I mean, she’s not exactly new to the circuit, and this particular story has stained newspapers and squandered airtime for more than a decade. It brings to mind the seamless coordination that surely exists between the editors of each newspapers eponymous monthly magazines when it comes to fashion.

Scandal, brought to you through the eyes of the same actress, like so much that is au courant on the white boards of designers who would never be caught dead in their own creations, yet appear back to back and standing left and right, every thirty days.

3) Uniform. In other news, a fashion columnist is kvetching in todays NYT about the lack of imagination shown by those who clothe female politicians in television and movie fiction. Particularly those actors who portray the necessarily fictional female presidents and almost entirely fictional VP’s ( I will resist all temptation beyond that little tiny barb). Seems they are all too conservative. Too masculine, whatever that means. Too many pantsuits (why aren’t they just called suits?). Not enough color.

Sorry. Calling BS. This is just a made up issue which barely survives investigation below the dust, let alone the topsoil.

Every job has a uniform. The more gravitas associated with the job, with or without justification, the less imagination one sees, regardless of sex. One need only recall the bipartisan ridicule that befell President Obama when he had the misfortune to follow the fashion mores of the non-elected, especially non-elected presidents of anything other than the United States, and wore a tan suit in the summer. An impeccably tailored and likely high four-figure tan suit at that. And yet, I’d wager that pictures of him so-clad probably still show up on the “no-fly” fashion lists.

FWIW I think the paper-clip holding the zipper on the pants together scene in The Diplomat makes the character more compelling and likely more electable than any color dress today’s NYT commentator would have chosen for her to wear.

4) Douthat. While I’m about the task of possibly painting yet another bulls-eye on my tee shirt, how is it that I’ve not really made the acquaintance of the weekend columnist Russ Douthat? There’s an underlying current today that addresses taste and the intersection between propriety and taste. Douthat dives into the larger than the issue debate about tearing down the least interesting part of the White House to create what he proposes is a long-overdo event space for the official programming of the President’s position of Entertainer in Chief. He compares the objective aspects of that project with similar activity surrounding former President Obama’s presidential library now under construction in Chicago.

One project, Douthat chooses the White House, is likely to be rather uninspiring given its utilitarian roots. The other, Obama’s Library, has garnered rather strong reviews that, on balance, seem to skew rather negative. One could, of course, argue that by definition presidential libraries are 1) not really libraries at all, and 2) unnecessary. I mean, other than to store all of those paintings that George W. Bush has been churning out in his retirement. (Note to self: build a library to hold all of my adult Lego projects). One could make a case that we should have called it a day after Monticello ran out of closet space and Jefferson founded UVA.

I predict the construction of a new East Wing ballroom cum event center will fade into the mist that engulfs all such banal, functional edifices, the strum und drang of the times notwithstanding. Mr. Obama’s obelisk? Well, let’s just say I’m betting it continues to make its way onto the editorial pages and into those monthly magazines purportedly catering to both sides of the street long after nobody remembers who built the East Wing v1.0 (Teddy Roosevelt) or v2.0 (FDR).

5) Living. “Dying is no big deal. The least of us will manage that. Living is the trick.” Red Smith, eulogizing a lost friend.

As we approach Halloween and Dia de los Muertos, it bears remembering that it is not in the dying that we should remember, but in the living. Red Smith, arguably one of the 3 or 4 greatest sports columnist to ever live, was noted for the eloquence with which he eulogized both sports figures and friends. Lives lived large or small, he said time and again that it was the living that mattered. We are confronted by the ghosts of the dead who demand to be heard on Halloween, and prompted to remember the names and the lives of our loved ones on Dia de los Muertos lest their ghosts cease to exist at all.

Both days exhort us to remember not the departures but the journeys that transpired on the way to that final exit ramp.

And so, at the risk of being accused of being a sentimental, and worse, preachy old man (guilty, of course, on both accounts), allow me to remind one and all that it is the living that counts. The living that we are about, each and every day. Today is not simply a day that we are not dying, a day that we did not die. Nope. Today is another day that we are alive. Another day that we are living. Today there are no obituaries to be written, no eulogies to be given. No caissons to be pulled. The horses in the stables are there for us. Saddle up.

Today we ride, again. Still. Let them remember how it was when we galloped.

I’ll see you next week…

1) Three. Our Hollywood email thread is the gift that keeps on giving. Launched way back before the Great Recession, we are a group of old men who went to a tiny little New England college in the 70’s and 80’s, we convene to communicate for myriad random, less than consequential reasons. Like wishing each other a happy birthday.

One such birthday wish went out to a buddy who once tricked me into participating in a psych study on the mechanics of memory. Turns out we remember things best in threes. Weird, huh? Like your TSA pre-check number. It’s 3 sets of 3!

HT and belated HBD to my boy Cows and his 45 year old insight.

2) Noblesse Oblige. Once upon a time there lived a class of people who were terrifically wealthy who felt something other than the deep self-satisfaction worn on the sleeves of today’s wealthy like another fancy logo that telegraphs their wealth. Indeed, unless surrounded by true peers, this group took pains to carry their good fortune with grace and, while not humility per se, some sort of, I dunno, restraint. Where now we see their ancestors strut toward their private jet with their FaceGram post letting everyone know that St. Tropez is STILL a thing if you are, you know, them, this earlier version of uncountable wealth simply went quietly about their way.

Not every “fortunate one” behaved like this back in the day, of course. One need only google “JFK Sailing” and you will find a bit of the self-aggrandizing that certain among this clan indulged in, albeit in analog media. But even those who indulged in a bit of self-congratulation still demonstrated a sense of social responsibility which I find lacking in today’s ultra-wealthy. Something we once called noblesse oblige.

The notion that from those who had much was the responsibility to give much back.

Even the Kennedy’s, for all of their self-serving faults, must receive kudos for turning away from the various louche pursuits of their day and spending meaningful percentages of their time in service of various kinds to country and countrymen. Did they happen upon additional riches bestowed upon them that were directly related to their civic and other contributions? You know, for all of the tawdry things we have learned about this generation of the super rich I find such details lacking. Contrast this with the most controversial politicos of our time, the Clintons and the Trumps, for whom no benefit from service is too gauche to turn down. A significant difference there appears to be the great lengths to which the Clintons have gone to hide the source of their wealth, and the complete lack of shame demonstrated by the Trumps cash grab.

I’m not really sure if there’s a bottom line or a lesson here, unfortunately. Maybe just a quiet little lament that the assumption of the responsibilities of wealth that can be consumed in personal pursuits that exceed even the imagination of the likes of Larry Ellison do not result in behavior that one might call noblesse oblige makes one sad.

Sad that we have so many more Jeff Bezos than we have, say, MacKenzie Besos.

3) Receipt. Sometimes you express your love for someone by letting them pick up the check.

In the world of my day job there is one massive conference for which attendance is obligatory for at least half of my professional colleagues. As a younger doc I would arrive early and leave late, especially after I found my place in the extended world where doctors intersect with the companies that make the stuff we use to treat our patients. For some 20 or so years I made myself available for the entirety of the meeting, giving my time entirely to professional pursuits.

While I can’t say for sure exactly when or why it happened, at some time over the last 6 or 7 years I started to carve out time for more personal pursuits. I became notorious for the “Irish goodbye” a day or two sooner than I would typically leave the meeting, occasionally skipping out on promises to appear at some fancy Surf ‘n Turf affair in favor of a burned grilled cheese sandwich with my Dollie and my man cub. It was the right call, for sure, despite my rather inelegant execution.

More to the point, though, is what I started to do from the jump at these meetings: prioritize the engagement with my people. My tribe. The people who are responsible for my continued attendance at meetings that quite honestly I don’t really have to attend. Like my friend, who will remain unnamed to avoid any embarrassment, who always joins me in arriving early so that we can spend an evening together just being friends. Or people in my life who through good fortune just happen to be near enough to these events that I can skip out and see them.

An early arrival on a trip to Washington, D.C. allowed me to actually be WITH John Starr when I was “Drinking with John Starr”.

This meeting brought me near enough to one of my aunts, one of my Mom’s younger sisters who’d been just lovely to me when I was little. My cousins scooped up their Mom and brought her out for breakfast with her first nephew despite her firm conviction that there was no real reason for her to either leave her house or entertain anyone there. What a gift! I got 2 solid hours with my Mom’s sister (and my cousins), and the only thing it cost me was missing a day at a conference.

Unlike my drivel above on noblesse oblige, there IS a message, and there is a lesson here: there are people you need to see. There are people who were so meaningful in your life that when you get within a couple hundred miles of them, YOU need to get up and go see them. And when you do, you need to make it about them. I grabbed the bill for breakfast and was about to head up to the cashier to pay the tab for my aunt and my cousins, but my aunt wanted one last chance to take care of her first nephew. The little lump of flesh who made her an aunt. To take care of me, one more time.

And I had the chance to let her.

In case you are wondering I had a very productive and successful conference from a professional standpoint. But it was so much more than that. I was able to set aside time with a close friend who had offered the gift of his time to me. And I was able to accept the gift of time, and the gift of care one last time from my aunt. To let her take care of me again after all these years. One more time. One more chance for me to thank her, for today, and all of the yesterdays that gave us what may very well be our last chance to say it. I didn’t miss my chance.

I let her pick up the check.

I’ll see you next week…

It takes very little effort to observe the intersection of cultural norms. Indeed, it takes a substantial effort NOT to notice them when they collide, as they must, in the polyglot that is the United States. Physicians, it’s been noted, are little more than paid observers; I see these collisions daily. What are we to do when cultures collide?

Now, I’m not talking about the “old as eternity” cultural divide between teenagers and their parents; in the end the teens will either hew closely to the cultural norms of their heritage or fall more in line with those of their present address. What I am interested in are those cultural norms that remain an integral part of the fully formed adult one might encounter in a rather typical day, and by extension whether and how one should respond to any cultural dissonance. Or for that matter, WHO should be the one to respond.

It’s the tiny ones that catch my attention. Personal space for example. The typical American personal space extends one arm length between individuals. Something shorter than a handshake, more like a handshake distance with bent elbows. The Mediterranean space involves an elbow, too: put your hand on your shoulder and point your elbow to the front and you have measured the personal space of a Sicilian. Asians on the other hand occupy a much larger personal space that can be loosely measured by a fully extended fist-bump. Something which would be anathema in polite Japanese company, but no matter.

My favorite little example of the variety of cultural norms that swirl in the soup of the great Melting Pot is the affectionate greeting. You know, what most fully acclimatized Americans would recognize as the “bro hug” shoulder bump and clasp, something that would be appalling to a Parisian or Persian, or indeed even to a Princess of the Antebellum South. Yet even here there are differences. The Princess, joined by legions of Housewives of Wherever and Junior Leaguers everywhere are ninjas in the practice of the single-cheek air kiss. It should be noted that ~90% of men are NOT ninjas in this particular art, and are expected by its practitioners to bungle the act.

Persians and Parisians, on the other hand, find the one-cheek air kiss to accomplish only half the job. They, and others who share centuries old cultures, warmly greet each other with a two-cheek kiss. I am sure that there are nuances involved here that remain unseen and unknown to both most men and certainly most (all?) who don’t share the heritage. (As an aside let me just say that I am a huge fan of this particular cultural norm because it means that one of my very favorite colleagues, Neda, always arrives bearing TWO kisses).

So what’s the point here? Two, I think. First, there is a certain boorishness in the failure to observe and recognize the existence of these cultural norms when they are encountered. Some, like those I’ve mentioned, are the relative equivalent of a soft breeze, neither strong enough to fill a sail nor de-leaf a tree. Recognizing them, even in the tiny manner that one tries not to trample on them even if they will be ignored, is a tiny gesture of kindness, respect, and courtesy.

The flip side, number two, is deciding which of these norms is the default setting. Here things get a bit stickier, especially when cultural norms run afoul of SOP on the particular ground they occupy. Think air kiss in Afghanistan, for example. Bowing in the boardroom of Samsung in San Clemente. There are more, and bigger examples, but you get the idea. Here I think geography holds the trump card: “when in Rome” should be your guide, especially with cultural norms where the collision may be substantially more impactful then whether or when you turn the other cheek, a tornado to the above tickling breeze.

After a 2 1/2 year struggle, at 8:07 PM EDT 10 years ago, I lost my Dad.

Four of us did, actually. Four middle-aged adults lost a father-in-law. 10 young adults are down one grandfather. Young Landon, the Lil’Prince, lost a great-grandfather whom he never met.

I am gutted.

My Dad’s been sick, really sick, for quite a long time. First hospitalized in January of 2013 he never recovered from an illness that we were told should have killed him every week since then. We’ve 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 the 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 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 have tried try to apply every day since, especially with my parents.

The speakers 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. But each one of those little phrases is a bit of a minefield, each one laden with a hidden meaning and a back story, each one the mid-point in a little journey with a “before” you know, and an “after” you can’t possibly predict. There’s a little risk in that “after”, too, and that’s why those 4 little phrases aren’t really all that simple, and why considering this is not at all trivial. All 4 of those little phrases make you look outward, look at another, and in the stating they force you to put yourself at the mercy of that other. Each one of those phrases is a little opening in our guard, an invitation to accept or reject not only the sentiment but the sender.

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. How will my parents react if I approach this when I visit? Do they/did they know it’s now the 5th act, that we are tying up all of the loose ends in the story?

How about my friends, my kids, my darling bride? 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.

I can’t believe it’s been 10 years. Richard E. “Dick” White 6/21/31-10/9/15. I really loved my Dad.

The secret to success just might be failure. Not abject failure, of course (although it’s always cool to use the word ‘abject’), nor consistent failure. But failure while pushing one’s limits or while exploring the new and the unknown might be the magic ingredient in the success recipe.

Why? Success is not simply the absence of failure, it is the defeat of failure. Success is over-coming failure. Indeed, without having failed at something some time, how do you know what success is? How do you know what it’s supposed to feel like?

Neither success nor failure need be any particular size. Small successes build confidence, and smallish failures teach. It’s important to qualify acceptable failures, though. Failure caused by sloppiness or laziness is ALWAYS bad. On the other hand, failure encountered while stretching beyond one’s limits, while reaching for something new, large, important…well…that’s the type of failure from which lessons are learned.

It takes a certain chutzpa to put one’s self at risk to fail while in the act of reaching further. I like Churchill’s take on it: “Success is never final. Failure is never fatal. It’s courage that counts.”

Be brave.