Sunday, June 18, 2017

Surgery Residency: Drop-Out Nation?

In the first decade of the 20th century, William Halsted---using principles he had learned from watching German surgeons---- implemented a new model of training general surgeons in America.  Replacing the old journeyman/apprenticeship paradigm was an intensive, arduous, all-encompassing program that integrated basic science with bedside patient care, emphasized repetition and volume under the tutelage of master surgeons, and introduced responsibilities and skills in a gradual step wise manner.  Resident surgeons basically spent 5 years of their lives living at hospitals, immersing themselves completely in the acquisition of essential skills and knowledge.  The Halstedian paradigm quickly became the standard across the nation as its tenets were adopted by the newly formed American College of Surgeons in 1913.

For most of the next 90 years, he basic training model remained constant.  Of course it was brutal and inhumane.  Young men (almost all men, during these years) literally never saw their families.  Pyramidal structured programs meant that most interns would never make it through the training.  Something had to give. Pyramid programs are no longer acceptable.  Work hour reform has allowed most residents to maintain at least a tenuous grip on sanity.  But there are no panaceas when you are talking about training future general surgeons.  If anything, the demands on a surgical trainee are much greater than even what I faced 15 years ago.  New technology, rapidly changing treatments algorithms, hyper-advances in basic science make it very difficult to acquire a firm knowledge base and technical proficiency in a feld with constantly shifting, expanding foundations.  And despite all the changes with work hour reform, general surgery residents have continued to drop out of training at much higher rates than residents in other specialties, even today.

Heather Yeo and her group at Cornell has a somewhat discouraging paper coming out soon in Annals of Surgery  that attempts to delve into this phenomenon  Theirs is a national longitudinal cohort study designed to identify factors associated with resident attrition.  One important finding, much discussed in a era where women make up slightly more than half of incoming general surgery residency classes, is that the female gender is the most important factor in predicting withdrawal from a residency program.  Further, minority women represent the highest risk cohort for dropping out from surgery training (35% will drop out before graduating).

The thing that jumped out at me was the overall withdrawal numbers, regardless of sex or race.  From an article Christina Frangou of General Surgery News wrote about this paper:
"For the past 25 years, attrition rates have remained steady in general surgery, with about one in four residents not completing training. That is much higher than other specialties, including surgical specialties. Orthopedic surgery has a dropout rate of less than 1%, OB-GYN is about 4.5%, and medicine is about 5%.
“It was thought that changes in work hours and the kinds of things might lower the attrition rate, but they have not. So we need to look at other solutions,” Dr. Yeo said."

Shit man.  You mean 20-25% of highly educated, extremely motivated young adults who have chosen to embark on a career in surgery end up bailing after a couple of years?  That's outrageous.  We're not talking about young buckos who quit McDonald's after a couple weeks because they can't handle the heat of the fryer in the summertime.   These are elite, highly prepared individuals who have busted ass for 15 years, excelled in college and medical school, done internships and sub-internships, sometimes even research in surgical sciences.  And they are quitting left and right.

I don't feel strongly at all that this persistent attrition rate over the decades has anything to do with race or gender or generational dispositions.  It's just that general surgery is fucking hard, man.  And you don't really see it until you start learning it, doing it, seeing older surgeons living the kind of life it requires.  It's a hard ass life.  Emergency and unanticipated cases will always represent 30-35% of a busy general surgeon's practice.  Doesn't matter who you are.  You will always have to take ER call.  You will always have to smile and say "no problem!" when a Primary doc calls you at 4:30 pm on Friday with a "painful hemorrhoid, can you see him in the office right now".

It's a hard, exhausting, brutal life at times.  Rewarding sure.  I can't imagine doing anything different (that's the brainwashing speaking).  But it will chew you up and spit you out.  The years will pass faster than the cards flying by you at a blackjack table in Vegas.

And this essential FACT resonates with residents.  They see what a community general surgeon has to do.  They see these older surgeons working harder than interns.  And I suppose it just gets a little demoralizing after a while.  Who wants to be a grunt for the next 45 years?  As they say in the military, only the nut jobs, eccentrics, cranks and psychopaths actually volunteer for the infantry.  General surgery, man, you're on the front lines.

Even the ones who make it through seem do do so with a jaded eye.  At many top programs, we see reports of 75-80% of 5th year residents going on to do additional training and fellowships.  No one wants to be this thing called a "general surgeon".

I think that's too bad.  We may be on the precipice of another paradigm shift in how surgeons define themselves.  Maybe there's just too much to know, too much to stay up on, too many advanced skills for one surgeon to acquire. Time will tell.  Maybe the pendulum will swing back in the other direction as wider and wider swaths of geographical America finds itself without enough broadly trained, competent surgeons to meet the needs of it's population.....

Sunday, June 11, 2017

Sunday Poem

Goodbye, My Ocean

We went to say goodbye to the ocean.
Our week elapsed, time a despot.
The morning was cold and ashen---
Weather more for a funeral than a summer respite---
And waves crashed in to shore in periodic roars.

I had brought her here as a baby years ago
---she doesn’t remember the picture of me holding her on a patio.
But she didn’t want to say goodbye today.
She was tired of the ocean, the rain and gray.
Instead she danced on a dune, a slow adagio
Her eyes closed, arms outstretched, around and around.
She didn’t hear when I called
(The waves crashing and roaring)
She was way up there and I was down here,
Foreign lands separated by a strip of sand.
She performed alone for lumbering curtains of cloud.
The ocean was vast and unconcerned, and much too loud;
It had been there all week, without end.
A little girl has other things to attend.

And the surf rushed up around my soles,
Soaked the edges of my jeans.
I was not yet ready to turn away.
I could have used another day.
I don't so much return to the sea
As the ocean returns to me.
(Words and phrases apt to fail the more I wish to convey)
It returns to me is the best I can say----
Albeit older now, chastened, more gray;
While the dark waters remain changeless.
And as the eroding shore yields to the inexorable surf
My mind yields to forgotten shame, repressed pains, when it all seemed to hurt----
Inchoate fragments of images and phrases

....Skeletons of shells lie scattered on the sand in the retreat of fallen swells....

It will always be there, the abiding sea.
May it someday be there for her too----
When the dance is done, when her songs go silent,
When the clouds part and blue shines through.
One day she too may turn to the sea in repressed terror, in sorrow, or defiant,
And gaze into an endless, merciless roiling gray----
Into her past, the days lost, a life episodic----
And vaguely recall a summer she watched her father rhapsodic
Turning slowly landward, down below, his form misted in sea spray


6/11/17

Tuesday, June 6, 2017

Dr Ferrari

Kevin Williamson wrote a piece last month in the National Review bemoaning the hand wringing he sees occurring across America surrounding the threat of millions of Americans losing their health coverage with the intended repeal of the ACA and its replacement with TrumpCare.  He calls this piece:  The "Right" to Health Care, with the scare quotes performing the task expected.  (What? Did you think you had a "right" to health care when you get sick, silly boy?) appended with the self-answering subtitle There isn't one boldly patched in the space before the opening lede.

He then goes on to construct a thought experiment utilizing children and apples to demonstrate that health care is a just scarce good and that all the nail biting over making sure all the kids get an apple is just cheap moralizing and coastal elite performative antics when, in the end, you only have 3 apples for 4 kids.  Market forces, you see.  Supply and demand.  What is needed is not a national reckoning--- the likes of which every other advanced western democracy has done--- with the idea that health care is a service/good that ought to be made available to all Americans, like schools and public safety and national interstate highways, but rather we just need to empower laissez-faire super entrepreneurs to plant a few more apple trees. This is thought-experimenting in its most primitive form, using the bare minimum of neurons.  Maybe 3 or 4 synapses get traversed at this cognitive level of "thought experiments".  This is like turning around and going home hungry because someone has placed a medium sized stone in the middle of the sidewalk on the way to the store.  The inability to conceptualize the apples as a totality, to be divided and sliced in such a way to ensure that everyone gets a fair nutritional share is punditry malpractice.  But Williamson doesn't care.  He has followed his thought bubbles to the terminus of his own choosing.

Rationing is posited as the true villain in this piece.  For Williamson, universal coverage is not worth the price we might have to pay in consequence; longer wait times for elective non-life threatening procedures, cost effectiveness barriers for new treatment approvals, lower profits for the holders of Capital etc etc.  This is his true dystopia, not the recent American past of a sparsely insured population wracked by medical bill induced bankruptcies.  For Williamson, health care is just another good on the market.  And the more it increases in demand, the higher its price ought to be.

And so we get this hopefully career defining quote:  "Rich people always get better stuff.  That's what it means to be rich." Let them take aspirin for their cancer, indeed.  Because hey, if you live in Africa and have HIV, that's all you get.  That's life.  Deal with it.

Meanwhile back in the world of Kevin Williamson, when a head cold just won't seem to run its course, he usually just struts into his fancy doctor's office in the suburbs, brandishing his American Express Platinum card, to see a doctor who is "always pleased to see me because I paid him out of pocket".  His insurance plan, you see, is called "American Express".  Cash is best.  What is wrong with all you dolts?  Are you plebeians not able to just whip out some plastic or peal off a couple hundies when it comes time to settle up with ol Doc Blowhard?  Not mentioned is the "thought experiment" of what might happen if Kash-man Kevin didn't need just a little Z-pack and, instead, came down with viral meningitis or perforated diverticulitis that resulted in a 12 day ICU stay and a charge master hospital bill of $79,850.  Even elite credit cards have maximums.

As Kevin gazes around at the opulent setting of his favorite doctor, he notices several pictures of Ferrari sports cars on the walls.  He kiddingly, nudge-nudge wink-wink, queries Dr Wonderful about the Ferrari's, suggesting that maybe he might be paying him too much.  And the good doctor replies: "Do you really want a doctor who can't afford a Ferrari?"  Yes, that groaning you hear is not some pipe swelling with the temperature change in your basement.  Kevin Williamson is the one person out of 100 who is impressed by a guy bragging about his luxury car.  I mean, I can just smell the overly administered Drakar Noir cologne emanating from my laptop as I read that.  This is either a doctor who does not exist or he is a guy who obtained a medical degree from the boardwalks of Jersey Shore, undid the top two buttons of his contrast collared Oxford, perfected his best shit-eating grin and went about the business of marketing himself to insecure but healthy dunces like Kevin.  It's a good gig if you can stand it.

Somehow, in a very short piece, Kevin Williamson of the National Review was able to accomplish more than even a well written parody could ever hope to achieve.  Parody works best when the target is limited and precise.  Nuance and complexity are the enemies of successful satire.  Somehow Kevin is able to be both obtuse (not understanding how health care is not a "good" like, say, lawn chairs or sausages to be purchased on the open market) while also revealing himself to be the embodiment of the crass materialistic John Galt elitist superman, so easy mocked by second rate late night talk show hosts.  He is the guy who thinks the dude with the muscle car revving at a stop light is the coolest person on Myrtle Beach.  He is the guy who thinks the tank-topped meat head grunting and squelching at the Gold's Gym must be "really strong and masculine".  He is the guy who notices when other men wear cuff links, and what kind.  He is the guy who must find out what car you drive within 10 minutes of meeting you in order to more properly form a judgment of your character and usefulness.  

Not to mention the complete lack of moral imagination that would prompt most intellectuals, from both the right and the left of the spectrum, to wrestle with the discordance of finding ourselves living in the richest nation in the history of human civilization while still somehow being unable to provide affordable, accessible healthcare  to 100% of its citizens......

Monday, June 5, 2017

Vacation Poem

Pour It Out

What we start with is not limitless.
The cask is not an abyss.
But I have always said: “Pour yourself out young man!”
Don’t be stingy;
Dispense yourself into many vessels
Don’t hoard it all within fortified castles
Allocate on the fly, improvise---- and soon.
A life can’t be meted out with a teaspoon;
A bit here, a splash there, a shot glass, a snifter, a highball, a mug runneth over with foamy head.

All these empty cups to be filled!
Choose them at your leisure.
Choose wisely and always pour with pleasure.
Cups for love, for work, for hobbies, for nothing, for something, for purses or mittens or coats,
For things forgotten and things that lodge in our throats.  
----But pour it all out we must

Have no pity for the obsessive workaholic; he has poured himself out
No mourning for the hollow eyed doctor wandering wards at night; he has poured himself out
Laugh not at the perpetually broken hearted; she has poured herself out
And never mock the failed poets; they too have all poured themselves out

They leave nothing to grieve.
They are empty bottles of wine sprawled like bowling pins
In alleys the morning after New Year’s Eve.
The only sin in lost time
Is leaving too much behind;
Trying to ration a vast reservoir,
Always in fear of having no more.
You save what’s left for a wave that never crests;
All that ambrosia sloshing around in your chest
---Untapped.

6/5/17

Sunday, May 21, 2017

Sunday Poem

Smile

So many smiles are gaping wounds
Deftly slashed into faces.
The spaces between what we mean
And how we hope to seem
Are the distances between parted lips.
Our false visages belie skittishness
And those shameful resistances
That compel us to embellish
With garish grins and rictal expressions.
Curtains will drop, facades like a solar eclipse


Your eyes have never lied.
A glinting of light
That breaks through the crinkled cracks in the corners of your eyes,
Lingers, then slowly fades without a fight
Skin smoothing to stillness like snack wrappers uncrumpling on the ground
A smile is an absence of flesh,
An aperture always in flux.
It is a wound, it is not a wound.
It is a mask of obfuscation, it is a life force that erupts


Wounds reveal or conceal
A smile can be real
A smile ought to be real

5/21/17


Mandate

A few weeks ago I was awakened by a 2 a.m. call from the ED regarding a case of pneumoperitoneum.  I barely recall the specifics of the conversation, but I vaguely remember snippets of phrases, words that light the fires and compel immediate action: "free air, tender all over, hypotension".  I donned some old scrubs and quickly drove in to the hospital.

The patient wasn't much older than me.  He looked healthy, had a robust build.  No other medical problems.  But his vitals were perilously unstable.  Heart rate 120's.  Blood pressure 70 systolic despite several liters of fluid.  The CT showed air under the diaphragm and inflammatory changes in the pelvis consistent with acute perforated diverticulitis.  And he certainly had peritonitis on exam.  I didn't have much of a choice.  He needed an emergency operation.

An hour later I had washed him out, resected the colon with the gaping hole, and fashioned an end colostomy.  Primary anastomosis was not a consideration given the degree of contamination and pressor sustained systolics in the 80's.  We call it the Hartmann's procedure; an old school operation that is not used as often as it once was.  We found that it isn't always so easy to reverse a colostomy (70% success rate) and the procedure itself can result in significant morbidity.  Nowadays we find we can treat many cases of perforated diverticulitis medically with antibiotics alone.  Primary anastomosis is performed even on unprepped bowel in cases of mild contamination and hemodynamic stability.  Sometimes you can even get away with just laparoscopically washing out the pelvis, placing some drains, and bringing the patient back later on, for definitive one stage surgery, once the sepsis clears.  Lots of options.  But there is still a role for the Hartmann's procedure.  Four or five times a year I find myself resorting to it, even still.

The guy did well.  Got better, cleared the sepsis, started eating.  Right before discharge, I received a call from the case manager.  She told me she would not be able to arrange for a wound vac or home health care assistance, as I had requested, because the patient lacked any health insurance.

I must say, I have received far fewer phone calls of this nature since 2008.  Obamacare (in all its iterations, not just the exchanges but the Medicaid expansion as well) has certainly reduced the number of "self pay" cases I have seen.   And this simply makes statistical sense.  The number of uninsured since the passage of the ACA has fallen from 50 million to around 20 million (which is still embarrassingly too high!)

I told them to discharge the guy home with wound care and colostomy instructions and some bags of extra dressing supplies and to see me in the office in a week.  There isn't much else you can do in this situation.

The first thing he asked me in the office was, as expected: "doc, when can you put me back together again?"  Well, it's complicated, I told him.  I had been dreading this moment because it inevitably casts me in the role of villain--- the predatory quid pro quo shyster who financializes the doctor/patient relationship.  You gotta get some insurance, man, I told him.  I do plenty of uncompensated emergency surgery.  I'll be damned if I willingly perform complex elective surgeries without the guarantee I will be remunerated for my services.  In addition, it isn't just about me--- there is an anesthesiologist and the hospital facility that will want to bill for services.  I could do the procedure gratis, but he would still get a bill for 20 grand or more.

And the guy was not some street urchin or derelict.  He owned his own landscaping business.  He worked 60 or so hours a week.  He was married and had children.  By all metrics, he was an upstanding, contributory member of his community.  But he didn't have any health insurance.  And the reason is because he was able to choose not to have health insurance.

There is a mandate built into Obamacare, but it is a fairly weak one.  The cost of not having insurance often was cheaper than the cost of purchasing a plan on the open market.  Furthermore, the Trump administration, via executive orders, has enacted changes at the IRS that make it easier for people to get away with not paying anything at all.

Outside of government-run, single payer health care systems like the NHS in the UK (i.e., the rest of Western Europe and many countries in Asia), everything hinges on universal participation.  Universal coverage directly correlates with universal participation.  If the pool of patients buying health insurance are only the sick, the critically ill, and those with chronic illnesses, a health care fund will need to pump up premiums in order to ensure financial viability.  You need the young and the healthy on those health care roles in order to justify enforcement of "community rating".

Sadly, I see us starting to slip back into old ways.  AHCA probably has no chance of passing in the Senate.  But there are other ways of eroding the incremental reform brought to Americans under the imperfect auspices of Obamacare.  Executive orders to "decrease regulations" are one such seemingly anodyne way of accomplishing this.  Simple administrative incompetence and mismanagement is another way to sow doubt in the minds of private insurance companies and impel them to withdraw from markets.

So yeah, we can go back to those "good old days" when 50 million Americans lacked health insurance, when medical bills were the number cause of personal bankruptcy, when a person could be denied reasonably priced insurance due to pre-existing conditions.  It would be just as shameful and inexplicable in the future as it has always been.  The wealthiest, most hegemonic nation in the history of the world, unable to muster the means to care for its own citizens when illness strikes.




Wednesday, May 10, 2017

Wednesday Poem

Easter

For Easter dinner I sat next to a Buddhist who claimed to have no thoughts
What do you mean “no thoughts”? I asked him
Where did they go?
What happens instead
On the inside and what fills your head?
He only smiled at me.  
He smiled and nodded his slab of a head


But I was serious.  How is that done?
He looked at me like I was dumb


Later on, I watched him blankly chewing a piece of cake
An urge to smash his face into the plate
How do you fill the time---the space---between the bites?
How do you imbue a mind with pure silence?
It seemed an act of violence----
A forfeiture, at best a bluff.
Not even a whisper or a cough
Like church when we were asked to bow our heads and pray
And instead of a higher communion I could hear
Only the creaking of pews and the scuffling of shoes
The birds twittering outside, the wail of a passing siren.
Instead of warm peace I felt only cold fear.
The whirling tumult of my inside world gone speechless, silent.
Nothing to say, haltingly austere
When I most wanted to speak, when I most wanted to hear.

5/10/17

Sunday, May 7, 2017

Sunday Poem

Count to Ten


There are things I could do
But none of them will help you
I could excise that tumor with my knife
But it will not save your life.
It’s spread; you’re infested,
Surgery should not have been suggested.


I was called because they always call.
It is up to me to say things like “infested”
To tell you what the others cannot.
They defer to my judgment
Someone must do what cannot be said:
Snatch the terminus of an unwinding thread.


Now let us close the door
And dim the lights.
I’m going to take a seat right here.
Close our eyes and count to ten
And then count again


That was twenty from ten
Shall we carve out another block of time
Like initials into an old oak, a forgotten forest from youth?
Will we get closer to the truth?
What was her last name again?


The IV alarms
Tubing occluded
Sir, you must straighten your arm
Let us count one more time
I know it is hard
You need not speak, just listen to my voice:
One, two, three…
When I get to ten
You can open your eyes
Will I still be here?
Will the lights be on?
Will you still be trapped between dusk and dawn?


5/7/17

Tuesday, May 2, 2017

Noble Hearts Crack

Deep in the trenches of childhood memories I recall always being told I would be a doctor.  Birthday cards addressed to "Dr J", surgical scrubs as pajamas, a heavy dose of science-themed gifts (microscopes, insect dissection kits and the like).  The message was undeniably clear.  You will be a doctor.  You, child with the good grades, the quicksilver Jeopardy answers shall become a physician, the highest of the high, the one true and noble landing point for a child of your talents and gifts.  When you are a child you don't even think to question it.  I was a typical first born boy who aimed to please, to make my family proud.  At all the Easter, Thanksgiving, Christmas family gatherings I'd be peppered with questions (what kind of doctor? kids or adults?  surgery or medicine?) I couldn't even begin to try to answer.

 In retrospect it probably wasn't fair.  To thrust that sort of expectation and pressure upon a young boy.  But none of it was of malicious intent.  I know they were all proud of me.  My mom was a Child Life specialist in a hospital and my aunt worked as an ICU nurse.  For them, the all-powerful doctor represented the pinnacle of achievement.   I understand it all, of course.  I may not have chosen my path, it may have been thrust upon me, but no matter.  After my parents divorced, my dad moved to Arizona and started a new family.  We grew up in relative poverty.  We were on welfare for a time.  I was a latch key kid until I could drive.  Absent the realm of hunger and true squalor, you never realize relative paucity of material well being until you get older.  I may have represented something for the older women of my family, something beyond the hum-drum mediocrity they had known.  (What they didn't realize was that life can be hum-drum and drab and mediocre no matter your station, but that's another topic...)

A couple weeks ago I saw Hamlet again on stage.  It is a work I have always returned to over the years.  I'm a dork about Hamlet.  I memorized the famous "To be or not to be" soliloquy when I was 17 and haven't forgotten it since.  (From time to time, usually in the car, I'll randomly spout it out to no one, and usually, for some strange reason, end up veering into a bizarro Australo-Irish brogue by mid-speech)  Hamlet speaks to me, as the wise asses say.  The melancholic, brooding youth paralyzed by fear and time and inaction.  Knowing there is but one chance along the path of time, that every decision we make is fraught with loss, life as a series of paths untread.

The older I get the more Hamlet stops "speaking to me" and simply informs me of who I am.  It isn't a conversation, it's "here you are, take it or leave it".  And that's fine.  I keep coming back to it so there must be some good to be had.

Hamlet, as per Harold Bloom, is the only character in Shakespeare we can conceive writing any of the actual plays of Shakespeare.  He is human in a way that most flesh and blood, most of the quick can only hope to aspire to.  He speaks and acts his way into existence.  He is the sort of character that, as Holden Caulfield says, we wish were a friend of ours, someone we could call up on the phone and talk when we wanted or needed to.  He has been my friend for an awful long time.   Sad as that is to say.  (I never "mixed" well).

The transformation that occurs in Hamlet from the time he sees his father's ghost to the final duel with Laertes at Elsinore is really quite astounding.  I never noticed it in younger days.  We too easily deposit Hamlet into the bin of "moody adolescent anti-heroes" without paying attention to what happens to the young Dane, the maturation that erupts forth, the flesh and blood human who rises from the pages by Act 5.  Too often we over-focus on the woe-is-me ninny in the first couple of acts who yearns that his "too, too solid flesh would thaw and melt itself into a dew" without recognizing the new man emerging at the end who stoically accepts the dictum of "let it all be".

In the beginning Hamlet is wracked by indecision and guilt and rage.  His father, the noble warrior King Hamlet, has been murdered, it is revealed, by the jealous scheming Uncle Claudius, who then seduces the grieving widow Gertrude; she, "with such dexterity to incestuous sheets", brings the mourning son of a king shame beyond description.  The ghost appears to Hamlet, reveals all and demands vengeance.  It is incumbent upon Hamlet alone to right the wrongs of a foul, foul murder.  None of these events are caused by any act or idea of Hamlet himself.  He is appropriated by filial duty, obligation, social and cultural pressure and urged into action.  He must exact revenge for his murder, but in doing so, risk losing his soul.  His manhood hangs in the balance.  Hamlet swears in writing "adieu, adieu, remember me!" as his ghost father passes into oblivion.  And then we get 3 acts of  equivocation.  To be or not to be.  The anguish that an actor could weep over fictional Hecuba with such volcanic emotional range while Hamlet himself is frozen despite having the "motive and cue for passion" to carry out his dead father's final plea.

In the end he never initiates, just reacts to events as they occur.  He forces Claudius to ignite the fuse with endless schemes and walks into traps willingly.  He stops giving a damn about what others might expect.  He stops trying to manifest the ideal foisted upon him by the Other.   He finds himself in predicaments of the moment and begins to face them with a newfound dignity.  The transformation is completed when he holds the skull of Yorick aloft:
Alas, poor Yorick! I knew him, Horatio: a fellow 
of infinite jest, of most excellent fancy: he hath 
borne me on his back a thousand times; and now, how 
abhorred in my imagination it is! my gorge rims at 
it. Here hung those lips that I have kissed I know 
not how oft. Where be your gibes now? your 
gambols? your songs? your flashes of merriment, 
that were wont to set the table on a roar? Not one 
now, to mock your own grinning? quite chap-fallen?

Memento mori.  All shall pass into dust.  The clay of the remains of even Alexander the Great could be used to plug up a hole in a beer barrel.  All pass into nothingness.  The cat will mew and dog will have his day.  Death becomes a tangible inevitability for the young Dane, not something abstract to theatrically fret and shed tears over.  Life will go on until it stops; whether we act or abstain, whether we lash out or hide behind ramparts, the end will come, far into the future or prematurely.  Life will end.  The path we have trod cannot be retraced and we find that the reasons for our steps assume less and less importance as the years elapse.  All reasons are forgotten in time.  There is only the moment of the eternally recurrent present in which you reside, briefly, before you die.

We find ourselves in places chosen by others.  We never had a chance to weigh in.  But a moment arrives and we make the best of it.  We choose to be, we embrace our fate with indifference, with what Harold Bloom calls a "noble disinterestedness".  By the time Hamlet kills Claudius, he has forgotten all about the ghost of his father.  The events that have driven him to the precipice no longer matter.  He has transcended the boy, become a man, by turning away from filial and social expectation.  His duty is to himself.  Once his fate has been sealed by the sharp tip of Laertes' rapier, he acts, fully in control of himself, for himself.

I still have those envelopes addressed to "Dr J" from years ago.  I keep them in a chest in the attic.  They remain a part of who I was but no longer impact the choices I make, no longer feel woven into my being.  I make my rounds not for those lost whispered promises from my youth, but for the sick, for mine own ends.  I have become the compilation of the days I have lived.  No longer am I an animated projection of the dreams of others.  And each dawn will bring the opportunity to add fresh material to the narrative of a life.

Hamlet walks knowingly into the final trap, despite Horatio's protestations:
We defy augury. There’s a special providence in the fall of a sparrow. If it be now, ’tis not to come. If it be not to come, it will be now. If it be not now, yet it will come—the readiness is all. Since no man of aught he leaves knows, what is ’t to leave betimes? Let be.
Yes, let be.  We shall be ready.  Hamlet learns that the question of "to be or not to be" is no longer a question about living versus dying; at some point along a lifespan it becomes about taking ownership of your own being.  Let it all come rumbling down from the mountain tops and let us rejoice in our transient freedom of the now, to choose to be our own best version of ourselves. Doctor, husband, father, citizen, son....

Sunday, April 30, 2017

Sunday Poem

"Minor Excision"

You’ll feel a pinch and a burn
Like the time she broke your heart.
At first the needle feels sharp
You won't forget, but you don't ever learn


My injection numbs the flesh, her
Touch warmed, ignited desire.
I’ll make an island of ice, a frozen slab
In the middle of your roiling magma of fire.
You won’t feel any pain, what you feel is just pressure


I’ll have it out before you know it:
The memories, pain, joy.  The sound of rain
On Saturday morning when you pulled her head to your chest,
When you closed your eyes, felt quiet and blessed.


That wetness you feel is your own blood dripping.
Almost finished, you can stop gripping
The edge of the table---
Your wound is not fatal.
Won’t take long to close it up.
Now it’s gone, a wedge of you floating in a cup.
It won’t grow back, I had the final say
The wound will heal, your scar may fade


4/30/17