Random Thoughts from a Restless Mind

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.

I wrote the essay below some 7 years ago. If you substitute “disagree” for “different” or “other” everywhere it turns up this very much applies to our present day world where single issue differences threaten to divide people who should actually be joining together.

“The original “word” for this thought was to be “enemy”, but the more I thought about it the less that seemed to apply. You see, “enemy” is really a very simple concept, one that is just too black-and-white in this world of grey in which we live. An enemy is nothing more or less than someone who has openly declared intent to do you harm. Nothing too very ambiguous about that.

This is very different from a person who dislikes you, or someone you dislike. It’s fundamentally different from someone who is angry at you. These folks can simply be ignored; they can be consigned to the trash heap of indifference. I’ve been known to say that it’s perfectly OK to make an enemy as long as you’ve done it on purpose so that you can assess the ramifications beforehand. Re-thinking this in light of a more accurate definition of “enemy” probably changes my tactical advise to “it’s OK to make someone angry at you.”

This is important today as we traverse our lives with our “situational awareness goggles” on high, important when we identify someone who is better described as “other” as “enemy” or “possible enemy”. By any measure we actually live in a world which is incredibly safe. We are not surrounded by legions of enemies but rather by “others”, people who stand apart for one reason or another as different. Maybe even odd.

If we view our world as one which is inhabited by only friends or enemies we are at risk to categorize these “standouts” as dangerous until proven otherwise, all data to the contrary. We are at risk to extrapolate the actions of one “other” to all, even those who share nothing with those villains besides their “otherness”. Is this really necessary?

Frankly, my worldview as a young man was very narrow, my willingness to even let the “others” be “something” less than zero. No, “others” were to be feared or ridiculed; they were certainly not meant to be ignored, let alone accepted. Now? Most of the “others” are just varying degrees of different, nothing more. Pick a number…99point whatever % are just that and will never be anything more diabolical or dangerous than a friend might be. They will never be an enemy, no matter how much their “otherness” sets us apart.

For most of us the world is filled with friends and others. We just don’t have that many enemies known or yet to be discovered. I do not advocate replacing our “situational awareness goggles” with “pollyanna specs”, but we really don’t need to have the setting on “high alert”. The risk of the false positive, the risk of identifying an “other” as an enemy is very, very high because there really are very, very few real enemies. Very few people who mean you, or anyone, true harm.

Don’t let the cacophony resulting from the rare sighting of an enemy, of evil, blind you to the fact that those who will not be your friends are almost always just “others.””

We may disagree. In and of itself this does not make us enemies.

While fooling around on Twitter the other day I stumbled upon the latest beauty from Robert Reich, the Nobel Prize winning economist who has been making a mockery of his earlier achievements as a present day pop-culture economist: 60% of wealth in the U.S. is inherited. Now if that is even true it is at best brutally misleading, verging on dishonest. If even 60% of the dollar value of wealth was inherited the reality is that over the last 30 years whatever the original value was of that inheritance it  has increased many, many times over, falsely elevating its percentage level. What is much more misleading though is the purposeful effort to let readers assume that 60% of the people who would be considered wealthy (pretty low bar to be wealthy but that’s a topic for another post) got that way by inheriting their money. That’s just not true; a super-majority of the global value of wealth in the U.S. is actually concentrated in a very small cohort of super-rich.

What makes Reich’s clickbait headline and lede even more galling is that he uses his little bit of data sleight of hand to dismiss the cherished “up by your bootstraps” (EBYB) story line that underlies the success of literally countless narratives told by American families about their rise from poverty. Indeed, the possibility of EBYB success is a large part of what continues to drive people from all over the world to seek a new beginning by emigrating to America. Reich is calling BS on the entire EBYB path to success and in doing so saying that to seek an EBYB success is a sucker’s game.

Reich is just the latest and most famous non-practicing celebrity economist to let his fascination by, and revulsion at the super-rich blind him to the day-to-day reality of middle class success.

It is the rise from poverty, the elevation from being among the working poor and taking an UBYB approach to leaving both of those states that matters. The creation of super wealth, even the creation of entry-level wealth, is little more than a pipe dream for almost everyone who desires to  rise from whatever financial straights exist at the beginning of their journey. What matters, and what Reich casually nullifies, is not the immigrant who amasses a billion dollar fortune by becoming the owner of the largest yogurt company in America, but the thousands of immigrants who scrimp and save and buy a retail outlet that sells yogurt and at which they will toil for endless hours in order to support their families. It’s not the second generation that takes over the family-owned car dealership but the hundreds of tiny entrepreneurs who buy a NAPA franchise in order to create a little nest egg that can’t be formed as a line worker at Ford. In that 40% of wealth lies a super majority of small “fortunes” consisting of the fruits born from UBYB success stories.

At the risk of being accused of substituting anecdote for analysis (albeit looking at the flip side of Reich’s own story coin) let me tell a couple of stories to illustrate that UBYB is much more than myth. My Dad was born into a family of the working poor during the teeth of the Depression. One of six children his family expanded (to 10? 12?) when his mom died and my grandfather remarried. Dad was a “cardboard in the shoes kid”; when your shoes got a hole in them you neither got new shoes nor a new sole, you stuck a piece of cardboard inside the shoe to cover the hole. Family lore has it that Dad was plucked out of the trade path in high school by a teacher who saw in him the potential to rise. Upon graduation he went to UNH on a football half scholarship, whereupon he promptly starved for lack of money. Like so many young men of the time he joined the Army. During his enlistment and his years fighting in Korea he rose to the rank of Sergeant First Class. After mustering out he went to UVM where a combination of another half-scholarship and the GI Bill got him through school. Dad graduated with a degree in what we would now call industrial engineering, the only member of his family to get a degree.

Our life in the early days of Dad’s career (Mom stayed home after I was born) was one of “enough”. We had risen above the level of working poor, but the most charitable description of our status would be to say that we clinged to the lowest rung of middle class. But my Dad was a true believer in the UBYB dream. He put himself through Business School as he slowly rose among the ranks of middle management at the company where he began his career. When that company was sold and much of the lower and middle managers were let go Dad caught on with a much smaller, older, family owned enterprise. After quadrupling sales at the new company he and two other senior mangers bought out the founding family. For 15 years of so our family was comfortably in what at the time would be the upper middle class. Mom and Dad prepared a wealth starter kit in the hopes that their good fortune would continue on the same upward trajectory.

Did we become wealthy? Did my siblings and I enjoy the fruits of my Dad’s success with a big inheritance or a big infusion of start-up capital at the beginning of our own journeys? Sadly, this was not to be. For all of my father’s brilliance at running a small company he was not equally adept at divining the effects of large macroeconomic trends. The 80’s brought crushing interest rates, inflation, and an artificially inflated dollar, all of which conspired to destroy not only my Dad’s company but the entire domestic industry of which he was a part (there are no manufacturing companies in the U.S. remaining in his industry). There will be no generational transfer of wealth; Mom just sold the family home and hopes that the sale will support her for the rest of her life. Was Dad’s UBYB story a failure? Of course not. My parents sent four kids to college, all four of us debt free on graduation. We are all economically independent and have been since graduation. We would all be counted among that 40% Reich dismisses.

Cynical readers, especially the young, would say that my parents’ story has nothing but historical relevance. Such an UBYB story was little but a historical footnote by the time my Dad bought his company. Nothing could be further from the truth. I have two very close friends, men I’ve know since school days. My oldest close friend grew up in a family that was devastated by mental illness. He and his father shared a one bedroom apartment, taking turns between the single bed and a couch, floating just above the poverty level of the 70’s. Mother and Father were high school grads; there was little familiarity with college as a goal. Like my Dad my friend was raised up by teachers and the parents of a couple of classmates and put on a straight shot to a college degree. He got some scholarship aid and took out a bunch of loans and graduated from a highly selective college. My friend has taken himself UBYB to where he now has generational wealth. None of it was inherited. There was no wealth to disburse when his Dad died a couple of years ago. Indeed, I think he paid for the funeral.

As an aside, as this is the Christmas Holiday season, my friend is the most grateful human being I know. His Birthday is on Christmas Eve. You know how some Christmas babies always resent the fact that they have to “share” their day with Christmas, complaining that they get shorted because of the overlap? Not my friend. There wasn’t anything under the tree or wrapped up in a “Happy Birthday” package; there wasn’t anything at all. To this day I have never heard a single word of resentment from my friend. He is grateful for every tiny blessing that comes his way, even if it has come because he bought himself up by his bootstraps. My Dad was like that. They are both inspirations.

So you see Mr. Reich, even if your data is accurate and tells the story you’d like us to think it does, it still doesn’t render moot the power of UBYB wealth. Wealth, it turns out, is sometimes better measured in smaller ways than those that catch the attention of starry eyed celebrity economists. Sometimes it is something as small as being able to resole a shoe or order a new pair of sneakers without worrying about the rent. UBYB might mean the next generation goes to college. Maybe they even graduate without debt. Where once there may have been inherited wealth for my siblings and me to look forward to perhaps there will be that kind of wealth for our children and/or grandchildren.

“Up by your bootstraps” wealth is about people, and there are many, many more people in that 40% you deride than those fortunate few who have assembled the 60%. The opportunity to raise yourself “up by your bootstraps” within sight of that 40% is still the American Dream. It is still the hope of a nation, the antidote to the pithy observations of economists enthralled by the super rich, the engine that lifts countless families out of poverty. “Up by your bootstraps” is no myth.

As hard as it may seem to believe this, I learned a valuable lesson about taking care of patients from an airline. Granted, this occurred because I had an unpleasant (for me) interaction on a rather long flight because a flight attendant had an unpleasant interaction (because of me) at the very beginning of that flight. My lesson can be applied any time one finds oneself on either side of the service continuum.

We should give a patient who may be having a hard day the benefit of the doubt.

This weekend I was in Las Vegas for a meeting with my very favorite people, fellow members of the small professional group called CEDARS/ASPENS. It’s a lousy time of year to be traveling, to be away from home. At my best I am a reluctant traveler when I am away from Beth, and at this time of year I’m also a little tired and cranky. Couple all of that with a late night prior to a very early morning flight (and a 3 hour time change to boot) and I was pretty much one big exposed nerve getting on the plane.

Knowing this would be the case Beth had helped me out by booking a bit of extra leg room, purchasing a carry on slot, as well as early boarding. On the outbound leg I had all of this too; I arrived at the gate a bit tardy and ended up with my roller bag 7 or 8 rows behind my seat. My bad, since I was a bit too casual getting to the gate. But on my return flight I was chilling in the gate area for area for an hour; when I got trampled by folks rushing to get on board first in that early boarding group my mood started to darken. Naturally all of the overhead bins around my seat were filled. My attempt to jam my bag in was unsuccessful. Once again I ended up with my bag several rows behind my seat. The flight attendant asked if that was OK and my instant, out loud response was: “nope. Not OK. Not even a little OK.”

I instantly regretted it.

You see, my tiny moment of petulance, during which I was admittedly behaving like an entitled brat, resulted in that flight attendant punishing me for the rest of the flight. For the next 4 hours she effectively ignored me. Not subtly, either. I sat with a credit card out to buy a drink and a snack while my row mate got a coffee. She failed to acknowledge this obvious cue that would otherwise have had her jumping to sell me something (and garner a tip). Newspapers piled up around me as she scooted by with the trash bag, and the beverage cart glided past my row during each trip down the aisle. Thankfully one row mate was sound asleep for the whole trip and the other only had that one coffee request. They did not suffer for my transgression.

Was I badly treated? Yes, of course I was. But I knew in a nanosecond after my micro-tantrum that it was going to happen. The flight attendant was not having any of it, and she was either unaware of the downstream risk she might be creating, or was willing to use her position of power while in flight to deal with any reaction I might have had to being “shunned”. Why didn’t I assert myself and request the same service offered to those around me? After all I was hungry, thirsty, and under-caffeinated. Looking back I am sure that I did not “raise my hand” because it was  obvious that my flippancy had created an enemy. I have spent so many years evaluating the micro details of the customer care experience from both sides that my reaction was to observe and analyze.

Which of course leads us to the question of where does the lesson lie and for whom is it meant? There is certainly a lesson for the young flight attendant but it is not for me to provide. I will tag the airline when I link this on Twitter in the hope that the lesson I learned might be shared with all of their flight attendants. I will not identify my flight; after all, the “original sin” was mine. Rather, I will look at this for an insight into how we as physicians and our staff might be better able to serve our patients when circumstances may not be optimal. Realizing how hard it is to be always “on” for passengers I am almost always solicitous and bring minimal demands to flight attendants. Most of our patients behave like this when they come to see us.

It is where a patient, the “served” individual in the service continuum, behaves less than perfectly that the lesson for me lies. An edgy or unhappy person should be given the benefit of the doubt as long as they do not persist in angry or unhappy behavior.  The young flight attendant whose job it is to provide a service did not give me the benefit of the doubt. My behavior after being seated was impeccable. I neither pouted nor complained. How often do we see a patient who comes into the office and instantly pops off to the reception staff about something trivial like filling out a form? You know, the equivalent of having to place your carry on a few rows behind your seat. Or in the exam room is a little aggressive with the first question? Do we as healthcare providers, doctor and staff, treat them from that point on as if they are the passenger who won’t hang up their phone, put their seat back up, or stay out of the aisle for the entire flight?

Or because we don’t know anything about what else is going on for them do we instead give them the benefit of the doubt? Allow them a few moments to demonstrate that their first little outburst was just that, a trivial anomaly, and not an indication that they are going to be an ongoing problem?

That’s the lesson I learned from the 4 hour punishment for my tiny, brief moment of pique. When presented with a patient who is on edge, who may be less than cuddly on first blush, we should offer them the benefit of the doubt. At least until they demonstrate that they are going to double down on their petulance rather than move beyond it. While I was pretty hungry by the time we landed, in the end I am thankful for the tiny lesson in customer care I received while flying home from Las Vegas.

Not gonna lie, Thanksgiving this year has been a tough go for me. As you know Thanksgiving is far and away my favorite holiday. The coming together of family and friends for nothing but the joy of coming together as family and friends has always touched my soul. That we would or could continue to do so year after year has been a bit of a touchstone for a kid (and a couple) who moved away. For more than 30 years we have alternated in some way between extended families. Where once we needed only manage two generations there are now four in the mix. 2019 was an “off” year for us, a year when children would prioritize in-laws (if even that was possible). Beth and I neither hosted nor traveled to be hosted by family for Thanksgiving dinner (hugs and infinite thanks to the Taylors for folding us into theirs and to Randy and his little family for joining us for brunch).

I missed everybody.

Seriously, I was a mess. Just a great big blubbering mess. I missed everyone, those both simply away and those who are gone. This longing was occasionally just below the surface, and to my wife’s great amusement bubbled through at pretty much every tiny little emotional prompt. It goes without saying that I sprung a leak watching “Mary Poppins” and “A Beautiful Day in the Neighborhood ” (the Mister Rogers movie), but come on, I cried at the end of “Downton Abbey”. Everybody lived! Everybody was happy! And I still cried. Don’t even get me started about that new “E.T.” commercial. Sheesh.

For whatever reason, well, probably because we wouldn’t have a typical family Thanksgiving, I’ve been thinking quite a bit about family members who are no longer with us. It’s been a tough few years for the White and Hurst families, and for the families of our sibling’s spouses for that matter. I’ve found myself thinking of my Dad and my Father-in-Law, wishing I could chat about any number of things. We stumbled upon a lovely picture of Sandy, my Mother-in-Law, making Christmas cookies. So vibrant, so alive in that picture. My memories of those holiday moments came alive, too, a rush of color and smiles and scents and laughter. Bob’s puns. My Dad’s terrible palate that could nonetheless parse the provenance and price point of Chateauneuf de Pape. They are here with me as if we’d had dinner yesterday.

If I had the guts I would re-watch “Coco”, that lovely little Disney movie about the Mexican day of remembrance Dio de los Muertos. I don’t, and I won’t, at least not now while I seem to be just one raw exposed nerve, but if I did it would probably help a bit. Remembering, that is. Harold Bloom, the Yale professor of literature and societal scold, has given this some thought: “Our beloved dead live only as long as we absorb them into our daily thoughts and feelings. When we die, our own survival will be the extent to which we have changed the lives of those who come after us.” Very Mexican, that. Still, both Bloom and Coco are right; Beth’s folks and my Dad have been here with us this Thanksgiving.

Are they in Heaven? Boy, for as much thinking as I’ve done about that over the years I still don’t know where that is. Heaven, that is. Is it a place like what Disney depicted in “Coco”, where our dead live for as long as they are remembered by the living? Does the Heaven of my upbringing exist as a place of eternal joy for those whose lives were deemed worthy? Or is there some other, more rational explanation like the one that my genius brother-in-law and I have explored through quantum physics? The multiverse of infinite time going both forward and backward?

Or perhaps it is not our beloved dead who are in Heaven but us. Maybe it is we who are in Heaven. Mr. Rogers: “The connections we make here in the course of a life–maybe that’s what Heaven is.” Maybe Heaven is here, now, and those we’ve lost in the flesh are nonetheless here with us in Heaven for as long as they are remembered. Make no mistake it is easier and far more satisfying to be warmed by a hug than a memory. But still, the connections persist. That’s likely the important lesson for me this Thanksgiving. The rituals help us to remember, and the remembering keeps those we love and have loved close by. My beloved Thanksgiving, in every version, may be as close as I will ever come to understanding Heaven.

And that it’s OK for me, for anyone, to want a little more of Heaven.

Thanksgiving musings…

For pretty much my entire adult life I have tried very hard to live by one of the core tenets of Taoism: the man who knows when enough is enough will always have enough. Through times both thicker and thinner, the more closely I’ve been able to hue to the intent here the happier I’ve been. For Thanksgiving Day I’ve come upon a companion piece that may very well bookend a philosophy for life.

“Gratitude turns what we have into enough.” (HT Mrs. Bill Livingston)

“The sign of a healthy ritual is one that can be changed.”

This is my favorite time of year. Thanksgiving, that is. I’m not so much a fan of the whole “Holiday Season” thing, given that it’s all about the commerce of Christmas. What I really love is Thanksgiving. It’s pure, or at least as pure as a holiday can be in our hyper market-driven American lives. For those of you who are now being launched out of your chairs with a knee-jerk response about the heinous effect of the Pilgrims on the indigenous natives here long before the westward move from Europe, save your breath. What I’m talking about is not in any way related to anything historical other than the traditional myth of generosity and comity I first learned about in kindergarten. Thanksgiving for me is simple and pure. We gather and break bread, the only reason to do so being that we are thankful for the opportunity.

We joke in the White family that our traditions, especially those around holidays, are set in stone. Do it twice and it’s as permanent as Stonehenge. While this is certainly true on average, looking back there have been some mileposts where a turn was made. Actually, more than a few. In the earliest of days my maternal grandparents hosted Thanksgiving in New Jersey. This went on until my Dad had enough of traveling with 3 and then 4 little ones. Turkey Day moved to our home for the next 20 years or so. I have to admit that I don’t remember whether or not Gamma and Gramp were there in the tiny house in Southbridge; I cannot remember a Thanksgiving without Gamma once we moved to RI, at least after Gramp died.

Why can’t I remember where she sat?

Take a moment and think about your family meal. What time did you eat as a kid? Do you remember why that was the time? And the meal itself; what did your family eat and how was it prepared? It was always the same, each year, right? We were a football house. In RI every high school has a Thanksgiving Day game. Same for Massachusetts. The annual rivalry with Bartlett (Webster) has been a thing in Southbridge for decades. I got to play in one as a freshman, but I can remember going to the game to see our childhood heroes, the gods who strapped on the pads for the Pioneers, from my grade school years. My first cup of coffee was at at Bartlett/Southbridge Thanksgiving Day game when they ran out of hot chocolate. We ate around 3 if memory serves. The games began at 11 and were done by 1:00. Long after I hung up my cleats in RI we all piled on our warmest outerwear and watched Lincoln High play its annual version of the game.

Stuff starts to change when you get married and the whole in-law thing enters into the Holiday equation. Beth and I are both first-born, first-married, first to have kids (and grandkids) in both of our families. Since our families lived 6 or 7 hours apart there was no way to pull off the double-dinner dance so delicately done by countless friends who married local. It’s funny how you notice the differences in family traditions so much more than that which is the same. The Whites and the Hursts all ended up with magnificent meals, both nutritionally and spiritually satisfying in every way, albeit by vastly different routes. Beth’s family sourced everything locally, each item plucked from the farm within days of Thanksgiving, every course and dessert made from scratch. In our house the turkey was frozen long before dinner, and the only things made from scratch were the mashed potatoes (Dad was very particular about them) and the stuffing.

And yet both meals were the best meals I ate every single year because they were baked in love and enjoyed in the company of those I loved and who loved me.

Change has continued to come to our Thanksgiving rituals as the next generation went to college and began to (yikes!) marry themselves. Two generations of in-laws to manage now. Whoa. Children living out of town with job schedules and travel logistics to contend with. Siblings who live close enough to give at least a passing thought to joining around a single table, and other sets of siblings just far enough apart that to do so would require a quantum computer and a Papal decree. Our little family alternates years as we did for so long when our kids were young. This is an “off” year for us. Beth and I will see one child and his family for a short time at brunch. That will be it for our family gathering, at least on Thanksgiving Day. Another family will fold us into the embrace of their ritual, a change for both of us.

The details change, but do the rituals of Thanksgiving change as well? I don’t think so. At least not enough to change how I feel about Thanksgiving or how I remember our Thanksgivings of yore. We will enjoy the rituals that have surrounded the signature ritual, the Thanksgiving Day meal, and for this year they will be enough. Pizza on Wednesday to usher in the Holiday, and the best steaks we can find on Friday. On Saturday I’ll try to find some way to serve lasagna; we always had Mrs. Cunniff’s ready to defrost after 3 days of leftovers. I’ll bring Cakebread Chardonnay (and think of my sister Tracey) to our friends’ house for dinner, almost 30 years of ritual in that little gesture alone. With those steaks we will drink Chateauneuf de Pape, the only wine my Dad could identify; he had the world’s worst palate and was subsequently the easiest wine drinker to please except on the Friday after Thanksgiving when only Chateauneuf de Pape would do.

The sweet sadness of change will be lightened for me by the strength of the rituals that persist. Each one has grown to fill the space created by inevitable change. By both loss and gain. The rituals that we have now have come from the same place as those they have replaced, a place of love, a place filled with thanks for that love. Yes, this is my favorite time of year. Thanksgiving is my favorite holiday.

Happy Thanksgiving to you and yours.

Sunday musings…

1) Wit. “Mustard’s Last Stand”. Name of a hot dog stand at Northwestern.

2) Streaming. Lots of churn about streaming fatigue, overload, etc. So many/too many new options layered on top of shows and movies you still need to catch up on. What’s a body to do?

I’m gonna read a book.

3) Burberry. I stumbled upon several articles talking about the new creative director of venerable clothing brand Burberry. All of them talked about their plans to change stuff there. While I am not a regular customer by any means I have had a couple of pieces from Burberry that fit my style and stood the test of time. Which begs the question: why must Burberry, or for that matter any iconic brand known for a particular whatever, change? Evolution seems proper, maybe even inevitable, but the incessant demand for the traditional to change is confusing to me.

Why must change be considered as a mandate rather than an option, especially in a successful endeavor?

I admit that I poke fun at fashion with some regularity, typically timed by the semi-annual release of fashion issues of the big national newspaper magazines. My fascination with the absurdity of what is promoted as good, or even possible knows no bounds. Nobody wears that nonsense, yet lots of somebodies continue to wear garments that are instantly recognizable as Burberry. Does this not denote success? Is this not what a successful venture of any kind in any space would seek to perpetuate? I think of the pillars of healthcare delivery, known for excellence in certain spheres because of their ability to successfully treat the most complex cases imaginable. One of them here in town has a new “creative director” who has decided that change means the equivalent of mass market growth in fashion. Like Givenchy designing and selling volume in Kmart.

How long can a successful brand sustain change before what made it successful has been diluted to the point of nonexistence? How many places can the iconic Burberry plaid be placed before it’s just another color? How far from the classic pieces for which it is known can the new creative director take the Burberry style before it’s no longer Burberry?

These are questions that apply everywhere a traditional product, brand, or name means something.

4) Candidate. Much noise has been generated by Michael Bloomberg’s flirtation with a run for the Democratic nomination for president. He is a political chameleon, running now as a Democrat after a run for mayor of NYC as both a Republican and an Independent. Mostly a down-the-line progressive when it comes to social issues he nonetheless has a couple of positions that would appeal to conservatives; his record for law and order in New York appeals to conservatives while at the same time revolting progressives due to the tactics utilized to achieve the goal. A billionaire many times over he seemed to find a balance in NY between promoting business and the creation of wealth while simultaneously protecting those at the bottom of the economic pile. As much as anyone in New York can, anyway. He likely gets bludgeoned in the primaries even though it is equally likely that he would win the presidential election in a landslide.

As interesting and intriguing as Mr. Bloomberg may be his potential entry into the race makes me think of the most impressive national figure I can think of in my lifetime who should have run for President, Condoleezza Rice. Ms. Rice was Secretary of State under Bush and is now a professor at Stanford among other pursuits. Possessed of a nearly unmatchable intelligence among recent government officials both elected and selected, she checks every conceivable box both as a candidate and as someone prepared to govern. I think I can trace my dissatisfaction with both politics and government in part to her decision to withdraw from public life. Not since Paul Tsongas withdrew from the ’92 race due to illness have I felt like the right person was there to be chosen. Her absence from the national conversation borders on tragic.

I fear that we are thus doomed to at least 5 years of braying from the far Right and Left, or just plain old braying if we have 4 more years of 45. In the absence of someone like Ms. Rice, someone of substance who transcends the pettiness of our politics, I will spend another 4 years waiting. Waiting for someone of substance who will speak to me and the 10’s of millions of us who inhabit the center of American politics. Some a little left and others a bit right of center, but all of us clustered far from what it apparently takes to be nominated to run for either party. I will wait for someone who makes me think of Mr. Tsongas or Ms. Rice. Individuals of arching intelligence and substance who have lived lives that citizens of all political leaning can agree have been honorable. Ethical. Candidates who will take and hold principled positions without denigrating or dismissing those who disagree. Someone who can both campaign and govern.

Watching her leave her post as U.N. Ambassador after a successful run as Governor of South Carolina I felt like Bert, looking skyward as Mary Poppins flies away after saving the Banks children. So long Nikki Haley. Don’t stay away too long.

I’ll see you next week…

1) Fall. As in fall back. Daylight Savings time is over. I will miss our sunsets.

That extra hour of sleep, though…

2) Toddler. We have been hosting our little Man Cub (and his Dad) while the Pipsqueak is away with her Mom. Nothing, and I mean nothing up to and including fusion, produces more energy over the course of a day than a male toddler.

Even that extra hour of sleep isn’t enough to catch up.

3) Goals. Mens Journal has a fluff piece about Michael Strahan in last month’s issue. Seems like a nice enough guy (though you’d like to see one of these whirling dervish success types manage to stay married). Got lots on his plates. It’s a fun peek into his work week. As is often the case there is a little gem tucked into the text, this one about how he sets goals: SMART.

Specific. Measurable. Attainable. Realistic. Time-Bound.

“Attainable” and “Realistic” are redundant, but the idea behind this little ditty is pretty good. After reading this I fired off an email to one of my teams at work about a service that we have not successfully integrated into our business. While we may still fail, putting my proposal in this format at least makes our process a better one.

As is so often the case it was worth reading about one more golf-obsessed retired athlete to get this one little pearl.

4) Traditional. Those of you (both of you?) who have been reading these Sunday missives for a bit will remember that “Sunday musings…” was  my way of giving back to the (much younger, earlier version) of the CrossFit community. I discovered CrossFit in 2005 and began to interact online in 2006. The website also had a Message Board back then; folks got to know one another in what I called the “cyber gym” both on CrossFit.com and the Board. Those free-wheeling, wild west spaces are long gone, replaced by a subscription/sign-in and monitored corporate locale befitting the grown-up business that CrossFit has become.

On Instagram, a place I do not visit, a pundit in the fitness arena opined that “Traditional CrossFit” is no longer, and that his version of “smarter” CrossFit was now what one should practice. What he is actually saying is that the practice of “CrossFit, the Sport of Fitness” is no longer what the masses should be doing, because so-called traditional CrossFit has really never gone away. The very best affiliate gyms have always used the kind of CrossFit that you found on CrossFit.com (with rational scaling options provided each night from BrandX)  from 2005 through around 2011 or 12.

While I no longer have any type of relationship with CrossFit, Inc. or a local affiliate gym (though I continue to be very friendly with the owners of the original Box here in Cleveland), I still work out much as I did when I discovered CrossFit in 2005 (interestingly in a Mens Journal article). There is still wisdom in the original version of “What is Fitness” published in the CFJ volume 2 ( the re-edited version is not of the same quality; I wish I’d saved a copy of the original). Constantly varied (do lots of different things) functional movements (do exercises that involve the whole body, not isolated parts) performed at RELATIVELY high intensity. That last part has always been key, and it is one of the parts that, if forgotten, leads to suboptimal outcomes and injury: intensity is relative to the individual on any given day. At 59 (and coming off a hip replacement) I am hardly going to have the same intensity I had when I started CF at 45.

Form, or technique (do the exercises properly), consistency (do the exercises properly all the time; adhere to a schedule of exercise and recovery), and only then intensity. This was once dogma that was unassailable. The “gamesification” of CF after 2012 prompted many a gym to lose this as they chased the competitor and as members chased competitions they had no business chasing. “What is Fitness” also introduced the masses to the 10 Characteristics of Fitness and the concept that a truly fit individual was equally competent in all 10. That IG opinionater  makes the classic mistake of stating that strength is more important than the other 9 characteristics. This  is as misguided as one of my other favorite reads, Outside Magazine, which consistently posits that cardiovascular endurance is the sine qua non of athleticism. Jeff Martin of The Brand X Method (who has no affiliation with CrossFit) should be credited with the real insight regarding strength: the vast majority of individuals are under-strong relative to the other 9 characteristics, and therefore supplemental strength training is necessary.

It’s not necessary to learn that IG opinionator’s name because he is just the most recent example of someone who almost gets it. Man, the conversations we had about this stuff in those halcyon days of CrossFit.com–scaling, strength, additional work, recovery–my kids called in “CrackFit” because we were all so into the intellectual side of this new way to approach fitness. Without a doubt “CrossFit the business” bears little resemblance to those early days, but the very particular way “CrossFit the program” applied classic HIIT principles was, and still is, revolutionary. Layering on traditional training techniques (periodization, supplemental exercises to address weaknesses) while remaining firmly committed to the original core principles (technique -> consistency -> intensity, etc.) is simply proper evolution.

With or without CrossFit, Inc. that particular era is far from over.

I’ll see you next week…

It really makes no sense. No sense at all. I live in a city that can be described as a mid-major, sure, but it happens to be a city that has a major league medical community anchored by two large research centers. Three if you happen to have a pediatric disease. And yet, with all of our local resources it can be absolutely maddening if you have a relatively rare disease, an unusual presentation of a common affliction, or if you happen to need highly specialized care at even the most mildly inconvenient time. There is a rent  in the very fabric of our medical system, the part of the general healthcare system where actual medical care is delivered to real, live patients by doctors and nurses and the like.

One of the main selling points of the Accountable Care Act was that it would encourage the creation of large vertically integrated organizations that would be so efficient that they would provide medical care to people with greater convenience at a lower cost. In reality, not so much. Where once a patient would call an operator sitting at the front desk of her doctor’s office to make an appointment, one now calls a large center that resembles the kind of place you call when you have a problem with your credit card. Your operator has no idea what’s going on in the office, and she has all kinds of rules that are in effect barriers to seeing the doctor. If you have an emergency there is only one answer allowed: go the emergency room.

Neither convenient nor cost effective, that.

What happens when you have a rare, unusual, or complex problem is even more maddening. Once upon a time institutions like the Mayo Clinic, Cleveland Clinic, and Cedars Sinai were willing recipients of referrals from doctors in the community (or from within their system) who had the very hardest medical challenges. Indeed, in my recollection that’s all they really wanted to see. They were so busy making brilliant diagnoses in the most confusing medical cases, and performing brilliant surgeries on the most difficult and rare diseases that they had no time to see the common, mundane diseases that make up the overwhelming majority of what most doctors see in their offices and the OR. More than that the doctors at these medical meccas were simply thrilled to have your referral if you, like me, were someone who saw the masses. The great professors were available 24/7/365.

Now? Not so much. The age of the Accountable Care Organization (ACO) is the age of the institution. What was billed as a program meant to return the patient to the center of the care experience has actually driven the patient to the bottom of the org chart. Where once the patient was truly the focus the most accurate description of the priority cascade is now institution (administration) -> government -> payer (insurance) -> doctor -> support staff -> patient. With few exceptions there is no such thing as A PATIENT; institutions (and payers, etc.) talk only about PATIENTS. Like customers at Target. An omnibus group to be assessed en masse, with conclusions drawn and then applied to a population, not a patient.

This works I suppose, at least it sorta works from a medical standpoint, if you are a patient who has a common problem that fits in the middle of the Bell Curve of presentations. Where once these vaunted institutions were staffed by a small cadre of truly elite practitioners, nothing but Generals and Colonels, there is now an army of  privates and corporals marching in lockstep. Like an army they are fed by a massive infrastructure that is unseen and uninvestigated, punching in and punching out, their output measured as precisely as that of a manufacturing company staffed run by a Six Sigma star chamber. But what if you, the patient or the parent of a patient, fall outside the limits of the Bell Curve? What if you are like the patients who used to constitute nearly the entire population of patients at what used to be called tertiary care institutions?

Let me tell you a couple of stories that seem to be representative of the law of unintended consequences. Unintended, that is, if we are being charitable.

While I was out of town last weekend one of my associates saw a patient in the office who we had inherited from one of the larger institutions in town. Inherited, that is, when our patients family had become exasperated by the barriers placed between them and the care they needed, especially when there were acute issues to be addressed. Although we are not a “mecca” our group is really very good, able to handle levels of complexity that are beyond the scope of a typical specialty practice in the community. Nonetheless, there are circumstances where care should be provided in a super-specialty setting, and such was the case for this poor patient. My associate was rebuffed by both institutions, never able to get by the second level of “civilian” phone bureaucracy at either institution to even discuss the case with a physician. One offered a visit at an associated local ER (with no specialty coverage), and the other refused to even offer that since our patient had once been seen in the other institution and was therefore “their” patient. When I intervened I did speak to an on call specialist who agreed to have our patient seen by their onsite (general) ER. I arranged care with a private subspecialty group.

Our patient got the care they needed because I have 30+ years of experience, and I have contacts I’ve built up along the way that I can call on in a pinch. What if you are a patient, or the parent of a patient, who needs something unusual, out of the ordinary, even if you don’t need it on an emergent basis? One need only look at the evolution of disease support groups on various social media platforms to understand the scope and character of the difficulty that this population faces when they need specialty care. Let me use our little family as an example (my son and daughter-in-law have been very open about their experience).

A child has a number of small but not inconsequential medical issues that don’t seem to be related, but there are just one or two too many to just chalk up to being a “little behind”. Mother and grandmother share their concern with the family doctor who agrees, but admits that it’s just a bit beyond their scope of practice. Mother used her considerable Google-Fu and discovered that there is a medical condition that explains everything that is going on, and she has spent some time in an online support group learning about it. She  has convinced both grandmother and family doctor that a rather rare but well-known entity is possible, so the family doctor arranges for the proper specialty consultation. The specialist agrees and orders the standard test, an MRI, and all hope for a quick confirmation so that a solution can be found.

So far, so good, right? A process that’s a little slow, but a process moving forward. Once the MRI confirms the diagnosis we will surely find an expert to do the surgery since we live in an area with not one, not two, but three world famous children’s hospital. Even if the MRI is equivocal the support group members assure our little family that the existence of the “occult” or hidden version of this condition is well known enough that we will be able to move forward locally. Until, you guessed it, the MRI was read by the infantry as “normal”, and the specialty surgeons declined to even see the little patient.

Mecca was closed.

In the age of the ACO this is such a common occurrence that the support group could not have been more blasé in its response. A dozen or more moms chimed in with carbon copy stories of large, prestigious institutions that no longer looked beyond one or two standard deviations from the mean. What has replaced the tightly nit and interwoven physician networks of trust in which a dogged pursuit by the family physician would carve a path to the necessary super specialist is the online support group. Where once a single doc could move the needle there was now a hive of collective knowledge and experience that sought out and then supported those few specialists who practice as if they were back in the era of the giants. And so it was that our little patient traveled from Cleveland, home to three world famous children’s hospitals, to Providence and the surgeon who would go on to confirm the diagnosis and perform the surgery that would lead to a cure.

What does it say about a healthcare system that has dismantled  the institutions that once cared only for the most complex and complicated medical problems, as our little patient experienced? It turns out that the MRI was misread; the diagnosis was obvious to the Rhode Island surgeon, and easily seen by mother and grandmother once it was pointed out. What does it say about division heads who are so consumed with acquiring market share in the most basic areas of a specialty or service that they allow the growth of a culture that is built around turning away these challenging problems at the door, as my patient experienced? Volume and margin have triumphed over the miracles that we once came to expect from great medical institutions.

What happens to the patient who doesn’t have an old, connected doc willing to get on the phone to find the right place and the right care? Or the child who doesn’t have a mother or grandmother who will doggedly pursue the diagnosis and care that was once pursued on their behalf as a matter of pride, a matter of course? What happens when Dr. House is too busy doing cash-pay executive physicals to see the patient he was trained to save?