Boreal B[l]og

“Experimentation is an act of humility, an acknowledgment that there is simply no way of knowing without trying something different.”  Sendhil Mullainathan

I read this in the New York Times, somewhat surprised by that Mr. Mullainathan had yet to perform the experiment that he said would be an act of humility.  The experiment was whether or not to change the diet soda he was drinking, that’s all.  He did mention an example of a brief tube strike in London; when it ended, about one in 20 riders had found different means to get to work and got there faster.  The others resumed their old ways.  I don’t consider changing diet soda’s being a significant life experiment, but then again, I’ve kept shirts for 25 years.

Experimenting is a life style choice, not necessarily a virtue: my wife has had two major interests, aside from me and our cats.  The first is horses, which has been as close to lifelong as could be possible; the second, radiology, she spent 40 years doing before retiring.  Many of the new things she tried were through me, but horses and films are her world, where she has been content and extremely competent in both.  She is exceedingly good at considering new alternatives when I bring up issues in my life, priorities, or time.  Her father took up hobbies of carpentry, gardening, sailing and golf.  He tried them long enough until he was comfortable with his competence, and then he did something new.

I’m the same way.  I admit it takes me a while to change computers, morning habits, or routes to places I commonly go.  Habits are an efficient way to get things done, and most of my life I have had to be efficient.

When it comes to experimentation, however, I go far beyond what kind of diet soda I drink (none, for I gave it up years ago).  I even go beyond the experimentation with becoming vegetarian, which was a big change in my life 27 years ago, but hardly the biggest.  Or doing without caffeine and even alcohol.

In 1984, I saw three bright planets in the sky, thought others probably saw them as well and might wonder what they were. I wrote the newspaper, asking if they were interested in an astronomy column.  Not hearing back, which didn’t surprise me, I wrote again and finally called, reaching a staff member who asked for 3 different length columns, which I submitted for consideration.  I ended up writing 750 columns, self-illustrated, over a 20 year period.  I had no formal training in astronomy, but I knew how to observe, write, and find answers to questions, even before the Internet.

A few years later, at 43, I decided, not on a whim, that I was going to take a 6 month leave of absence from a busy neurology-neurosurgery group to go volunteer for the US Forest Service as a wilderness ranger in the Boundary Waters of Minnesota.  I was going to be away from home, in a place where I had no reputation, nobody I knew, and a job I wasn’t at all sure I could do but thought I could and would like.  I suspect more than one of my colleagues thought I would be back at the office in a month, but I found I could do the work, loved it, became competent, stronger than ever before in my life, and left somewhat sad, because I knew I had a very special experience, one I would never repeat.

I then did another experiment after I returned when I changed jobs at the peak of my earning power.  I left practice to become medical director of a hospital, a hybrid individual neither physician nor administrator, distrusted by both groups.  I stayed in the role 5 1/2 years, grew, became interested in quality improvement, rising to vice president in both state and local medical societies, respected for the analytical knowledge and approach I brought to my job.

Lest one think that I went from one high powered job to another, without any risk of failure, I then undertook, at 49, one of the biggest “experiments” of all.  I bet my career on being able to become a Masters trained statistician who was also a physician.  To do that, I had to apply and get accepted at an out of state university, review calculus I hadn’t seen for 30 years, and then commute nearly 300 miles one way, every week, to be a graduate student, about as lowly as a medical student, for two years.

Somehow, I got through the first semester of Mathematical Statistics, my happening to know (in class) one day the integral of log (x) dx*, which the professor, later my advisor, told me, “I realized then you were for real.”  School wasn’t easy, and every night I cussed at integrals, matrices, computer programs, at the same time as I was teaching two days a week and caring for my class.

When I got my Masters, alas, I had not taken a course in marketing.  I found minimal work discovering I could understand “no” by the sound of the disinterested voice on the other end.  I failed economically, but by then, despite my bitterness at the medical community, which took me 5 years to get through, I looked for new opportunities and found them in several other fields.

I became interested in medical errors, their similarity to aviation with the exception that aviation had a system where one could learn from them, and back then medicine did not.  I wrote two bills for the Arizona legislature creating a reporting system for medical errors.  The bills died, but from that failure, I was asked to write a monthly column for the medical society.  I became a writer.  I wrote three different monthly columns at one point: astronomy and reasons we make errors being the two others.  I won the Creative Expression Award for Human Values in Neurology in 2003 and my article “Astronomy for Writers and Editors” was a finalist in the Writer’s Digest Competition.

I brought my math to bear in the public schools as a ten year volunteer, before becoming a substitute teacher for four years in one district, my statistical and real world knowledge of math helping me immensely with the students.

In 2008, I became a volunteer at Rowe Sanctuary in Nebraska, and two years later, after seeing my eleventh total solar eclipse with a German tour group, I decided to learn German. I had no idea I would teach people about cranes, see as many (17) total solar eclipses as I have, all over the world, and could learn, if only to the intermediate level, a foreign language.  I watch German Krimis (crime movies) for relaxation.

Life is to be lived.  I sometimes envy my wife, who is satisfied with a deep knowledge and love of horses. I have never been able to stick with an interest as long.  On the other hand, to any who might envy my interest in so many facets of the world, I say simply to keep your eyes and ears open, for opportunities are common but are not often announced.  Failure is a big, often recognized, opportunity. It is your life to live, and it is your decision—nobody else’s, unless you cede authority—to choose.  Finding yourself truly content is a sign you are probably living properly, regardless of whether you run “experiments.”

*log(x) dx is integrated by parts

u=log x; dv=dx

du=dx/x; v=x

From this, the result is uv-int(v*int(du))=xlog(x)-int(x*dx/x)=xlog(x)-x or x(log(x)-1) (+C).

I was medical director at a hospital back when medical directors/physicians in management were relatively new.  There were two Catholic hospitals in town, each with a medical director, and at the time there was a loose arrangement of the two hospitals with one overall medical director, my boss.

I went to a meeting one day at the other hospital about the roll out of an integrated medical delivery system, which I assumed wouldn’t involve me too much, but would start integrating practitioners in both hospitals and add a third hospital in a rural city to the network.

That night, I failed to show a major Profile in Courage moment: to stand up for what is right when one has absolutely nothing to gain and a great deal to lose.  My boss, whom I respected and liked, was passed over for the job of medical director, for which she was perfectly qualified, in favor of a family practitioner who was an EEG tech when I was a resident. I didn’t speak up against this outrage.  I can still remember hearing the name of the new network medical director. No, I didn’t stand up to the elderly nun, an institution in the hospital and community, to say, “Sister, this is wrong. Unless you reconsider, I am resigning.”

Yeah, I was making good money, but my wife and I could have swung it had I quit. Maybe I was so stunned that the doctor chosen didn’t have the qualifications. Maybe I was afraid.  But I certainly failed to speak up, that is quite clear, and I should have.  I might not have changed the decision, and I might have been fired had I not resigned, but the chance to do the first and risk the second was a risk I should have taken.  My boss resigned, the family practitioner had a very uncomfortable first meeting with me and was gone from his job within a year.

I subsequently worked under a new senior medical director, part of the executive team (I was never allowed into that sphere) before I had enough and finally left for graduate school, two years later.

My failure to speak up remains a big regret, and I can date it, because there was a total lunar eclipse that night, and I still remember standing outside looking at it and wondering why I hadn’t said something.

Profile in Courage moments may be more minor, but they are clearly speaking out against injustice when staying silent is easier and safer.  At one medical conference, the organizer commented on work that had been done on lymphapheresis for multiple sclerosis.  He quoted a study I happened to know quite well.  Not sure what I was doing, I suddenly found myself standing up.

“I disagree with you, sir.”  That turned everybody’s gaze on the 31 year-old nobody well back in the room.  “I was one of the physicians involved in the study, and while as an academic I want publications on my resume, I asked to be removed from this one, because I thought the study was poorly designed, biased, the data incorrect, and the conclusions unwarranted.”  Shaking, as I do when I speak passionately in public, I sat down amid a lot of murmuring.  The organizer mumbled a few words, and I simply shook my head no.

I can think of another time when I suddenly stood up, which I knew enhanced my words, the shaking, and the passionate comments.  The chief of staff at the hospital had lambasted me in front of the Medical Executive Committee, saying that I was examining patients, and I had no business doing so.

“I was called by the nursing staff because the patient was admitted to cardiology, and no doctor the nurses called wanted to accept the patient.” (Yes, those sorts of things happened.)  “I examined the patient, wrote some covering orders, then called an internist I knew who took over the patient’s care.”  At this point, I was winding up, so I let go with one more.

“I have also taken over the care of a Parkinson’s patient whose family fired the doctor, so he just quit, which is unethical behavior.  It is incumbent upon the physician to transfer the care, and this one just walked away.”

If I remember correctly, I walked out of the room down the hall and outside and cried for a few minutes.  One of the better things I learned—too late in life but better late than not at all—was how to cry.

Like perfect squelches, words one says that are absolutely perfect in time, place, and content, Profiles in Courage are one—two—three—five in a lifetime events. I can date every one of the four perfect squelches in my life. I blew my big Profile in Courage moment.

We need more Profile in Courage moments in Washington.  We need elected representatives to speak out against a president who doesn’t belong in office.  Many are apparently saying this in private.  Mr. Flake did a decent job, but he limited his Profile in Courage moment.  He could have done what few politicians are willing to do: quit his party and caucus with the other, stay in office, and let the voters decide whether he was adequately representing them. Mr. Flake would have rocked the country in doing so. While he would have taken a huge amount of heat, maybe a recall election, he would have earned the respect of millions, including me.

We need someone in the halls of power to speak up and say the emperor has no clothes (the visualization of which is abhorrent), that Congress is co-equal and will act accordingly, with both sides of the aisle having a say in legislation, even if one side is outvoted.  We need someone to say that much as they like the chance to put through a conservative agenda, that to do so without addressing the dysfunction in the Executive Branch is wrong, and Congress can and must do something about it.

The irony to me is that before #metoo many Profile in Courage moments I’ve seen have come from Iranian women who don white every Wednesday to protest the forced hijab.  For years, many have removed the cover altogether and shown videos of themselves walking without it.  These women are very courageous.  Many are insulted. Some have acid thrown in their faces.  Others are beaten, arrested, even killed.  They are putting their lives on the line for something they believe in, and if the running of the United States of America is less important than whether an Iranian woman should cover her hair, then we would do well to open immigration to those women, should any actually want to come here, in hopes they might light a fire under our lawmakers.

We now have American women speaking out against sexual abuse, which has involved my own alma mater, which really hurts.  Many of these women never spoke up, but when the time came, they took their Profile in Courage moment and ran with it. Some won elected office.

In these days of Roy Moore, Michelle Bachmann, clean air is unhealthy, more guns makes us safer, $1000 savings in taxes allows one to buy a car, adding $1.5 trillion to the debt is a good thing, grabbing them by the pussy does not disqualify one from becoming President, taking off the clothes of a 14 year-old girl doesn’t disqualify one for the US Senate, each of us needs to be on the lookout for a Profile in Courage moment.

It’s fine to shake, to sweat, to speak passionately.  Don’t be afraid to pause.  Mr. Obama often paused when he spoke.  He did it for effect, but he also did it to think about what he was going to say next.  We need a lot of thinking these days.

“Westerners don’t fear these restrictions (on fishing), even when their right to bear fishing poles isn’t secured for eternity in the Constitution.  But when it comes to the right to bear arms, the reasonable limitations of fishing are swept downstream with sanity.”  

Marty Jones, Writers on the Range, hcn.org/wotr

Every time there is a mass shooting or some other a significant deadly event, I look at the number “critically wounded,” for many of them will not survive.  It won’t make the news when some family member has to give permission to pull the plug to some doctor who doesn’t like pulling it, but needs to do it, in order to allow someone with irreversible brain injury to die, maybe after some organs are taken for transplant, maybe not.

“Saves” out in the field that get much news coverage may not be saves. If the rescue were too late, the individual would be irreversibly brain damaged, and some guy like me eventually would tell the family the person would end up in a persistent vegetative state. At best, the family would agree on removing life support, because “(the victim) wouldn’t want to be like this.”  At worst, the family would be divided, shattered, occasionally because well-meaning people in or out of the medical field would offer up platitudes like “you never know,”(we do), “hearing is the last thing to go,”(proof?) or “someone once woke up after 5 years,” (and was quadriplegic with limited cognition).  I did get news coverage once, in 1983, after recommending discontinuing life support on a woman who failed to wake up after cardiac surgery. The husband agreed, but the sister did not.  It went to court, and my name was in the public eye for a couple of days.  I guess I said some good words, because people didn’t lambaste me (that was before anonymity of online comments), the judge agreed with me, and the woman was allowed to quietly, with dignity, die.

Two years after Roseburg, there was a brief article about a young woman who received a major brain injury and could not speak.  She survived, but the hell she and the family went through, as well as the costs, born by them, those who cared for them, and society in general, were not publicized.  They can’t be.  There are too many—73,000 gunshot wounds a year— and I’m not even discussing auto accidents, falls, and other often preventable tragedies.

I’m not convinced the death toll from Las Vegas will remain at 58; we may not hear about the others. In the New York Times, there was an article about a woman 15 years younger than I who is now quadriplegic.  When I heard “500 wounded,” I wondered how many were going to be like her.  I still don’t know.

The woman probably has a C5-6 injury, got her elbow flexors partially back, but won’t get her hands or her legs back.  Not at this stage.  She ran a company once.  Now she runs a wheelchair courtesy of Go Fund Me.  I’d rather national health insurance pay for national medical costs.  Then, we could see  where our tax dollars are going, and ask why we aren’t trying to control firearms.  I don’t know the size of her medical bills in Nevada or now in California, where she is getting rehab not far from where the San Bernardino mass shooting took place.  These days, it’s not difficult to be close to a past mass shooting.  I am within 10 miles of the Springfield, Oregon high school, where four died 20 years ago, an hour from Roseburg, and two hours from Portland.  I lived 4 miles from where Gabby Giffords was shot, and six people died.  I came within a whisker of being at that Safeway that morning.

It’s ugly.  If the pain, suffering, and destroyed lives doesn’t bother The Other Side, they as taxpayers ought to be outraged as I am at paying for preventable medical and disability costs. Eight died in New York City on Halloween, and that day the president wanted to end the diversity lottery program. Fifty-eight died in Las Vegas a month ago, and he offered no suggestions.  The next night, three died in Thornton, Colorado by a shooter who walked into Wal-Mart, fired, and walked out.  One tragedy gets a snap judgment, and the other is ignored: Americans have a right to as many guns as they want with absolutely no restriction. It is time right now to discuss control of terrorists in our cities. NYPD had already contacted 147 businesses who rented trucks to be on the look out for potential misuse.  It’s also time to discuss some form of gun control, like repealing the second amendment, which would not prevent sane people from owning a firearm. It won’t happen, of course.

The statement that we don’t remember what happened to those who were injured is not new.  Many in World War II had shell shock and were never the same.  After Korea and Vietnam, we changed the name to TBI or PTSD.  After Iraq and Afghanistan we started seeing people with no limbs and more PTSD that couldn’t be treated well, because we don’t have a good treatment for it.  That alone should be enough to think long and hard about going to war, because in war not only do people die but at least ten times as many get PTSD.  We should have more diplomats and fewer tweets, instead of the opposite.

War is so bad that people repress it. My brother never spoke about Vietnam other than a vague memory about being on a helicopter going somewhere.   I hike with a Vietnam combat vet who once made the comment, “after I was blown up….”  which is the most he ever said about his service other than the single word, “Hué,” which told me enough.  When we go to war, we ought to realize that the cost in lives will be far more than we anticipate. That doesn’t mean we shouldn’t go to war.  Not at all.  But we ought to ask why we are fighting, what we want to achieve, and at what point it’s time to leave—totally leave.   Like PTSD or vegetative states, there are political states that just can’t be fixed, and trying to fix them is like trying to fix a vegetative state by physical therapy.  It accomplishes nothing and costs a lot of heartache and money.

I end with another form of PTSD and abuse, eloquently put in a letter in The New Yorker. The writer was raped, weekly, for four years, beginning at age 10, by one of the elders in her church.  She actually complained and was told she was crazy.  Who, after all, believes a ten year-old? She repressed her feelings for years, because nobody would take the word of a girl over a good Christian man who was a pedophile (something else not treatable, other than mandatory avoidance of children).  The fact that the woman’s own daughter is now ten brought back unpleasant memories.  What stuck with me were her comments, “Others had to have known, but they didn’t think he’d do it to one so young.”

Those who have managed to make a decent life for themselves in spite of horrors they have suffered speaks volumes about the human spirit and to those individuals themselves. It also speaks to the need for each us who is able to try to prevent such harm from occurring in the first place.  While it is reassuring to know that many obstacles may be overcome, it would be a lot better not to have such obstacles at all.