Random Thoughts from a Restless Mind

No good deed goes unpunished. Everyone’s heard this. Do you think it’s true? Does fear of the unforeseen consequence give you pause, make you think twice and maybe choose NOT to do that good deed?

There’s a young man who bags groceries at my local supermarket. He’s a special needs kid who went to school with my guys.  Let’s call him Billy, obviously not his real name, but he’s still a little kid in a young man’s body and he goes by a kid’s name like Billy. I always try to check out in a lane where Billy is bagging because he’s just a nice kid. Always smiling. Happy to be there. I’ve never seen him having a bad day. Sometimes if the line is long in back of me I’ll bag alongside him and we’ll race to see who can bag he most groceries the fastest. He kicks my ass every time.

Billy is a huge Cleveland Cavaliers fan and an even bigger LeBron fan. In season we always deconstruct the last game and make predictions about the next. I’m tellin’ ya, if Mike Brown and Danny Ferry spent just a couple of sessions with us the Cavs would be hoisting their third championship by now! Billy always tells me about his viewing plans for tonight’s game, and we talk about any game he might be attending for weeks in advance. The kid just loves his Cavs.

I’m a pretty lucky guy. Check that, I’m a VERY lucky guy. I live in Cleveland, not Boston or New York or LA. Even though I’m just a guy, not a big hitter or classic gobbersnopper, I know some pretty cool folks here in town. Several of my friends have seats that would make Jack Nicholson or Spike Lee jealous. How cool would it be to take Billy to a Cavs game and sit courtside? Give him a chance to see how big LeBron is in real life. So I asked him if he’d like to take in a game with his sneakers on the court, sitting across from the home bench and chatting up the refs from, oh, 3 or 4 feet. He said he’d ask his Dad, which I agreed was a really good idea, and he seemed pretty psyched.

Flash forward a couple of weeks. I’m on my way into the store and I stop by Billy’s aisle and apologize that I haven’t been around, tell him I’m still working on those tickets. Billy’s face kinda drops and he sheepishly says that his Dad doesn’t think it’s such a good idea, seeing as how his Dad doesn’t know me and all. I agree with Billy’s Dad and tell him so, and I promise that I’ll give his Dad a call if the tickets materialize. And then I start the second guessing.

Was I wrong to offer those special tickets to Billy? Was it a little bold to offer to bring him to a game? I can definitely see his Dad’s point of view; I can almost hear the conversation at the dinner table between Mom and Dad, can’t you? Who is this guy? Why Billy? What does he want? All reasonable questions, so I thought I’d ask them of myself and maybe have a little virtual conversation with Billy’s Dad in the process.

Why are you bringing this kid to a Cavs game, using courtside seats with a kid you barely know? The first and most obvious answer is because I CAN. I can get the tickets. I can drive the car. I can make a little something special happen in the life of a nice kid  whose universe is happy but a little small. I imagine him asking “But why? What are YOU getting out of it?” There’s the rub, eh? What would I be getting out of it?

Have you ever been presented with that rare opportunity, a chance to do an unpunished good deed? A freebie. Almost no one knows about it but you and maybe the recipient of the good deed. The internet corollary of “no good deed goes unpunished” seems to be “no good deed goes UNPUBLISHED”, but that’s not the case here. You’re gonna do the deed, you’re gonna feel good, and you’re gonna move on. That’s what I’d ask Billy’s Dad. That’s what this one feels like. It’s just a kid who loves basketball and LeBron and his Cavs. An open shot…the ball feels good…the basket looks as big as a hula hoop…a freebie…a free throw.

Listen, nobody does any good deeds without some kind of payback. Some need more payback than others, but if it didn’t feel good you wouldn’t do it. Maybe that’s where I went a little wrong here. I didn’t really look too much beyond the universe of me and Billy at the end of the aisle in a grocery bagging frenzy. He’s a special needs kid; his family doesn’t know me. Duh. Bad execution built on insufficient forethought, albeit based on good strategy. My heart was, and is, in the right place. It’s still that rarest of good deeds, one that might very well go unpunished. The execution just needs a little polish. Maybe it’s Billy and his Dad who need to take in that game, four feet from one family on the floor.

That’s not the point, though. How you pull it off is really not the point. The take home message is that there are good deeds out there to be done. Little deeds and large. Equally good whether the stage is grocery store or global. The essence of these good deeds that may go unpunished lies in both intent and outcome. The net benefit must land with the recipient, no predictable or probable harm should befall the recipient (it’s your responsibility to perform that particular due diligence), and for Heaven’s sake it should be unpublished, a private deed for the sake of nothing other than the deed itself. (This still qualifies; you have no idea who Billy is, and you won’t have any idea whether or not I’ll be able to pull this off.)

Have you ever been here? It’s a freebie. No one will know. You’ll probably get away with it, that most rare of things, the unpunished good deed. You’re right there at the free throw line. The ball feels good in your hands. Really good. The basket looks as big as a hula hoop.

Take it. Take the shot.

Teen drama. Remember it? Of course you do. If you’re like most of us, no matter how old or young you might be, there’s more than enough teen drama still  rolling around in your life. There’s very little of it in the White house right now (knock on wood), but I had an interesting conversation about this in the office with some grandparents talking about watching their teen grandkids being raised. We all had it, the drama, and so did they, but they were pretty distressed by what they’ve been watching in the homes of their grandchildren. It seems to be a universal observation that teen drama is of a greater magnitude now. Why is that?

If you are of a certain age (like me) you communicated with your friends by telephone. You know, the one on the wall in the kitchen, typically the only one in the house, the one that you shared with everyone else in your family. I know, I know…those of you NOT of a certain age have only seen this on “Leave it to Beaver” re-runs on Family TV, but it was really like that. One telephone with a rotary dial, no call-waiting and no voicemail. Maybe there was a Texas Instruments calculator the size of a toaster in your Dad’s office, and somewhere in the house you had a manual typewriter with a worn-out ribbon. The only computers in existence lived at the Pentagon and GM; you certainly didn’t have one at home. Cell phones? Please. You couldn’t even spell “cell” on your 10th grade biology test.

Your teen drama took place primarily face-to-face in school, or transpired one-on-one on the phone at night. You had a limit to how long you could talk (your stinky brother wanted the phone), and the “phone game” of a story growing and evolving with each transmittal was the real deal because, well, there was only one call at a time. You learned to deal with your drama face-to-face because you actually stood in front of someone and talked to them. This wasn’t all good, of course. I seem to remember many more real, honest to goodness fights, boys and girls, in my high school days. Teen drama was like a slow moving train heading toward disaster.

Fast forward to 2010. Verrry fast forward. Teen drama, whether it’s a bunch of teenagers, a bunch of Crossfitters, or a bunch of workers at Google  involved, is indeed a much more intense phenomenon. It hits harder and faster, and it spreads at the speed of light because it TRAVELS at the speed of light. Cell phones, Twitter, Facebook, Text…drama transmittal is now exponentially faster so drama growth is not linear but exponential as well. No longer is the “telephone game” played in a daisy chain of teenagers, each juicy nugget of incendiary chat passed along from one combatant to the next like so many buckets of flaming kerosene. Nope, now it’s 5, 10, dozens of drama queens all in the arena with flame throwers lit firing away in all directions (have you noticed how “drama queen” is no longer gender specific?).

Teachable moment? Eh, I dunno. I guess if you are a parent or grandparent it helps to understand why it is that your teen and young adult kids seem to be hit so much harder and so much faster when the same stuff you experienced hits them. Remembering how much slower everything developed when we were teenagers probably shows us the proper intervention: hit the brakes. Time out. Unplug. Yes, this is how our kids communicate now, but not a one of them will be irreparably harmed if we disconnect them for just a bit. Let the roaring flames die down.

As an adult exposed to your OWN drama, though, I do think this knowledge should give you pause, encourage you to actually pause when in the midst of this kind of thing. No one is going to unplug you. You may actually be required to stay plugged in order to remain employed. But the multiplier effect of modern means of massed communication, everyone in and on at the same time, explodes our adult versions of teen drama at the same exponential rates. Hit the brakes; downshift. Compose YOURSELF before you do any composing.

Because you can’t un-ring a bell, and when you ring that bell in 2010 the sound travels at the speed of light. Whatever tune you tone rings forever in the vast electronic symphony hall. Teach your teens, but don’t forget yourself.

You’re a big kid now; slow it down.

Like most physicians my age I have been sued in a medical malpractice case. It happened to me many, many years ago, and the error in care actually happened before I did anything for that particular patient. An anesthesia accident occurred prior to the OR, and my role was to simply identify the problem, do what was necessary to stabilize the patient, and then refer the patient to the appropriate specialist. Although I had no role in the actions that caused the harm to my patient I was included in the lawsuit because my name was on the chart.

Welcome to the American medical malpractice experience.

While I have yet to be sued again (visualize me running through my house frantically tapping every wooden object), that first case brought an invitation to become an expert witness. As nervous as I was in the deposition for my own case I  managed not to drool, vomit, or soil myself ; this apparently constitutes the minimum requirement to be an expert witness in med-mal cases. I have been a consultant in dozens of cases in the years since. I enjoy the intellectual challenge of deconstructing  a case, the detective work involved in recreating the history. I find the tactical discussions with the attorneys to be intellectually stimulating, similar to creating a game plan in my former life as a football offensive coordinator. Each case unfailing provides some precious nugget, some valuable piece of information that can be brought back to my own practice to make our care and our outcomes better.

But mostly what I have learned from my exposure to the American medical malpractice tort system is that everybody loses every time the game is played.

Let’s break it down, shall we? I’ll use a case in which I was recently involved, among others, to illustrate (obviously all of the names and any other identifiers have been changed). Dr. Z saw Patient X who probably already had a particular disease in 2004. Dr. Z didn’t really pursue some of the findings present in the exam and history at that time, and in effect failed to make a timely diagnosis. Patient X then had a dramatic change in vision after a surgical procedure, a procedure that was done perfectly without any adverse events or complications. This dramatic decrease in vision was really a burden for Patient X, and so an attorney was hired and Dr. Z was sued for malpractice because he failed to make a particular diagnosis in 2004 which MAY have caused the loss of vision in 2006. As it turns out the loss of vision was NOT caused by the disease that went undiagnosed and Dr. Z prevailed at trial.

Let’s quickly look at another case, one in which I had no personal involvement but one that I am familiar with on a personal level. A young mother and father, parents of three healthy little kids, notice a bulge in the belly of their youngest. Maybe he’s two or three at the time. A little umbilical hernia, very common, a snap for a pediatric surgeon to fix, is the diagnosis. They live in a city with many very fine medical institutions and they choose one with a sterling reputation for the surgery. A terrible accident occurs during the surgery, a “never” event, a clear case of medical malpractice. Their beautiful third child suffers irreparable, irreversible brain damage and will now require 24/7/365 care for the rest of his life, a life that will likely be cut short, but a life that will dramatically alter the lives of this young couple and their two other children. The case never goes to trial; the hospital and all of the doctors settle the case and the devastated couple and their children receive a very large settlement.

Let’s look at these cases, shall we? Let’s see who won and who lost. First off we should deal with the lawyers. Think of the defense lawyers, the people who defend the doctors (and their malpractice insurance companies), as the “house”. Defense lawyers ALWAYS get paid, just like the casino always takes its cut. Neither a winner nor a loser, the defense attorney just takes his cut. How about the plaintiff’s attorney? Didn’t they lose the first case and win the second? Well, sort of. A better way to think about the lawyers who sue doctors is to consider them professional gamblers who place their bets with someone else’s money. Some are backed by investors who cover their expenses, and others simply use the proceeds of the first settlement they receive. If the defense attorneys are the “house”, the plaintiff’s attorneys are professional gamblers who make their bets using “house money”. Neither winners nor losers here, just scavengers who feed on the carcasses of…

…EVERYONE ELSE! The doctors, the patients, their families, the hospitals, even the spectators–you and me. Everyone loses. You don’t agree? Let’s dial in a closer look.

In the first example Dr. Z made a mistake. He made a delayed diagnosis. Didn’t provide very good care for that particular problem. When Patient X had something bad happen he was convinced it was because Dr. Z missed a diagnosis, and an enterprising plaintiff’s attorney convinced Patient X that he suffered his bad vision because of malpractice. So they sued. It’s pretty clear that the patient, poor X, lost any which way you look at this. Bad vision in one eye. Hopes raised that not only would that bad ol’ Dr. Z be made to pay for his mistake, but Patient X would also receive a financial settlement, maybe even a windfall. BZZZT. Wrong. Sorry. Johnny, tell Patient X about our lovely parting gifts. Not only do you STILL have bad vision, but now you’ve had all of your false hopes dashed adding bitter disappointment to your loss column, not to mention all of the time you spent in the company of all kinds of lawyers.

But…but…what about Dr. Z? He WON. Really? Ya think? Look back at the story. Dr. Z was sued in 2006. He has had to live with this case and everything that went along with it for 4 years. Time out of the office. Time on the phone with lawyers. Giving depositions. Reading depositions in which his patient and a hired-gun physician expert said he was a bad doctor. 4 years of wondering and worrying, thinking about the case, thinking about losing. Looking at every patient as “the next case”. No, Dr. Z lost, too. My world is littered with the carcasses of physicians, and lives, and practices, and marriages, and families that were destroyed by the process of malpractice cases that the doctors WON. Alcohol abuse, depression, suicide, all in cases that the doc won. Nah…Dr. Z lost, too.

How about the second case? Pretty clear that the doctors and the hospital lost this one. Big time. Huge settlement. They messed up and paid the price. That young family won. Made ‘em pay, just like the fancy lawyer ads on TV. Big money. But really? Seriously? That child was still grievously injured, and that family is still living with the knowledge that he will never be the child he might have been. 24/7/365 care for 10 years. Housing, schedules, LIVES all determined all the time by medical malpractice, a case in which they prevailed legally. Winners? Hardly. I know this family, and they are gracious and wonderful people who have soldiered on for 10+ years, the only ease being a freedom from the financial burden of their tragedy. What if they had gone to trial and lost? That happens, you know. Sometimes real malpractice happens but the doctors win in court. Nope, no patients ever win in medical malpractice. Not here; not ever.

And the spectators? You and me? Well, we lose every single day. Every time a doc does a little extra just to cover himself in case of a trial, orders an extra test or X-Ray that doesn’t really do anything to promote a better outcome but makes for a little better paper trail, we all suffer due the expense of that defensive medicine. Every time we wonder about why our doctor might be ordering that test or asking that question we lose. When a doctor looks at a patient and sees a potential lawsuit instead of a patient who needs help he loses. The patient loses. We all lose. Think about how many medical errors there are that happen again and again because they are never reported, and therefore are never evaluated and examined to see if they could be prevented, because a doctor or a hospital was afraid that reporting the error would launch a lawsuit. Lose.  Everybody loses in the Medical Malpractice Game.

Well, ALMOST everybody. I guess the “house” continues to win, and the folks gambling with the “house’s money” continue to win. It’s just everybody else who loses. Everybody who counts like every single patient and every single doctor in every single medical malpractice case.

Everybody…like you and me.

We have an interesting problem a Skyvision Centers, one that we have all anticipated with a combination of longing and fear. We are about to become too busy to see emergency visits.

Let me back up a little bit and explain why the entire Skyvision crew is experiencing agita over this before it becomes some version of reality. Skyvision is that rare entity that continues to try to be exactly what it professes to be. In our case, while not unique, Skyvision is a rare example of true patient-centered medicine. You can read about our story here http://skyvisioncenters.com/blog/?p=108. I’ve also been very frank about how I feel about the mega-trends in medicine, trends that is seems will be magnified and accelerated in the coming “Healthcare Reform”. http://skyvisioncenters.com/blog/?p=145. None of these current fads or trends are terribly helpful blueprints for the solution to our new “problem” at Skyvision.

The ultimate consumer service industry is healthcare. Oddly enough, I wrote something about that: “The Ultimate Consumer Service Business” http://skyvisioncenters.com/blog/?p=56 (I’m clearly not above self-promotion here!). Everyone at Skyvision Centers is  on board with that concept. We’ve all quaffed the same Kool-Aid as it were. That’s how we have come to the conclusion that we are about to run out of time to see patients with an emergency, at least in the patient- centered way in which we have done so in our first 5 years. For you see, we have allowed our patients to define what it is that constitutes an emergency FOR THEM; we have not imposed any internal definition of “emergency” on our patients, and we have responded to every single patient-defined emergency with the same response: “come right in.” We have also evaluated and responded to every “oh by the way” additional problem that our patients brought up in the exam room but forgot to mention on the phone when they scheduled an appointment.

So how do we know that it’s a problem now, or about to become a problem really soon? Well, we still measure and evaluate all kinds of metrics that relate to the customer experience in the office. Some of those metrics are really kind of objective, like time and volume and such, and they lend themselves pretty easily to trend analysis. We know, for instance, that our average patient volume is dramatically up, especially over the last 6 months. We also know that the average time that a patient spends in the office for our core service has increased by 6 minutes over the last year, and that one of the internal intervals–how long it takes to be brought into the exam after your paperwork is ready–has increased by 4 minutes. We know that the average number of emergency visits (ER’s) is now 6/day, and that the range is 0-12; there is no meaningful pattern to the ER’s, no actionable mode.

We have been able to handle our ER load in the past because of our dedication to the concept of “process”, our adherence to clinical protocols and flow protocols, aspects of Skyvision Centers that were learned and adopted from the Toyota manufacturing processes. Our internal benchmarks for patient experience were established when we had so few patients and so much time to see them that I found myself telling childhood stories to entertain my patients, lest they feel they were getting the bum’s rush. We find that we have now bumped against the outer limit of “acceptable” by our own standards, standards which place us in the top 1% of patient experience, and must now make capital investments in order to remain there.

It is the ER load that has forced our hand, for it is the ER visits that have pushed us into the “discomfort zone” of longer patient waits and longer patient “transit times”. Without ER visits we would still be have “running times” like 2008 or 2007, even though our schedule volumes are dramatically higher, and we would perhaps be able to make smaller capital and staff investments more slowly. Adding more equipment and more staff is scary, especially in this economy and with all of the uncertainty surrounding Healthcare right now. Skyvision Centers is a business after all, and no one has received a raise in our first five years (indeed, I am still working for what amounts to an 80% pay CUT). Simply throwing more staff and more exam space at the problem isn’t so effective if it bankrupts the business. Kinda tough to provide a wonderful patient experience if the doors are padlocked.

So the question is now how do we handle ER visits? I know of a number of practices, probably the majority in our region, that simply give the ER patient the next available open appointment, whenever that may be, even if it is days or weeks ahead. Should we do that? Still others send patients to a local Emergency Room; it’s an emergency after all. One of our local institutions, widely lauded by DC gobbersnoppers including our President as the bellweather example of all that we should aspire to in healthcare, directs all patient-defined same-day ER visits to the World Class Hospital Emergency Room; even if you are an established patient with an established doctor-patient relationship their triage in the Emergency Room directs you to a doctor-in-training for your ER care. Should we simply “turf” our ER visits like World Class Hospital?

Thus far we have allowed our patients to define an emergency as anything they, the patient, feels is an emergency, and we have seen them right away that same day. Should we take back control of the definition of emergency and perform telephone triage? My staff and I certainly know the difference between emergency, urgency and inconvenience. We can define and ascertain what constitutes severe and what constitutes minor. Should we perform triage and schedule ER visits in open slots on subsequent office days according to long-established standards of severity and then availability? Tough call. A foreign body sensation is a “next couple of days” triage, but have you ever felt like you had something in your eye? It’s maddening. Imagine waiting a couple of days to be seen.

Should we openly state to all of our patients that we will continue to see ER visits as we have always done? Severity defined by the patient and “come on in” our response? In tandem with this will our scheduled patients agree to the implied contract that any increased wait they experience is an “investment” in their own future ER care? That they are agreeing to wait a little longer for their scheduled visit because of the “there, but for the Grace of God” phenomenon, that they, too, will go to the front of the line should an emergency befall them?

We’re all patients; I fear that that we  will all experience this in the near and not so near future, especially if the DC gobbersnoppers get their way with “Healthcare Reform”. We at Skyvision Centers are quite frankly way better at providing an enjoyable patient experience to go along with best in class medical outcomes already, and I fear that we are going to find the going even more lonely as we agonize over issues like this. I don’t see a whole lot of folks on the “service” side or the finance side of this equation spending too very much time thinking about the effect of emergencies in the medical office and how they affect our experiences as a patient, the person receiving the service.So what do you think? You’re a patient. From the patient’s point of view what would YOU have us do?

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Man, turning 50 has not been an easy proposition. I’ve been turning 50 since the day after my 49th birthday and quite frankly I haven’t been doing such a great job of it. The highway between mile markers 49 and 50 seems to be strewn with all manner of psychological speed bumps and potholes, pretty much all of which I’ve placed there myself.

Why is this? Why so much angst about 50? I didn’t really have any issues with 18, 21, 30, or 40, at least not any that I was so keenly aware of. In fact, I don’t recall ever thinking about the process of TURNING any of those milestone ages, not a minute spent thinking about the run-up to any of those birthdays. I suppose 40 might have presented an opportunity for at least a little introspection, or at least a little taking stock, but “turning40″ angst was preempted in the course of a single ride on a chair lift in Utah the week prior to my 40th birthday. My chair-mate, noting his own near existential angst at the prospect of turning 40 several years prior shared the wisdom a priest friend had offered. 40 is when your still healthy, strong, and vibrant body meets the experience and wisdom of your now mature mind. That worked for me! 40 made sense after that.

In a dazzling display of prescience and foreshadowing, my lovely bride Beth responded to my epiphany with “wait ’til he turns 50! That’s gonna be a problem!” Shortly thereafter she contracted the mother of all cases of pneumonia and tried to die on me. Any little bit of an issue with turning 40 got pretty much short circuited in the elation that accompanied her recovery.

And yet, here I am. Turning 50.

What’s the big deal you ask? It’s just a number. You’re a January baby. It’s nothing more than another calendar to throw out.  One more tax return. What’s the problem here? Aren’t you the guy always looking forward, wanting what you have? The “no regrets” guy? Cut the crap! Find your balls. Snap out of it.

To which I respond sure! There you are going all left-brain/left nut on me. Trying to impose logic and rational thought on what is clearly a right-brain, visceral “feel” kinda thing. It’s all about the right nut, the squishy can’t get your hands around it illogical nonsensical unease that resists both explanation and resolution.

My own left-brain gets it. Hari, one of my Crossfit buddies, nailed the rational aspect of turning 50. According to Hari our first 50 years are all about preparing. We spend our lives preparing either ourselves or someone else for something that is yet to come. We grow and get ready for kindergarten, so that we can prepare for grade school. Grade school begets junior high where we get ready for high school. High school prepares us for college which leads to job and adulthood. We then transition to the task of preparing others, our children, and spend the next however many years engrossed and engulfed in that pursuit. 50 is when we are done with the preparing. 50 is when we we exit Route Preparation and begin our journey on Route Me. At 50 we can learn for the sake of learning, not because we need to knock off a pre-req. We exercise and eat for the here and now, for how we are hoping to feel right at the moment. The first 50 years are about preparing; the next 50 are about living.

Why then, if I get that, am I having so much trouble TURNING 50?

As I’m sure you’ve gathered if you’re spending any time here on Random Thoughts, I am a physician by day. I finally think I figured it out one day in the office when one of my patients mentioned that she was having some issues with turning 60. We took a little detour, talked a little while about our “turning” issues rather than her eyes. 60 meant “old” to her, and old was more than a little frightening. She didn’t see “old” in the mirror, and didn’t want to think about any part of “old”. Her tactic? Classic–She simply decided that she was younger and told everyone she’s  55! How about me, she asked. You’ve made it. Successful practice and a wonderful professional reputation, healthy family, a marriage to be envied. Your biggest problem should be deciding how to celebrate! How will you mark this milestone, this success?

And there you have it. There, in that lovely compliment from a patient I barely know, was the issue. How indeed would I mark this milestone? The cartoonist would have put an enormous light bulb over my head, for here was at once the solution and the problem. I couldn’t say how I was going to celebrate turning 50 because I can’t celebrate in the way that it turns out I always thought I would, and that fact lies at the base of all of my angst, all of my discomfort, all of my difficulty in turning 50.

Physicians play a game early in their lives called “delayed gratification”, a game in which they willingly put up with the hardships of training and postpone most of the trappings of success. Tiny apartments and old clunker cars are OK because there is a world of plenty just over the horizon, a reward for both the sacrifice and the success that students of medicine encounter on their journey. Their preparation, as Hari would say. Once out in the real world, out of medical school and finished with residencies and fellowships, both the willingness and the ability to play “delayed gratification” slip away to be replaced by a sense of pride in having played,  not terribly fond memories incentive to never play again.

There’s the rub–I am once again playing “delayed gratification” and I simply can’t even consider doing some of the things I thought I could think about to mark this milestone. You know, classic 50 year old dumb guy birthday stuff like, I dunno, buying a Porsche. I don’t think I’d actually do that, but I DID always think that at 50 I would have been able to decide NOT to buy a Porsche, even though I could have if I really wanted to. Even the more meaningful stuff I’ve talked about to mark turning 50, stuff like climbing Kilimanjaro with my sons or accepting that invitation from Geoff Tabin to teach native surgeons how to do cataract surgery in Tibet, I’m not going to do those things because I CAN’T, because I am once again playing the game of “delayed gratification”. I might never have done any of those things, or any of a number of other things I might have thought of, but I always thought I’d be able to decide, that I COULD if I wanted to.

I can’t, and I find that I resent that. It makes my sad, and both of these feelings make my left-brain more than a little unsettled, for there is no rational response. No solution. No pithy sentence to conclude this particular Random Thought on an up note. At the end of the day there will be nothing other than sucking it up, moving on, and getting over it, getting over myself. There will be nothing other than trying to play the game of “delayed gratification” just as well at 50 as I did as a much younger man, for in the end I really have no other rational choice. I will have to hope, to try to be much better at BEING 50 than I have been at TURNING 50.

Because I’ve really sucked at turning 50.

Admit it. How many times have you heard or read a professional athlete utter the words “it’s not about the money” and forced yourself not to gag? Seriously, it’s ALWAYS about the money.

We hear this ad nauseum during the free agent season in every professional team sport as players from superstars on down to less-than-super subs angle for the biggest payday possible. The phrases “max contract”, “salary cap”, and “veteran exception” vie for our attention with batting averages, rebounds, and sacks. We the fans are spectators not only to the games but also to the gamesmanship between owners and players, each trying to maximize their piece of the pie. It’s ALL about the money.

The realist in me wants to acknowledge that this is simply the labor/management battle played out on the front page of the Sports Section. How, I ask, is this any different from the headlines in the Business Section where the “Masters of the Universe” keep score with their multi-billion dollar spoils?

But then it hits me…in the board rooms and the banks how much money you make is the ONLY scorecard. There is no other way to rank the players or the teams. The person with the highest salary wins. That’s it. Nothing else. The company/bank with the highest profit is the “best”. If Goldman Sacs makes more money than JP Morgan then Goldman is the better bank and Lloyd Balnkfield is better and smarter than Jamie Dimon. Money is the only metric, and no one sits at home playing Fantasy Wall Street or cheering for their home town Hedge Fund.

And there’s the rub–the games we watch all have a scorecard, and we keep the score of the games the same way whether it’s the Cleveland Browns vs. the Miami Dolphins in the NFL, or the Shaker Heights Eagles vs. the Southbridge Mass Ponies in Pop Warner. A free throw is one point whether it’s Bingo Smith at the line in the NBA or bingo (yours truly) at Tri-City Park in Rocky River. If you’re playing the game in the back yard, or if you’re a fan of the pro game it doesn’t really matter. What you care about is winning. Period.

When was the last time you heard the words “it’s not about the money” from a big-time athlete, spoken or unspoken, and you believed them? I can come up with exactly one, and I’ve been following pro and college sports since I could turn on a TV. I really did believe Tim Tebow, the kid from Florida, who came back for his senior year to play quarterback. I mean, what did he have to gain money-wise by doing that? Heisman trophy winner. Leader of two NCAA champions. Top five pick in the draft whenever he came out. I really think the kid just loves college and being a college student and football player. Other than him? Shut-out.

But there’s something really interesting blowing in the winds of the NBA. You know that place, home to the “Bird Exception” that allowed the Celtics to pay Larry $33 Million in his last season. Where Michael Jordan took home a cool $30 Million despite making somewhere north of $50 Million in endorsements each year for 10 + years. Some upper mid-level power forward–I can’t even remember his name–agreed to hold off on signing his contract with the Cleveland Cavaliers, promised a huge raise and the chance to play with LeBron James, only to exile himself to Utah when an offer of more money arose. I DO remember what he said in the paper, though. Yup…you guessed it…”it’s not about the money.”

Still, there it is, a whisper dancing just outside the conversation. Someone, a very important someone, has a chance to utter that fateful phrase, “it’s not about the money”, and really mean it. Here now is LeBron James, a free agent at the end of this NBA season, who has the opportunity to sign a contract that is all about his team winning. LeBron, who makes somewhere in the vicinity of $80 Million in endorsement money, can sign a “max contract” that will pay him around $100 Million or so over 7 years, maximizing his income from playing the game but also maximizing the difficulty that General Manager Danny Ferry will have gathering talent to surround LeBron in order to win. Win like you and I think about winning, as in winning NBA championships.

It’s just the tiniest of breezes now, barely enough to tickle what’s left of the leaves on the trees in Cleveland, not even enough to rustle the top sheet of the Plain Dealer as it sits in your driveway. LeBron could sign for the veteran’s minimum, about $2 Million per year. The $2 Million wouldn’t even count against the Cav’s salary cap! Doing this would free up, what, $20, $25 Million per year? That’s enough to sign not one but TWO major players, especially if they, too, sign on just a little bit to “it’s not about the money”, it’s about playing with LeBron and WINNING. Dwayne Wade AND Chris Bosh in Cleveland with LeBron James. In Cleveland, playing to win.

It’s still about the money, of course. I’m not naive enough to think that there wouldn’t be massive positive PR for LeBron if he took a minimum contract and stayed in his hometown city and then won. I also know that he can revisit his max contract option in 2 or 3 years and get pretty much the same number he would get now, even with the massive increase in off-court income likely to come his way if he played it my way. But still, a chance to say “it’s not about the money” and really mean it, even if it’s only for a couple of years? It’s man bites dog stuff.

Who knows if it will happen but I get a little smile as I think about the hurricane that will tear through the Player’s association if LeBron does this. I love thinking about David Stern’s office after the tornado plows through if LeBron comes out and says “it’s not about the money” and means it. If LeBron James is the first professional athlete in modern sports history who literally puts his money where his mouth is.

Hey…anybody out there have Maverick Carter’s cell number?

Customers? Whadda we need customers for? We don’t need no stinkin’ customers. We got PATIENTS!

Has anybody else noticed the forgotten players in the great American Healthcare debate? You know, the people on the receiving end of the health care? The patients? The only time we see any real attention being paid to a patient, the person in a doctor’s office or a hospital, is when someone in Congress or the White House is trying to come up with the title of a Bill or proposal. “The Patient Protection and Affordable Care Act” is the latest flag to be hoisted above an omnibus that otherwise pretty much ignores everything about the patient, about what it means to be a patient and how it feels to be a patient and what matters to a patient receiving medical care.

I’ve written elsewhere on “Random Thoughts” that medicine is the ultimate consumer-service business. The more you think about that the more obvious it becomes, I think. When a patient seeks medical care there is something that we either need or want, sometimes very badly and sometimes very urgently. We are seeking a service, and like any service industry the patient is the customer in that particular relationship. Very few of us, even doctors, are able to be truly informed customers when we are in the doctor’s office or the hospital; there’s just too much to know about too much, even if we have the time to do lots of research, and even if we are not spending any time researching costs. This is such an unbalanced service provider/customer relationship that innumerable ethical guidelines, regulations, and laws have evolved to mitigate against the provider abusing this knowledge mismatch.

What is it that we read about when patients complain about their experiences while obtaining medical care? Do they complain about outcomes, how they eventually turned out after receiving medical care? Not really, in part because people who get medical care almost always get better in America.  What we hear about, time and again, is what their EXPERIENCE was like. How they FELT about the experience, and what was either good or bad about the experience. And let’s face it, people are much more apt to complain about something they didn’t like than they are to praise something they did. When I look at the proposals to “reform” American healthcare  I don’t see anything that even touches on this in passing, and I see all kinds of stuff that is almost guaranteed to make the experience worse.

All because no one has either the insight or the ball’s to look at this whole issue through the eyes of the most important player in the game, the patient. The customer. It’s all about the process and the price, all evaluated from the provider side of the service relationship with no thought given to the customer.

So what exactly am I talking about? What are some examples, Smart Guy? Well–glad you asked; I just happen to have a couple handy. The “flavor of the moment” in the reform movement is the very large healthcare organization that encompasses both physicians and hospitals, organizations that negotiate with payers as a unified whole, and organizations that specifically pay their doctors a salary (presumably NOT tied to the volume of work done by an individual doctor). There are a number of them in the U.S., and most of them are cut from the same cloth. Let’s call this organization the “World Class Hospital”.

It’s 4:59 PM on a Tuesday and you call your doctor’s office; it’s not yet 5:00 so her secretary picks up the phone. She can see you in 5 weeks. You have an emergency? Why yes, she IS in the office right now, and yes she will be here for another hour,  but she doesn’t have an open appointment even though she’s been your doctor for X years. Go to the Emergency Room if you have an emergency. Make the same call at 9:01 in the morning and you might find an open slot, or you might get an associate, or maybe not. Make the call at 5:01 PM and you never even get your doc’s office. Heck, you sit on hold–press 4 to talk to a nurse.  Do not pass go, do give us $200 on top of any exam fee, and proceed directly to the ER.

So you are directed to the ER, because that’s how it happens in “World Class Hospital”, and you now cool your heels for 3 or 4 hours while waiting to receive care from 3 or 4 doctors whom you’ve never met. But don’t worry, they have your Electric Medical Record so it’s all good. They don’t know YOU, of course, but now they know your CHART, and you and your chart are taken care of by Dr. Stranger and his team. After 3 or 4 hours of waiting they  took another hour to take care of something that your own doc would have covered in 10 minutes, but hey, you’re in “World Class Hospital” and you just received a best-in-class medical outcome. What’s your beef?

Two days later you receive the bill for your successful medical outcome. Amazing how efficient “World Class Hospital” is when it comes to getting that bill out, huh? Your bill is 3 pages long, with all kinds of technical jargon and fancy financial lingo, and My God it looks like you were in ICU for a week. Who are all these doctors who I supposedly met? What are all of these extra charges, these “facility fees”? I just had a little problem that I wanted my doctor to take care of. I have Medicare; it’s supposed to be simple. Isn’t that what all of these new plans are supposed to copy, Medicare? It’s now 30 days later; who are all of these people calling me to ask how and when I’m going to pay this bill that I can’t understand? They sure have a lot of people to call me, what with how hard it was to talk to someone when I was sick.

It’s all about process. It’s all about the system. System and hospital and money before doctor, doctor before staff, and staff before patient. Think about that. You, the patient, are the customer, and you are last in line. Would you stand for this anywhere else in your life? We’ve proven at Skyvision Centers that it’s possible to put the patient first, before the doctor or the staff or the insurance company. You can buy Almay cosmetics at Nordstroms, Dillards, or Kmart. Same price. Just like cataract surgery, it costs the same no matter where you go, and the outcomes are almost identical just like Almay is Almay no matter where you buy it. But you sure feel better buying it at Nordstroms, don’t you? They put YOU, the CUSTOMER first in line. YOU are the most important player in the game.

Healthcare reform, at least what’s in front of Congress now, and the proposals to make more and more of your experience like “World Class Hospital”? Meh…not so much. You’re a patient, after all. Can’t you just hear the discussions behind closed doors, in Congress, in the White House, in the back rooms at United Healthcare et. al. and in the executive offices at “World Class Hospital”: Customers? Whadda ya talkin’ about, customers. We don’t need no stinkin’ CUSOTMERS. Ya gotta CARE about customers. We got it way better…we got PATIENTS!

Nobody cares about patients.

They found me. I knew it would happen; it was only a matter of time.

I’ve been “friended” by high school classmates on Facebook!

It’s funny, but I feel kinda strange about this. Unsettled. It’s a “Rafikki” thing I guess, you know, “it’s in the past”. I’m a little surprised, neither in a good way nor a bad, and I’m a little surprised that I am surprised. I shouldn’t be, though, because Beth has had a wonderful time being rediscovered by her high school friends, and a couple of my college buddies have surfaced on other social media sites like Linked-in. The question now before me is “what now?”

I attended two high schools back in the day, Southbridge High in Massachusetts, and Lincoln High in Rhode Island. My family moved after my freshman year in high school and I graduated in a class of kids with whom I had not grown up. Lincoln High was a happy place for me, and some of the years in Southbridge were equally so. I confess to being curious about the fates of some of my childhood crowd. Actually, I’ve been very curious for quite a few years. It’s actually odd to say that out loud since I’m the guy who keeps writing about not looking back for fear of opening the door to regret. And yet, the curiosity remains.

What to do? It was always so difficult, the task so daunting to track down the players from the past that I could set aside my curiosity quite easily. Who has the time? There’s so much on my plate that I have to take care of. How can I justify the effort? Stuff like that. My father-in-law tracked down all of the members of his Navy Band in order to organize a tribute concert for his retiring Navy Chief. This was about 8 years ago, and he did it by painstakingly searching for his mates on the internet of the time, coupling his search with some rather ingenious detective work on the phone (you don’t want to know!). Bob was retired and the massive time element involved was actually a bonus for him–he needed something to fill his day, he was determined, and he enjoyed the process. Every time I was ever curious about my past the memory of his efforts cured me of any notion that I might do the same.

If Bob did the same thing now he would simply search for his buddies on Facebook, Linked-in, Twitter and the like. In all likelihood he would be one or two degrees of internet separation from everyone on his list. Very efficiently and quickly the task would be complete, which would not have been nearly as satisfying for Bob, I think, but knowing that makes my question a little harder to set aside. What now, now that it would be so much easier to explore the past?

As much as I profess to avoid looking back I DO think of certain people and certain events from my childhood. I grew up in a rather tough mill town, a town that was already dying a slow death, although no one knew it at the time. We were all pretty much the same in those days; the financial gulf between management and line had not yet developed, and white color workers were really more very light blue than really white. If you lived in a house it was small, and your neighborhood was right next door to the town’s apartments and duplexes. We were all foul-mouthed punks, the college-track kids indistinguishable except by classroom number from those kids who would never see a college campus in their lifetimes. The “good kids” different from the “bad kids” only in that they never got caught. What happened to the guys I called my friends back then, the guys I ran with for 14 years until a massive fight severed the ties? Did Neil go to law school? Is Tommy a fabulously wealthy dotcom guy or financial wizard? How about Timmy, my oldest friend, 3 of 4 older brothers dead before 40 from heart attacks? Is Timmy still alive?

You read all kinds of “bad ending” stories about people who went and found old boyfriends or girlfriends on social networking sites. Kinda scary, really. My “girl next door” and I have connected on all of these sites (Hi Maureen!), but our folks still live next door and we’ve never really been UNconnected over the years. I don’t really have all that much curiosity about the girls I dated in the past. To be honest, I was a lousy boyfriend to pretty much all of them, and any re-connection would be more like that movie about the guy who traveled around to make amends with past loves, or the other one about the guy who was haunted by past girlfriends. Not a lot of upside to that particular search. But as in all things there are exceptions and here it’s no different. I AM curious about one girl, a girl who was my closest friend in Southbridge as well as my first love. She was dealt a couple of jokers after I moved, yet she played every hand with dignity and grace. How is she doing now?

As I think about it while I’m writing it’s really about the curiosity more than the connecting, at least for me. I’m still not really interested in visiting or re-connecting with my past, I’m just curious about what’s been going on since I stepped off of the pages of that particular story. I don’t need the view that’s available to me 30 inches away on my screen through Facebook; the view from 3,000 feet, or even 30,000 feet would be plenty. Call me a coward, call me callous, call me the same self-centered SOB I might very well have been back then, but I still can’t see myself reaching out now in order to connect. Perhaps I’ll take a page out of my father-in-law’s book and just do a little detective work, staying one or two degrees of separation away, a kind of “novelization” of my search if you will. In the end it seems to be just as I have preached to my children these many years: if you don’t go where trouble can happen, it’s harder to get in trouble.

Whether you go back to the future, or ahead to the past.

“We often think of medicine the way we think of math. We go through the diagnostic process and at the end we get an answer.”*

The modern era of computer-assisted medical diagnosis and computerized medical records began at the University of Vermont in the early 1980’s. I was a medical student at UVM from 1982 to 1986, and my professor Larry Weed, M.D. is occasionally credited as the “father” of computerized medicine. Dr. Weed and I engaged in several epic “battles”, publicly disagreeing about the place of computers in the down and dirty acts of medical diagnosis and treatment. My problem, then and now, was the very premise upon which he based both his work and his conclusions, that the education and experience of a living, breathing doctor was not a match under any circumstances with the power of mathematics in a beeping, buzzing computer. And this was in 1983!

Fast forward to, say, 2003. The term “outcome-based medicine” is starting to be in vogue, the new darling of both the academic intelligentsia and the Beltway policy wonk set, an infatuation that rests on the notion that this concept is somehow new. A cognitive breakthrough. Revolutionary. A way of thinking that will surely improve medical care in the United States while simultaneously saving countless Billions of dollars. If only we would embrace the power of math–the answer’s right in front of us–we would surely succeed! And yet “outcome-based medicine” isn’t really all that new. Dr. Weed used the example of serum lipids and heart disease, medicine vs. cardiac bypass surgery, with years survived as the outcome and diagnostic data as the input to his programs. Heck, the granddaddy of all medical trials, the Diabetic Retinopathy Study, was nothing if not “outcome-based medicine” and it was published in 1978!

“In math, you can check your results by flipping to the answer key in the back of the  book. Medicine is rarely that certain”. When doctors treat a patient the “answer” is the outcome. Did my patient get better? Does he see better after I removed his cataract? Did she live? We evaluate the input on the left side of the “equation” only when the output, the outcome, arrives on the right side of the equal sign. Unlike math where the laws of the equation remain ever constant, in medicine the equation takes place in the black box of a real, live, patient.

“We make our diagnoses based on likelihood and risk.”* On the front side of the equation, where data and diagnosis are the input, doctors are in many ways number crunchers or risk managers. Here it is possible that Dr. Weed’s computers might come in handy, but even here the softness of the data, the input, weakens the power of his math. Did the patient give his entire history to his doctor? Did he forget something? Did he tell the truth, or did he relay what he WISHED was the truth?  Did the doctor hear everything the patient said? Did she have enough time to ask the next follow-up question? Was every sign that would make the diagnosis more secure present at the time of THAT particular exam? Were the right tests ordered and were the results all conclusive and consistent enough to place all of the information in a tight silo of clinical characteristics so that some medical math might apply?

There is a certain arrogance in the notion that our education and our experience are sufficient to make a diagnosis, sufficient to choose and implement the correct treatment, whatever either may be. It is, however, an arrogance built on decades of results, each year bringing better outcomes than the last. It is difficult to quantify and validate this position because it is difficult to evaluate the nuances built into both sides of the medical equation, the diagnostic input and even the outcome output. In math a “2″ is ALWAYS a “2″, no matter where one finds it in an equation; the quadrantic equation never lies, and it is always solved if you follow the rules. In medicine a “2″ is only sometimes a “2″; it is just as likely to be a “2ish” on both sides of the equation, and it is startling and maddening when you realize that this is usually the case.

The arrogance of medicine, built on history, is exceeded only by the arrogance of those who would impose strict math on the practice of medicine. For these people, the Beltway policy wonks and omniscient pundits, a “2″ is always a “2″. Why shouldn’t it be? That’s the way it works in the budget and on Wall Street. Look what happened when people wished that “2″ was really a “4″ when they signed their mortgage papers! If only we could get doctors (and hospitals) to follow these strict guidelines on how to take care of diseases A, B, and C. We could have better, healthier people and spend less money! All of this is true, of course, as long as a “2″ is always a “2″. I hate to sound all mysterious and “in the group” and all, but have you noticed how few people who feel this way about the practice of medicine have ever actually practiced medicine?

We are imperfect beings, both we who are doctors and we who are patients. Until we have diagnostic tools like that of “Bones” on the original Star Trek, that magic hand held wand he would sweep over the stricken on the Enterprise, it will be impossible to look at medicine as we look at math. We will always be uncertain to some degree about everything that is on the left side of the equal sign. Every “2″ necessarily “2ish”. Did we get the right diagnosis? Did we get the right result? Did we get the best possible outcome? “Uncertainty is the water we swim in. Often we can’t know if the answer was right, only if it was right enough.”* Medicine is not math because the answer key at the back of the book will always be printed out of focus, slightly blurred and not sharp.

Is that a “2″? Dammit, Jim, I’m  doctor, not a mathematician!

*Lisa Sanders, M.D., New York Times Magazine, 4 October 2009

I was the best-loved grandson in the history of all mankind!

My birthday is January 7th, 1960. Gama was “born” about a year later–I couldn’t get my one year old tongue around the word “grandma” and it came out “Gama”. Now, the White family is really big on precedent, and since grandchild number 1 called Mom’s mother Gama, Gama it was for everybody. Subsequent grandchildren, great-grandchildren, friends, neighbors, heck a few Romans who lent an ear for all I know called Jane Knopf “Gama”. (This precedent thing turned out to be not so good in the next generation when my nephew, grandchild number three, called my parents “Bam” and “Grump” and it wasn’t allowed to stick, but that’s another story.)

As the first grandchild in my Mom’s family I had the perfect set-up, and the fact that I was the first male in a generation didn’t hurt one bit. My brother was born 17 months after I was, and with the two of us so close together it was apparently a burden for my folks. Turned out to be quite a break for me, though, because my brother was born in May, and at the end of June I was shipped out to stay with Gama and Gramp at the Jersey Shore, the first of countless solo visits with my grandparents. Thus began a most privileged relationship with my maternal grandparents, especially with my beloved Gama.

It’s hard to describe, especially in these days of ultra mobility where extended families live apart, how critical it was to be loved by a family member without condition. Accepted and supported with no strings attached. Time spent with Gama was time spent in a guilt-free bubble. You behaved because it just felt so good to be in that bubble, and if you misbehaved forgiveness came in waves a very brief instant after any punishment. I visited my grandparents for weeks at a time, especially in the summer. My aunt Barbie, 16 years my senior, made it OK for the rugrat to be around even though I was clearly messing up her “only child” status in the house. Those were good times. I had a very special and unique relationship with Gama and Gramp. If I close my eyes and it’s very quiet I can still hear them…”Dar”.

Apparently everyone in my family saw what a special relationship I had with them and sought to preserve and protect it. It does no good to share any dark family secrets, but it seems that all was not as warm, loving, and tranquil as it appeared to me. It never is, eh? In fact, I was the last to discover any of the family’s darker secrets, long after my siblings, long after the cousins 10 and 12 years my junior. I was 30 when my aunts visited us in New York at the end of my residency years when I became aware of how much I’d been “protected” from over the years, protection so effective that any present day revelations cannot dim or diminish the memories of my life with Gama.

We lost Gramp when I was around 17. when he succumbed to his nth heart attack. That whole time is really just a blur, from the phone call I took in Rhode Island with the news from my uncle to the memorial service in Miami where I stood next to Barbie as she tried to read her farewells. What I remember–indeed all I really remember clearly–is Gama saying over and over, “I didn’t get to say ‘goodbye’.” I didn’t get to say ‘goodbye’ either. Maybe that’s why I can still hear Gramp every now and again…”Dar.”

Gama stayed in Florida at King’s Creek for a couple more years, living in the same apartment I’d visited so many times before. I even made one last solo visit when I brought my new college buddy “Kid” for a week of spring break fun during freshman year. Every family seems to have one adult who’s cool, don’t they? Yours does. Admit it. There’s a parent or an uncle or a grandmother who’s just cooler than all of the other adults, right? Well, in our family it was Gama. My Gama was cool! As the years went by as more and more of our friends got to know her it seemed she just got cooler, but it turns our that Gama was ALWAYS cool. She entered college as a pre-med student in the days when women did not become doctors. Almost got away with it, too, until her mother found out and transferred her into education. She dated the gay boys when she was younger because they took her to the best clubs and they were the best dancers (and she didn’t have to worry about getting pawed on the train home from New York).  Yup, Gama was cool.

After a few solo years in Miami Gama moved in with my folks in Rhode Island, spending several months each year with my aunts and their kids in Florida. She never really called us just by name, it was alway “MY Dar”, my Ran, my Tracey, my Kerstin. My Jenny, Rick, Mike or Ed. All eight grandchildren now clearly had a unique and special relationship with Gama as she was now living with all of us. She was still my biggest fan, my brother Randy’s defender (Ran was the “black sheep” by choice when we were younger), Tracey’s cheerleader and Kerstin’s confidant. Even though I can’t describe them as well I know that each of my Florida cousins had some version of the same specialness.

Some time ago, I was in my early thirties, Gama fell and broke her hip. Word came from the hospital that she was failing–a broken hip is often the end for older women. Beth called me on the way to the OR, on my way to do cataract surgeries. Numb, stunned, I couldn’t think. I did what we have always done in my family, I went to work. It was Beth who knew better, who cancelled my patients and put me on a plane to Miami, Continental through Greensborogh, North Carolina. Beth who let everyone know that I was on the way, alerting everyone in Florida when I was delayed in Greensborogh so that Barbie knew where to to leave the message. I sat sobbing in the airport after the  gate attendant told me Gama had died. I wouldn’t get to say goodbye.

My Mom and I spoke at the memorial service representing the children and grandchildren, Mom all icy control, me crashing and burning and choking my way through. I told one of my favorite stories, the one about the little girl who was standing in front of her grandfather’s casket, stomping her feet, clearly angry. “He can’t be dead. I wasn’t done with him yet!” That’s very much how I felt when Gramp died, and I think if we’d had the chance to ask Gramp he would have told us that he wasn’t really all that done with US when he died, either. I definitely wasn’t done with Gama, either, but Gama was done with us. She was ready to go, so long after Gramp left, so long living alone among all of her special kids. I said then, and I still wish today, that she just hadn’t been in so much of a hurry. I never got a chance to say goodbye.

Maybe that’s why even now, when it’s very quiet, if I close my eyes, I can still hear her…”Dar.”