Sunday, February 25, 2018

ACS statement on Parkland

The American College of Surgeons (I am a Fellow in the College myself) released an official statement last week in response to the horrific school shooting in Parkland, Florida:
Statement regarding the events of February 14, 2018
The American College of Surgeons (ACS) is extremely distressed by the continuing violence at our nation's schools, churches, and other places where people should feel safe. At its most recent meeting, the ACS Board of Regents unanimously approved a plan to expand the College's focus from the very successful Stop the Bleed® program, which has trained and equipped thousands of people to stop severe bleeding from any cause, to a broader prevention initiative that focuses on strategies that include research, advocacy, and strategic collaborations. A specific action plan is under development that will ultimately lead to open dialogue on the issues standing in the way of meaningful change and the eradication of these tragic events. We will keep you apprised of further developments.
My thoughts on this statement, and the Parkland shooting in general,  run as follows:

  • I must say I am somewhat disappointed with this rather vapid statement from the ACS.  The Stop the Bleed program is a worthy initiative.  Teaching the population at large how to apply pressure to pulsatile wounds and the basics of tourniquet technique is a public good (similar to widespread CPR training programs made available to the public in previous eras).  I have no problem with disseminating this valuable information.  But in the context of this epidemic of mass shootings in public spaces, perpetrated by disturbed individuals armed to the teeth with military grade weaponry, it misses the mark.  High velocity ordinance fired in quick cadence from semi-automatic rifles tear gaping holes in the flesh of children at school. You cannot put a tourniquet around a blown off limb.  You can not stanch the flow of blood exsanguinating from a portal vein or aortic injury; you're just ruining all the gym towels.   You cannot  expect a teacher or custodian to "Stop the Bleed" of an injury heretofore most commonly seen after a firefight on the streets of Fallujah during the aughts.  To emphasize on-site field intervention by ordinary citizens is to willfully obfuscate the obvious.  It is to meet a measles epidemic with a reductionist slogan like "Wash Your Hands" without saying a word about vaccines. 
  • The second part of the statement is vague and unpromising.  Sans specifics, we are left with the underwhelming promise of future research and "strategic collaborations".  This is a hedging, craven kind of corporate speak that means nothing.  It is a covenant written in sand.  It is a  pledge to follow up on abstract good intention.  Just you wait, we are told.  Very smart, very well credentialed people are working tirelessly on solutions.  
  • Taking a stand is always a form of courage.  The worst form of cowardice is to try to dress up an equivocation as firm advocacy; to say nothing at all while going through the motions of going out on a limb with an official proclamation.  The College would have showed more courage is they had just stayed silent.  Or simply stated something meek and capitulating, such as--- The ACS has no comment on the shootings at Parkland, or mass shootings in general, because inevitably such talk veers into the realm of gun control legislation and, frankly, that is just too much of a political grenade for us to touch right now.  We further have too many members in the College who might be needlessly alienated if we took too strong a stand on this issue.  Thank you. We will keep you apprised of any changes.  This at least would have been honest and therefore more courageous than the blathering, equivocating statement the ACS put out.  
  • And there is no reason for this cowardice.  Currently there is broad support, across the political spectrum, for reasonable gun control legislation.  In particular, the public disdain for these weapons of mass destruction seems to have reached a tipping point.  Furthermore, mass shootings are directly related to the profession of trauma surgery.  Level I trauma centers across the nation are taxed for resources as it is.  The last thing Maryland Shock Trauma or Cook County Trauma need is a sudden influx of 50 patients seriously wounded by military weaponry. It is a public health emergency especially relevant to our chosen field.  There is no reason why the ACS could not take a stronger stand on politically charged but broadly popular initiatives such as banning semi-automatic weapons like the AR-15 (involved in so many of the recent mass shootings) and banning or minimizing high capacity magazines.  
  • I have yet to hear a cogent or convincing argument for why weapons like the AR-15 should be legally available for purchase in this country.  There are two schools of thought I hear from gun advocates. One, are those who believe any and all form of regulation of forearm sales is an attack on the 2nd Amendment.  Of course, following the logic of this radical position can only lead one back to an anarchic, lawless world where anything at all is possible.  Surface to air missiles, grenade launchers, automatic weapons.  An attempt to outlaw or regulate any aspect of firearms is an attack on the entirety of the 2nd Amendment.  A strange notion when the very wording of the Amendment contains the notorious phrase, "a well regulated militia"....
  •   The other, more adolescent, argument I hear proffered is that these weapons are necessary to ensure "American freedom from tyranny of the federal government".  It would be a laughable conceit if it weren't true that so many Americans actually believe this nonsense.  Once again you have to ask these people to follow the logic of their own avowals.  Imagine some dystopian future when the US government, having veered inexplicably into fascist authoritarianism, suddenly decides to train the full force of its massive military upon its own citizens.  All that will save us then, according to the Red Dawn fan boys, are the various rag tag collections of Real Americans who horded a stash of semi-automatic rifles and 50 round magazines, along with various other commando cosplay equipment, just for such a moment.  And they will emerge from the woods in their pick up trucks and camo gear to reclaim American autonomy from.... battalions of highly trained infantry, enough F-16 fighters to darken the sky, squadrons of special ops commandos, the world's largest Navy, and, by that time, an elite armada of drones and AI robotic soldiers?  I mean, come on dude.  

Sunday, February 18, 2018

First, Do No (Self) Harm

When a doctor in your hospital system kills himself, the entire medical staff receives a mass email informing everyone of “Dr. So-and-So’s sudden unexpected death”.  Thoughts and prayers for his family and loved ones.  Perhaps a link to your Employee Assistance Program is provided, for those who may need counseling or grief assistance.   This is followed later that day with another email detailing the schedule for the final arrangements.  Calling hours. Funeral.  Directions to the church.

Not everyone will have known the physician.  So most scan the email and then go about their day. But then you pass people in the halls; residents, peers, nurses who knew him, worked with him, laughed with him, and so you see the smudged mascara, the middle distance gazes, the shattered disbelief of those who now believe in ghosts.  Your eyes meet and neither of you know what to say.  What the hell?  What happened?  And the other will say, didn’t you hear?  Shot himself.  In his own backyard.  Called EMS just before doing it.  Jesus you say.  Jesus.  I wondered if he had children.  Another way of asking,  was he loved?  And it’s absurd and unkind and naive and ignorant.  Was he loved.  Or more gently, did he leave behind someone he ought not to have?  

I had known this particular doctor.  Not particularly well, we weren’t friends or anything.  I didn’t really know the first thing about his inner life.  He rode a motorcycle to the hospital.  He had a long braided ponytail.  He was sort of odd and eccentric.  He used to have big blow out summer parties for all the docs while I was still a college kid.  I sometimes saw him in the locker room early mornings as I changed into scrubs and he was putting on his jeans and leather jacket after another midnight shift.  We exchanged pleasantries.  Seemed nice, laid back, untroubled.  When he called me about patients he always seemed to know his shit, didn’t blow things out of proportion.  He was reasonable.  I trusted his judgment.  But I didn’t know him.  I knew nothing at all.  Not once while he lived did I ever think to ask.  In retrospect I had been a blind fool.  He had seemed thinner over the past year, almost cachectic.  Appeared older than his actual age.  Walked with an increasingly awkward, ambling gait. Seemed just a little too sad in the early mornings with his quiet voice, those faraway looks that never really met my gaze..  Maybe I chalked it up to end of shift shell shock.  I had my own worries to dwell on.  My own inner demons and struggles.  He was not someone I looked after when he left the locker room...Not one time did I ever look after him when he walked away….

Suicide rates in the United States have risen 30% over the past 15 years.  For men age 45-65, the rates have surged 50%.  For women in the same  age cohort, suicides have jumped 63%.  We talk about how firearms are the cause of 30,000-35,000 deaths every year; two-thirds of those deaths are actually self-inflicted gunshot wounds.  It is a trend that has taken on epidemic proportions.  And American physicians are not immune to the ravages of depression and despair.  We doctors place ourselves in a  very high risk professional cohort for burnout and depression.  The reality is that suicide claims lives of 400 doctors every year.  That's an entire medical school graduating class. It is the leading cause of death for male medical/surgical residents in training.  Professional dissatisfaction, emotional depersonalization and physical exhaustion all contribute to exploding rates of burnout among doctors.  Recent surveys suggest that over 50% of practicing physicians report being burned out and dissatisfied with their career choice.

The effect of burnout and job disillusionment is far more insidious for a practicing physician.  More so than other jobs or careers, medicine is not supposed to be merely a means to an end, not simply a way to pay the bills, to allow you to do the things that "really matter" when you are not at work.  Medicine is, to be cliched and sentimental, a calling and an end in itself. Yeah, yeah, don’t look askance at me with those arching eyes of modern irony.   An end in itself. If you’re doing it right, it most certainly is.  And when a disconnect arises between one’s professional goals and ideals and the lived experience of being a doctor--- the stress and overwork, the money demands, falling income, med school debt, accusations of negligence and malpractice, disappointment/disillusionment, alienation from the person you meant to be--- then a doctor can find him/herself staring into an abyss.  You start to feel yourself falling far short of that vision you had from the formative aspirational years of anon.  You feel alienated from that archetypal person you had spent so many years first conjuring and then honing in your mind.   After a  lifetime of hard work, self-sacrifice and deferred gratification, the day finally arrives--- the white coat, the title, the responsibilities, the opportunity to help and heal the sick every single day for the rest of your life---and if at the end of the long climb to the pinnacle you find the summit to be intolerably disillusioning and dehumanizing and unworthy of the effort, then the foundations of a life can start to tremor, and the pillars and walls thought to be unassailable, suddenly unsteady, can collapse…

These are ideas I had been peripherally aware of for a long time.  Especially for surgeons.  All those divorces and alcoholics and suicides....  Watch out.  I wasn’t too troubled though.  I loved my job.  I told myself that every single day.  Operating gave me joy.  To be in a room with a patient.  All doubts disappeared when I was fully engaged in my work. I never woke up dreading that I had to drive in to the hospital for 12-14 hours of toil. There were people there who needed me.

But then one morning last year I sent a text to my dad at 5am that read: no matter what happens, remember I will always love you.

Then I went off to work and did a bunch of Sunday morning cases and made rounds.  The purpose of the text wasn’t to send some sort of dark and disturbing cryptic farewell message to my father.  At least I wasn’t consciously aware of anything like that.  Some mornings, when it’s still dark and the house is quiet as caverns, I wake feeling full of sugary sentimentality.  My dad and I had been in some minor rift (politics or something, presumably) and I just wanted to dash off a message telling him that all was ok, all is forgiven, let’s move on.  By the time I checked my phone later on, my in box had blown up with texts and phone messages.  All the people I cared about and loved and needed had been looking for me.  My mom had called my answering service repeatedly and there was a message from the call center lady imploring me to please please call your mother Dr Parks.

What followed was a frenzied series of texts and emails and phone calls.  Yes, I was fine.  I’m just at a coffee shop.  Working on a poem.  Just reading.   I’m ok.  Please.  This is all crazy.  I’m sorry I worried you all.  I was just working.  I was working.  I’m just taking a few moments for myself.  I just needed some time alone.  I never meant what you think.  Not that thing you think.  Not that.  

But was it true?  Was the view from a place outside my own head a more accurate interpretation than the meaning I thought I had intended?  What did they see, these people who had known me for years, for decades?  Were they more attuned to the dangerous course I had set for myself, a path littered with landmines? Did they sense something in the way I was living my life, the enormous pressures, the barely concealed strain?  I had thought I was just feeling sentimental in the early morning.  Feeling bad about a transient estrangement that had developed with my father.  But was there also something else in that text, something darker, subconsciously harrowing? Truthfully, I had been feeling a variety of strain and pressure unlike any I had ever experienced before. I had always been able to "soldier on" but something seemed different this time. Had absolute hopelessness set in? Was I crying out for help? I don't know if I'll ever be able to really answer that question.

There is always another question lingering beneath the surface of consciousness, whispering, needling you until it gets an answer: Who am I now and what have I become?  What is the picture others see when they flip open my book to a random midpoint?   A man entering middle age under tremendous pressure.  Long hours, interrupted sleep schedules.  The constant call demands.  The challenges of a second marriage and blended family.  The burden of financial responsibilities.  The heavy unspoken weight of patient responsibility.  The ceaseless strain of being a busy general surgeon.  The relentless unpredictability of an open ER and the impending surgical disasters being wheeled through its doors at all hours.  The muffled silence of a man who never speaks, who internalizes the ceaseless inflow of stress.

Were they worried about me for good reason?  Were they able to perceive something that I had willfully averted my eyes from?  

Depression and anxiety remain marginalized diagnoses in modern America.  Mental illness is still stigmatized by the ethos of a nation that glorifies personal responsibility, the entrepreneurial spirit, the Self Made Man.  Mental illness is mental weakness.  Snap out of it, the depressed are told.  Go see a doctor and take a pill.  Stop whining about how miserable your life is.  Who do you think you are?  Buck up and get back in the game.  Join a gym.  Lose some weight.  Go back to school and get a masters.  Get a job. Depressed?  It’s on you.  Depression has long been the unmentionable skeleton in the American closet.  In the land of unfathomable wealth and opportunity and self-actualization, there is only room for unbridled optimism and hope and ever increasing self aggrandizement.  Pessimists and the brigade of the unenthused, the unsold, have had to restrict themselves to the dark fringes.

For most of human history, depression was a poorly understood mental state known as melancholia.  References to the melancholic state date back to the ancient Egyptians. For the ancients, mental illness was attributed to demon possession or the arbitrary wrath of the gods.   Hippocrates redirected attention to intrinsic causes, such as they were (one theory being the over abundance of black bile in the spleen).  But then during the Roman empire and throughout much of medieval Christendom, there was a return to the dogma of demon possession.  Enlightenment thinkers conceived of mental illness as an inherited inevitability.  There was nothing you could do.  The mentally ill were packed off into asylums, never to be seen again.  Freud postulated that depression was a form of neurosis, precipitated by subconsciously remembered childhood traumas. It wasn’t until the 1950’s that the “chemical imbalance” theory arose and has subsequently dominated the understanding and medical treatment of depression even to this day.  When I was in medical school, I was taught that depression was a function of the relative concentrations of dopamine and serotonin and norepinephrine in the brain.  A lack of serotonin would lead to depression.  Depression was a physical defect, a malfunctioning cerebrum, misfiring central neurons.  It became something quantifiable, measurable, and thus manageable.  It also opened up a potentially lucrative niche for drug companies who could create pills that would ostensibly correct these chemical imbalances.  Prozac Nation was born.  

Johann Hari wrote one of the best books I’ve read in the past 20 years (Chasing the Scream) which detailed the history of the “War on Drugs”, misunderstandings about the nature of addiction, and alternative approaches to the scourge of drug abuse.  I can’t recommend it highly enough.  His latest book, which somehow exceeds his first, is called Lost Connections and his subject this time is depression and anxiety.  The essence of his thesis is that depression is not simply a chemical imbalance that can be corrected with medications that raise the levels of neurotransmitters in your brain, an explanation so ingrained in our culture it now seems counter-intuitive to doubt it.  As the research of Irving Kirsch has revealed, much of the benefit of chemical antidepressants can be attributed to mere placebo effects.

Hari postulates that depression is rather a symptom of something deeper than just biochemical disarray.  Modern research suggests that depression is to a large extent the brain’s natural reaction to a life of estrangement, both from other people and from meaningful values.  Depression isn’t what happens when there is something wrong with your brain; it is how the brain reacts when there is something wrong with your life.  The “lost connections” of the title refer to how modern American life with its emphasis on hyper-individualism, efficiency, and materialistic aspirations has alienated us from other people, from meaningful work, from timeless intrinsic values.  And as we drift further and further away from the things that matter most, the things that make us human, we arrogantly think we can just fix the inevitable psychic pain that arises in response with a cocktail of pills and various self help books.  

You know, I have to take a minute to pause here.  This won't be an easy thing for me to write but it's necessary. I’ve been a pretty messed up person on the inside for most of my life.  Highly functional, mind you.  But totally screwed up on the inside.  As long as I can remember I have doubted my own worthiness.  I never really felt that I fit in, that I was even deserving of anyone’s attention.  I’ve progressed through the stages of life feeling I had to scratch and claw for every square inch of acquired turf.  We all acquire maladaptive defense mechanisms when children, more so when there is any form of trauma or disruption. My childhood wasn’t some Dickensian tale of woe, by any stretch.  I was never beaten or abused.  I never felt unsafe.  I felt loved in my home.  We were poor but I always had food and clothes.  My parents divorced when I was 7, but there isn’t anything unique about that.  Divorce rates peaked at over 50% in the 70’s and 80’s.  But a little boy who grows up in a lower middle class home with just a mom and sisters and sees his father in Arizona only in the summers develops certain tendencies.  I always felt a little off, like I didn’t belong amongst my peers.  That I was strange, even odd.  That there was something fringe and abnormal about my upbringing.  My dad was 2,000 miles away.  My mom was angry and frightened and unsettled.  My sisters were so young and uncertain and looked to me for guidance and support.  So I decided at an early age that I was going to be tough and strong and stoic for them.  I was going to be the man of the house, to the extent that I understood the concept of “man”.  To this day I still don’t really understand my process, but I remember making a conscious decision that a real man had to be cold and distant and enduring.  That the way to transform from undersized boy to Strong Protector was to erect barriers all around my inner vulnerability.   It was based on nothing.  I hadn’t modeled my behavior on anyone in particular.  It was simply a decision I had made on my own at a very young age.  Maybe I knew that on the inside I wasn’t strong at all.  That I was weak and frightened and insecure.  That the only way to hide the fraudulent nature of my being would be to mimic and play act and don a mask of invincibility.  I decided that I could best prove my worthiness by denying myself the warmth and softness of love.  Deprivation of human contact would be the price I paid for taking on responsibilities beyond my years.  I know, it doesn’t make a lick of sense.  But I was serious about it.  I acted on this conviction.  I stopped telling my parents I loved them.  The word itself, love, dropped from my vocabulary.  I stopped hugging or kissing my family at events, at goodbyes.  I remember for the longest time being extremely uncomfortable whenever a grandparent or aunt or sister tried to hug me.  I didn’t like being touched.  My outlet for normal human emotions and feelings became shelves and shelves of books of fiction and the scores of notebooks filled with my furious private scrawlings that I toted along with me wherever I went; college and then medical school, then residency.  My best friends were Jake Barnes and Stephen Daedalus and Holden Caulfield and Seymour Glass and Alyosha Karamazov.  It’s so sad and pathetic, I certainly realize.  They seemed real, but I knew they could never see me . While the other kids were all running around having fun together, bonding, growing together, I would crawl out my window onto my roof alone and whisper to the stars.  Among others, I felt alienated.  That the gaze of the Other somehow knew the truth of my insufficiency.   And so I became most comfortable when isolated in the presence of imaginary characters written on paper. I became a delusional, naive young man convinced of a future destiny in medicine, when all would be revealed to me, when all the years of patient toil and deferred happiness would suddenly bear fruit, when it would all fall into place.  In the meantime, there I remained, a slowly desiccating shell of a formerly full person, clutching to my chest those worn yellowed books while sleeping alone (for the most part!) in dorms and apartments as I grew older and older.

So that's the peek behind my curtain. I can't help but harbor regrets, certainly, but not shame. I think we all have our own meandering routes that can lead us back to the same dark place.

Anyway, I didn’t just want to be a doctor.  Subconsciously, I needed to be a doctor.  I think my inner being saw a life in medicine as the only way i would ever allow myself to reconnect with humans again.  Sad as it is to say.  The decades of deprivation had caused irrecoverable damage but throwing myself into the idea of becoming a doctor would at least save me from complete self-annihilation.  That’s the way I see it now.  My subconscious self was trying to protect me.  That voice I kept hearing in my head--- you must be a doctor---- was a distress signal, an S.O.S. from the depths of my psyche.    

And so I became a doctor of medicine.  I fucking did it.  I trained as general surgeon and commenced a life of “service and skill and tireless effort”, as they say.  I would turn down nothing.  I would say yes and yes and yes like Molly Bloom and the Andalusian girls under the Moorish wall.  I would be ever available.  I would be there for these strangers behind curtains, in tiny rooms, in oversized hospital beds.  I would touch them, know them, be an empty vessel into which they poured their longings, their pains, their fears.  I would martyr myself on the altar of selfless vigilance.  Jesus, the soaring rhetoric we employ to explain away our own selves….The flowery verbiage we reach for to justify our own self loathing.....

As long as I was a surgeon I could be someone else.  I didn’t have to be that insecure, lonesome, emotionally stunted little boy from Massillon anymore. I was a surgeon.  It became an avatar that I could inhabit every day, a portal through which I could transform into somebody different; noble and caring and emotionally present.  Just by pulling on those scrubs something magical would occur and suddenly I was not adrift.  I had found terra firma.  I was part of something valorous and meaningful. I had a name.  People listened when I spoke.  I could be the Man I had aspired to be; I could shed my desiccated cocoon and finally spread my wings.  The question begging to be asked, of course, is the question the belligerent high school bully always asks the nerd who blossoms into prominence at the 25 year reunion: who are you without your title, without your white coat??  Aren’t you the same shrimp I used to abuse at the corner of Andette Ave and Beatty Rd, waiting for the bus? And that bully is right. It's not enough. It's simply not enough, just to take out an appendix, to save someone with an emergency airway. It's not enough to push a body to the limits of physical and mental endurance while allowing yourself only to love abstractly. Eventually you have to go home. You have to face the people who love you. And they will eventually ask you: why can't you be for me what you are for your patients at work?

Michael Chabon had a beautiful little piece in the New Yorker a few weeks ago, reminiscing about his elderly father who was an old school country doctor. His father would occasionally take young Michael out on evening house calls to see patients which, as the years passed and he became Michael Chabon, renowned author, had the effect of arousing a certain bittersweet regret.  He writes:

“But I have been an eyewitness to a number of displays of my father’s other remarkable skill, one that is never the focus of his storytelling: an uncommon gift for reassurance, for making his patients feel that he registers and sympathizes with their pain or discomfort and their anxieties about treatment itself; that he is really listening to them, really seeing them.  Later in life, I will encounter and come to understand other self-centered people capable of great feats of empathy if only within certain narrow yet powerful contexts--- while writing novels, say----but for the moment I cling to the misguided hope that the ray of my father’s compassionate attention will one day be directed toward me.” (emphasis mine)

I read this while waiting for my son to exit the locker room from his hockey game and it froze me in my tracks.  Jesus, man, I thought.  I don’t want to end up like that.  I don’t want to be that guy! Incapable of connecting with the very people he loves most, all his energies of deepest intimacy expended on random strangers staggering into ER’s and clinics with belly pains.  

But a self-imposed exile is the deepest cut.  The walls we erect around ourselves are the thickest, the strongest walls, stanchioned by habit and a fearful austere comfort.   We find that if we choose to venture beyond our lonesome ramparts to our former lands, the people we return to seem suddenly unfamiliar, unknowable, vaguely evocative but lacking definitive shape.  All those years you can’t have back.  The frayed fibers of connection eventually fail to tether you to a past if there’s just the least bit of pressure. The rope breaks, you drift away into the open void.  

The psyche is a strange thing.  The deep well of self preservation is an underground ocean of unharnessed, undirected power.  We float along on its currents without being aware that we are even moving.  We find ourselves millions of miles from home and we want to blame the world.  We want to shout from the roof tops, rue our dispossession, the injustices of fate. We never realize our drift is a self-protective propulsion; our waxing crescent moon, unseen but for a close reading of the sky, silently tugging us along.

What can we do to augment our awareness of tectonic drift? We all want to be little boats anchored in save havens, in curled off coves beyond the ravages of storms.

Johann Hari in Lost Connections suggests addressing the fundamental disconnect that has arisen in modern life. Find those broken bonds and strengthen them anew. For too many Americans, the basic human needs are not being met by our culture. Too many have to scratch and claw for essentials like food and shelter and healthcare, toiling long hours at meaningless work and still barely having enough to make ends meet. Too many Americans are consumed with insatiable materialistic pursuits. Too many minds are cluttered with the specious distractions of social media and celebrity culture. The intrinsic meaningful values of humanity have been usurped by the superficial, the ephemeral, and the mass of humanity wanders through a life with a gnawing pit of hunger in the middle of their souls. We have feasted upon a simulacra of sustenance for far too long and all the technology and ease that modernity has to offer will never satisfy that ravenous appetite. We have to find a way to refocus on the meaningful values. Re-emphasize a more communal approach to life, without negating the dignity of the individual. Find a way to slow down the mind, sweep it clear of the clutter of distraction, whether it's meditation or prayer or simply blocked off periods of holy silence. Spend more time composing sympathetic narratives to explain the actions of others and less time ruminating over your own self-justifying narrative. And most important, accept that we were never meant to be alone. Love the ones you love. Allow yourself to love them, to express it, and let them love you back. Love your mom and dad. Your sisters and brothers and husbands and wives. Love your cousin best friends. Love your accumulated roster of friends, the ones you've collected along the different way stations of life and all the friends (that you don't even know are friends) with whom you spend your current working days. Love them deeply and with all your heart. We can all open our hearts just a little bit more. I know I am trying. But more than anything else, you have to find a way to reconnect with the most important participant in the short, grand, beautiful thing called life: somehow you have to learn to accept and love your self. Derek Walcott's poem "Love after Love" sums it up the best:

The time will come
when, with elation,
you will greet yourself arriving
at your own door, in your own mirror,
and each will smile at the other’s welcome,

and say, sit here. Eat.
You will love again the stranger who was your self.
Give wine. Give bread. Give back your heart
to itself, to the stranger who has loved you

all your life, whom you ignored
for another, who knows you by heart.
Take down the love letters from the bookshelf,

the photographs, the desperate notes,
peel your own image from the mirror.
Sit. Feast on your life.

You have to learn to look in the mirror and love that face you see.  And not just metaphorically  This will sound absurd but you have to actually say it to that face in the mirror, out loud, and mean it.  Say it like you did to your spouse on your wedding day.  Like you did to your mother when she kissed you goodnight as a child.   The first time you do it will feel weird and awkward.  You won’t be able to stop yourself from wryly smiling, rolling your eyes, a lifetime of ironic detachment baked into your being. This is ridiculous, you will think. But you must do it. And then again. Keep doing it until the irony and sarcasm slowly drains away. You must learn to say it to that little boy or girl hiding inside, past the gaze, past the grizzled, grayed, creasing face, the one who used to get excited for Santa Claus or when daddy got home, the one who was afraid of thunder, the one who wanted a BMX bike for his birthday, the one who dreamed of being a hero with powers beyond the comprehension of mere mortals, who wished upon stars and always knew he would end up right here, in this place, right now, staring back at you in the mirror. And when you figure it out, when it finally makes sense and you say it the way it ought to be said, your eyes will flood and it will be like someone has reached down and removed some invisible weight you never knew was there. You will see your face for the first time. Just a happy, sad-ass face. Like all the goddam others you see, but don't really see, every single goddam day. And it will be one of the happiest moments of your life.

The day of the dead doctor's funeral I had made mental plans to get to the cemetery. But the list of patients to see was long and the damn ER kept calling. Appendix, rectal abscess, bowel obstruction. One thing led to another. I ended up with 4 or 5 cases that Saturday. We worked deep into the evening. I never made it to the funeral. I was in the hospital amongst the living. I was with my colleagues. I was with all my friends. We were working hard. We were happy.

Post script: 
 This was a long rambling piece and for that I apologize.  I wanted to share a personal story in order to open up a more universal conversation.  Any physician out there struggling with depression or despair, or if you just want to shoot the shit, unload on a fellow traveler, please feel free to reach out.  My cell phone is 440-637-4571.  My email is


Tuesday, February 13, 2018

Non Weekend Poem


Every bonfire starts as a boiling
Before it becomes a burning

The dead chopped logs seemed dry
In their orderly brown gray stacks.
You have forgotten that morning drizzle from days ago:
The dew, the wet earth, the sludged soil,
The dampness silently absorbed
Into pockets of air braided into a hard core,
The tiny reservoirs where the rain gets stored.

The heat increases and the logs hiss and seethe.
The little oases agitate, become steam,
Find fissures of escape through the grain,
Burst forth to freedom with a triumphant scream

You’re not so dry yourself
You tired old husk of bark.
There are gaps and lacunae yet
In the mass of your solidity,
Untapped pools of liquidity
Patiently resting like glacier ice
Just waiting for a warming
Just waiting for a spark.

You must find a way to light that fire.
It’s never an easy game.
(Did you know we’re mostly water?)
Without a match or a lighter
You can rub some sticks together
Heat, smoke, then a flicker of flame
To release a vapor that rises to become cloud,
Become rain to slake a parched throat,
The scorched earth.

We must all be boiled
Before the rest can all burn