Random Thoughts from a Restless Mind

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.”

When did I become the bad guy?

Dirty Rotten Scoundrel, M.D. Apparently that’s me, and for the most part pretty much all of my physician colleagues if you listen to the President, Members of Congress, and various and sundry pundits from all sides of the political spectrum. There is a over-riding assumption of ill-will and mal-intent when the public is asked about doctors and how doctors behave in our modern medical system. Everyone talks about bad behavior, how doctors are at the root of many (most?) of the “problems with healthcare” in the United States, looking out for themselves first and always, rather than looking out for the best interests of their patients.

The stories told and the statements made are really quite amazing. Mind you now, there are really never any statistics offered that stand up to scrutiny, but the stories are just SO good and SO important that they just must be told. And told again. And again and again until through the sheer volume of the telling they just MUST be true. Like the recent statement by President Obama that Pediatricians would much rather remove a child’s tonsils than treat an infection with antibiotics because they, the pediatricians, would be paid so much more for doing the surgery. This one is pretty hurtful for countless reasons, none the least of which is the fact that neither the President nor any one of his minions is aware of the fact that pediatricians do not perform ANY surgeries, and that pediatricians do not garner any income whatsoever when an OTOLARYNGOLOGIST  removes a child’s tonsils. Recent discussions in pediatric, infectious disease, and otolaryngology circles about the fact that childhood infections have RISEN in the decades in which tonsillectomies have declined, and that perhaps we are doing TOO FEW tonsillectomies now seem rather quaint and pointless in the face of such blatant political pandering. After all, how important can decreasing childhood infections be, really? We’ve got a healthcare system to save!

Is it really true? Do all doctors, or even most doctors, or even a measurable minority of doctors REALLY put their own economic well-being first? Is the first level of decision making in the office truly “which treatment will make me, the doctor, more money?” Could this possibly be the case? I really don’t see it.

In the U.S. becoming a doctor has always been a rather difficult task. American medicine has always been a true example of America as a meritocracy. Our doctors have traditionally been among the brightest of our citizens, students who excelled at every level of their education simply in order to qualify for the privilege of suffering through the pain of a medical education. Those who excelled in their medical school and post-graduate years started out with the best jobs in the nicest locations, or became the academicians who did the ground-breaking research that produced the dazzling array of medical advances that serve us today. A very large percentage of each town’s best and brightest became physicians.

Why? Why did so many of our brightest young people go into medicine? The men and women who are in the primes of their careers right now, did they do so in order to become rich? Was that a reasonable expectation, and were they told how to do this in school? Not to my memory.

Once upon a time, around the time that most of our doctors now in their prime were in grade school, the doctors in a town were held apart from other citizens–seen as different for accepting the calling of medicine. There was an assumption of goodwill born out of the experience that the doctor would be there to take care of you whenever you needed him. A high degree of respect and deference was granted those doctors, whether they were pediatricians or otolaryngologists  or any other type of doctor. Physicians were well-off but they were not wealthy unless they were born to wealth. Being a physician was actually considered one way for a child of wealth to give back to the community. The wealthy in town were merchants or the owners of the factories. Doctors lived in nice houses in nice neighborhoods, but they did not live in the NICEST houses or THE neighborhoods. They often belonged to a country club, but not THE country club.

Doctors of that time, and indeed doctors up until relatively recently, had two very powerful incentives to work hard. In a free market where one is paid for doing work and for doing it well, the more hours you worked and the better you worked the more money you made. It has always seemed that it is easier to find the private practitioner, the doctor of any specialty who works for himself, when an emergency arises at 3:00 AM don’t you think? But more than that, the harder a doctor worked, the more he put aside his own time (and that of his family), the greater was the respect he earned in his community. Hard to value in dollar signs, but clearly valuable enough to create the archetypical American doctor, on call for his patient night and day. In return for devoting your talents to medicine, and in return for devoting years to the toils of becoming a doctor, and in return for placing your time at the disposal of your patients, your doctor recieved a very comfortable living as well as uncalculable respect.

With the exception of the 1980’s during which a small minority of doctors did, indeed, become truly wealthy from practicing some kind of medicine, doctors really did NOT, and do NOT get rich from their jobs. Some time  in those 1980’s things started to change as more and more of our nation’s healthcare was purchased by the government or by insurance companies that took their cues from the government. All of a sudden the doctor was suspect, guilty of gaming the system at every turn. The medical record was no longer a tool to be used in the ongoing care of a patient but was now a legal document, the trap in a perpetual game of “gotcha” as third party payers and malpractice lawyers started to grind away at the reputation and goodwill of our doctors.

Why? Why did this happen? What am I NOT seeing in my offices and in the offices of every physician I have ever known that makes this so? The short answer is that I am not really missing anything at all. There really is no greater incidence of greed and graft on the part of physicians than ever in the past. It’s a ruse, a strawman.  What is greater now is the benefit to be gained by individuals and institutions when all of that goodwill, that assumed respect accorded our doctors is slowly eroded, when doctors can then become a target that diverts attention from any number of more culpable groups.

Might this trend bear fruit? Might this, in fact, be the route that we take to controlling the healthcare economic problems in America? Aye, perhaps, but this is likely to be yet one more instance where we have the opportunity to see the genius of Henkel,  There Ain’t No Such Thing As A Free Lunch. Or perhaps this, from the Esteemed Physician in ‘Atlas Shrugged’: “Let them discover the kind of doctors that their system will now produce. Let them discover, in their operating rooms and operating wards that it is not safe to place their lives in the hands of a man whose life they have throttled. It is not safe, if he is the sort of man who resents it…and still less safe, if he is the sort who doesn’t.”

You might miss me, the eye surgeon Dirty R. Scoundrel, M.D. and my colleagues Snide Lee Whiplash, M.D. the otolaryngologist, and Boris and Natasha Karloff, the husband and wife pediatricians. You will most certainly miss our children and the rest of the best and the brightest of their generation, none of whom are likely to be there to answer your sick call at 3:00 AM. They will most likely be home asleep in the NICEST house in THE neighborhood, tired after an evening at THE country club.

For they will not have become doctors.

My wife Beth and I celebrated our 24th Wedding Anniversary this past weekend! How did we celebrate? We went on a date.

Our first “official” date took place when I was a first year medical student and Beth was a senior in college. There were six Williams grads in my class and we had planned a group trip to watch the Williams/Middlebury soccer and football games in Middlebury; I invited Beth to come along as part of the gang. As luck would have it the games turned out to be on the weekend just before our very first set of med school exams. One by one all of my classmates begged off and our casual group trip to Middlebury turned into a date. 27 years later we’re still dating.

In the early going it was pretty easy to keep right on dating after we got married. A quiet evening of board games over a glass of Riesling might be followed a few days later by a rousing night on the town in Burlington. We were college kids, accustomed to the rhythm and rhyme of the school schedule, with lots of common interests and pursuits. It was easy to be together and easy to get on complementary schedules.

Things got a little rougher when we left Burlington after my graduation. Internship and residency are just a grind, and Beth’s first job was third shift at the hospital. 70 and 80 hour work weeks with every third night on call meant some planning was going to be necessary, but we were still only responsible to and for each other. Pretty much every non-working waking hour was spent together. Well, every waking hour for at least one of us at a time, but we were together.

Then along came child number one. Biggest life change ever! Bigger than going to college, choosing a career, or even getting married. Whoa! Only one schedule on the board now, boy. Is he up ? Is he down? Our firstborn started walking at 7 months–a body without a brain. Where did he get to? Have you seen him? Like pretty much every new set of parents our entire lives revolved around the young “Heir”. We were too poor to afford a sitter, let alone childcare. Beth retired from active nursing to stay at home and we became Mom and Dad. Along came number two and the die seemed to be cast. No longer Beth and Darrell, we were parents now. Give me a kiss; I’ll see you after high school when the kids are off to college.

Have you ever seen that comic, the one where the husband dips the corner of his newspaper and the wife peers over her coffee as the last child skips out the door? “Hi, I’m John! Who are you?” I suppose nowadays it would be a Blackberry and a laptop between them, but you get the picture. So did we. Man, it seemed like everyone we knew with kids just off to college was getting divorced, especially the doctors. We missed each other, and we both saw that same, scary comic at the same time. Uh uh. Not us. This “Mom and Dad thing” might be the biggest part of our lives for, oh, 25 years or so, but some way, some how, we were going to find a little place for Beth and Darrell, too.

Thus was born “Date Night.”

Deeply in debt at the conclusion of residency we were too broke to do very much on those early Date Nights. Many’s the time we would have just enough to pay the babysitter. Our date on those nights might have been a single cup of coffee at Burger King, shared between us as we held hands across the table. But the ground rules had been set: other couples were welcome but no kids allowed, and pretty much nothing was more important in any given week than going out on Date Night.

The arrival of the third and final addition to our family coincided with a major move and gifted us with the Lutz sisters. Kerry and Krissie were our go-to sitters for years and years of Date Night. Our ballroom dancing phase (hug your spouse for an hour!) was followed by Ballet subscriptions, wine series, and countless restaurant “discoveries.” Date Night with babysitters made it through two Lutz graduations and and at least one wedding, long enough for us to head out and leave the three White progeny alone at home with their homework.

Until…well…we got kinda predictable I guess, and probably got a little cocky for a bit as well. There we were coming home a little on the early side from a new restaurant, giving ourselves a pat on the back for how well everything was going with the kids at home, when we turned into our EMPTY driveway. It seems son number one ,all of 15 years old and well-versed in the rhythm of Date Night, had taken his Mom’s car out for a drive with his buddies. We got a good chuckle at our own expense while we were awaiting their return, and Beth got quite a giggle watching me work up enough faux indignation to be convincing during the ensuing “discussion”.

Alas, thus ended Date Night as we had known it.

We tell every young couple about our Date Nights, especially where there’s a doctor involved. It’s really still amazing to the two of us how many marriages still fall apart when the kids are gone and it’s back to the original unit, the couple. You see, Date Night really hasn’t gone away; it’s just evolved into something new and something more of the same. Now it’s  up together in the morning after the dogs get going and before any of the kids contemplate  lift-off. Sharing breakfast and reading the newspaper to each other. A Sunday spent strolling the Hudson Food Festival listening to The Wiggles sing Woodstock (you had to be there). The same rules apply: other couples are welcome, but no kids allowed!

People talk about the importance of going 50/50 in a marriage. I think Beth is more on the mark, though. She talks about marriage as 100/100. Each spouse  gives 100% of everything to everything every day. Each hand is “all in”  every time you play when it comes to your marriage. Makes a ton of sense, doesn’t it? Date Night was just a small part of 100/100 for us, albeit one that made us smile and gave us lots of great stories, like the night our son called the close of our official Date Night program!

But not the end our our courtship! I almost forgot to tell you about our Honeymoon. What a blast THAT’S been. Next month we’re going to spend a long weekend in San Francisco. Maybe take a drive up to Napa for another visit to wine country.

The Honeymoon isn’t over until you say it is…

The eminent philosopher Yogi Berra has captured the essential problem with the current fascination among our legislators and government bureaucrats with Electronic Medical Records (EMR or EHR). “In theory, there is no difference between practice and theory. In practice, there is.”

In my mind I have an image of the well-intentioned men and women who are developing the next generation of EMR. I see them as this generation’s equivalent of  a pre-Foundation Bill Gates, or Steve Jobs before the black mock-turtle tee shirt. All nerdy and earnest, focused on the software solution to a problem they’ve read about. They peer out at the world beyond their screens, convinced of their ability to solve a problem they view from 30,000 feet, perhaps dreaming of becoming wealthy should they succeed.

I also have a picture in my head of the legions of un-elected bureaucrats in state capitols and in Washington who have latched onto this notion of EMR as the panacea, the magic solution to the American “Healthcare Crisis”. Equally earnest, white-paper educated omniscients convinced that a technical solution is all that is missing from the equation. They deal each day in the business of spending tax revenue and the legislative give and take that eventually results in a state or federal budget.  Their time is spent with eyes glued to their laptops and their Blackberries, only seldom establishing eye contact with another of their kind ,and only then if absolutely necessary.

In THEORY this EMR thing is a no-brainer, isn’t it? Who wouldn’t think so? A true EMR is a system of record keeping for medical data in which all of the information is entered digitally and stored in hard drives instead of paper charts. Every time a patient is seen by a doctor or a nurse-practitioner his entire medical record is there for the viewing. No lost pages. No missing data. No struggling with the abysmal handwriting of the busy specialist who saw him for an emergency at 4:00 AM. What’s not to like about that?

In THEORY a universally applied EMR should also create some economic advantages in our healthcare system as well. We would theoretically need fewer billing assistants since all of the charge information would flow automatically from the medical record to the billing system, and from there straight to the payer. There would be few, if any billing errors since the coding and reporting requirements for each insurance company (or the federal government) would be built into the software. Since all of the information about medical outcomes would now be instantly available we would now be able to evaluate competing treatments and determine objectively which ones work and are therefore worth their cost to provide.

Unfortunately it turns out that Yogi Berra is not only a philosopher, but in this instance he is also a genius. You see, in PRACTICE all of this theory falls apart because of a rather messy and unpredictable variable in the system that the EMR designers and the all-knowing bureaucrats just can’t remove from their programs or their systems: all of the patients and all of the healthcare workers are PEOPLE. People who are sick and become patients. People who don’t want to be sick and try not to be patients. People who come to work fresh and adequately caffeinated, and people who are really patients that particular day and don’t know it, spilling their Starbucks on the keyboard.

Computers and the software that runs computers reduce work and increase efficiency in their optimum usage. They enhance the experience of all who encounter them “in the wild” when they fulfill their potential. At the same time that we have all of this talk about the urgent need to get every doctor’s office and hospital computerized coming out of one side of the collective mouths of the “reformers” we also hear out of the other side of the need to improve the patient’s experience when she goes to see her doctor or when she is in the ER. Those same bureaucrats and policy “experts” scampering through the legislative ant hills who extol the virtues of computerized efficiency also demand more time for patients from doctors and nurses, time  spent one-on-one in providing medical care. Not too much time, though; these budget-watchers  also bemoan the existence of so-called “concierge” practices, the ultimate expression of patient-centered medicine, because this model reduces the pool of doctors available to provide care.

The only conclusion that one can reach is that none of these EMR developers or policy developers has ever been a patient in an office or a hospital with an EMR!

The most important entity in the exam room or in a hospital room when an EMR is in use is the computer. The bigger the institution the more this is true. Mandatory questions must be asked in sequence and data entered in order. Imagine your doctor or her nurse as the best-educated data entry clerks in America and you get the idea. And it doesn’t matter whether it’s a computer and a keyboard or some sort of handheld gadget, the eyes of the doctor is on her screen, NOT her patient. The doctor has a relationship with her computer; the patient has a relationship with the back of the doctor’s head.

And you know what, it takes time to enter all that stuff. Much more time than it takes to jot down a couple of notes or a little data. Where will that time come from? Well, either it comes out of the time devoted to looking and listening, or it comes from decreasing the number of patients a doctor can see each day. Fewer employees necessary to run the computerized office? Really? What other customer service business has successfully reduced the number of people involved in providing that service to the satisfaction of its customers? It’s also really expensive to buy and implement and maintain an EMR. We’re talking about Billions of dollars up front and every year hence. Where will this money come from as doctors and hospitals struggle to remain afloat?

The EMR fails “in the wild”. It fails in PRACTICE to do either of it’s most important tasks; it neither increases efficiency nor does it improve the experience of the user. An EPIC fail (pun most definitely intended for you Epic users).

In the end the only winners in this EMR game at the present time are regulators and third-party payers. When we put all of the advantages of EMR in THEORY  into PRACTICE the losers, once again, are patients and their doctors.   With the present state of technology we will spend more money to buy systems that will decrease our efficiency and reduce the quality of experience that both our patients and doctors will  have when healthcare is provided. And we haven’t even touched on the difficulties of maintaining the confidentiality of all of that information, or whether or not you can really pigeon-hole all of those messy, unquantifiable individual patients into tidy little  treatment groups.

I have another picture in my mind, a picture of Yogi Berra in his doctor’s office. Yogi’s getting on in years you know. Probably has a couple of medical problems; probably taking a couple of medicines, too. Can’t you just see him, all ears and nose and those huge glasses underneath a vintage Yankees hat?

“Doc. DOC! Who ya lookin’ at? Hey. HEY DOC! I’m over here!”

“If you could go back and change something, or have a “do-over”, what would you change in your life?”

Do you ever get asked this question? How do you respond? Do you look back and find unhappy episodes or periods of time, seeking to uncover the root cause of the upheaval in order to change that event or decision? Whether you view your life as a whole or your present circumstances as good or happy, do you ever indulge in this flight of fancy?

When I am asked this question I typically say something along the lines of: if you could tell me that I would be right here, right now, talking to you, with the same healthy and happy marriage and family, I would have been an art history major at Williams instead of a biology major. Not too many people are too very interested in the 5 genomic point mutations between prairie grass and maize (ZZZZZZ), but I’ll bet I could have discussed the differences between Monet and Manet a couple of times at cocktail parties and such. But even at that I still don’t think I’d change a thing.

On a flight home from Denver after visiting my son “The Heir” I sat next to a very nice man, Robin. We had about a dozen “one degree of separation” contacts to chat about, but we spent most of the time talking about how we had arrived in our lives at those two seats on that plane on that day. One of us seemingly sailing along, still on the ascent on the typical professional scoreboard, and one seemingly descended and becalmed.

Robin, in full sail, offered a regret. He regretted that he did not take 3 years off following college and prior to law school to live in his favorite city, Paris. I find this line of thought coming from a successful professional amazing. Always have. I find the choice of the word and sentiment “regret” to be puzzling, though.

In the truest sense of the word one would regret an act of omission or commission that causes harm to oneself or another. One can be sad that things may not have turned out as planned, or sad that an opportunity may have been missed, or even sad about an error or mistake that was unfortunate or embarrassing but did not result in any harm.

You see, for Robin to regret his decision to go directly on to law school would be to regret all that has come to him since that time, and I believe that this is a straight shot to a lifetime of unhappiness. Had Robin gone to Paris he would not have met his wife of some 30 years, would not be the father of the particular 3 successful daughters he “introduced” me to. Indeed, Robin and I would never have found ourselves sitting together, pleasantly whiling away the hours between Denver and Cleveburg.

Some years ago the White family decided to stay in Cleveburg when offered the opportunity to leave. It turned out to be a very bad economic decision, and to be quite honest, I am very sad about that. But as those of you who have read me these last couple of years know, my wife and I had a very sick child. Because we WERE in Cleveburg “Lovely Daughter” got exactly the right treatment from exactly the right people at exactly the right time. Don’t get me wrong–I really wish the economic realities here were different. The economic outcome has been dismal, with one inconvenience piled on top of another, and no way to ever truly recover.

But I don’t regret our decision for one minute, for each day I awaken I am still the father of a daughter. There is no way to know that I would still be able to say this if we had moved, if we had made a different decision and were, then and now, thriving economically. In truth, every decision we have ever made contributes in some way to where we are and what we have become today. Going back and teeing it up again might certainly create a better address today, but then again, perhaps not. I stayed in Cleveland and the little blond fluffball who reached up her arms–”Ina huggie!”–is still here, now reaching across at eye level for Daddy hugs.

I shared this story with Robin. I suggested that his wonderfully successful life probably afforded him the opportunity to live in Paris for a bit NOW, but this time with his wife of 30 years and visited by his own “Lovely Daughters”.

Robin said he’d send me a postcard.