ACS surgery thread reply

ACS Surgery Discussion Forum regarding recent AMA statement on health care as a human right.  The objectivism trolls had hijacked the thread.  This was my poorly received response:


Dear Dr X(and those of similar vein)-


I must respond to your impassioned excoriation of the idea that healthcare is a "human right" (scare quotes rendered as a show of respect to you) in the name of the dignity of surgeon labor.


Your initial salvo is an interesting mashup/admixture of both the Declaration of Independence (We hold these truths to be self-evident, that all men are created equal, that they are endowed by their Creator with certain unalienable Rights, that among these are Life, Liberty and the pursuit of Happiness) with the US Constitution (i.e. 5th and 14th Amendments prohibiting deprivation of property without due process).  Your inclusion of "property" (my scare quotes, my turn) is interesting, to say the least. Similar arguments were made in the infamous Lochner vs New York case of 1905 that upheld the "right" of a bakery to violate employment laws that limited the number of hours a baker could work in a week, under the auspices of honoring the sacredness of the contract.  Similar arguments were made, most infamously, and perhaps more familiarly, in the Dred Scott decision of 1857, using the same due process, right to property arguments. Dred Scott was merely the "possession" of John Emerson (an army surgeon, imagine that!) and therefore had no recourse to the noble, high fidelity rhetoric contained within the holy writ of the US constitution.  John C Calhoun made similar arguments during the nullification debates decades earlier.


But let's not spend too much time nosing around in Supreme Court history.  Your argument mounts an army of straw men to fight a battle you will never see.  No one is dragging Dr X out of bed at 7 am to operate all day long on an endless list of self pay patients.  No one is mandating uncompensated labor. This has never happened in your life. And if it has (bad call draw, bad weekend ER luck) then universal healthcare would have made such future events impossible.  Which begs the question: what is it you are going on about again? What is your point? Universal health care would guarantee that you are compensated for every operation you do. Do you just not like the idea of people getting "free care"?  Do you turn away Medicare patients? Did you know that most people on Medicaid work? Your diatribe about free care and uncompensated physician labor only seems applicable to the current status quo, i.e when self pay patients show up with appendicitis.   A world of universal health care would obviate the existential pain you seem to be suffering from regarding the dignity of physician labor. Your gnawing angst about a future world of…...too many patients being covered by insurance seems to be..….at odds with what you originally purport to fear. As someone said earlier in this thread, 50% of healthcare is provided by that horrible, totalitarian "government" you demonize.  Ask recipients of medicare, of VA benefits, of Tricare how they feel about the care they receive. You may receive a higher reimbursement from private insurance but that's only after the population at large has had their paychecks and wallets picked over by marauding bands of parasitical insurance companies and third party administrators.


Yuval Harari has a fascinating new book out called Sapiens, a historical review of our human species.  One of his themes is this idea of there being "imaginary orders" that humans collectively agree upon. Think of all organized religion, the divine mandate of kings, feudalism, master/slave relationships, race hierarchies, and then, post Enlightenment, the idea of individual human rights and government of the people and by the people.  None of these ideas has any basis in empirical or mathematical reality. They are all necessary figments of the human imagination that we have at one time or another collectively internalized as truth. Thus, there is order and structure to our lives at certain points in history. The ideas derive their power not from some transcendent unassailable Truth but simply from the collective societal decision to assent to their tenets.


The point of this little digression is to say that imaginary orders, in general, are somewhat arbitrary and can be altered as time passes and circumstances of human existence change.  Human rights in the era of authoritarian monarchy, nascent democracy, and mercantilist empire were thought to include, at the very least, a guarantee toward life, liberty and the pursuit of happiness.  But that doesn't mean Thomas Jefferson stumbled upon some sort of special theory of relativity of political philosophy. In the context of his time, his writings rang true (and still do for the most part).  But that doesn't mean he had the ability to foresee the eternal unfolding of human history. Further, we do ourselves no favors by limiting our views on human rights to those of an 18th century American slave owner.  I have a more expansionary perspective on what ought to be deemed necessary and proper to all living souls. Human rights is a living, evolutionary concept.


In the context of a  21st century America, an America that is unquestionably the wealthiest, most powerful nation in the history of nation states, a nation that spends more on its military exploits every year than the next 10 countries combined,  where millions of men and women avoid basic health care due to high deductible private plans or go uninsured entirely, where medical bills represent the number one etiology of personal bankruptcy, where life expectancy has fallen vs the rest of the world, where the USA alone among advanced democracies remains the one nation that does not guarantee universal health care, in this particular context, I aver that health care belongs in the pantheon of human rights.


This is my imaginary order.  For what is liberty if you are afraid to take a new job or start a new business for fear of losing your employer based health care plan?  What is the pursuit of happiness without having the right to obtain the medicine and care needed to mitigate illness and pain? What is the right to life without having the ability to afford the necessary measures to amplify, maintain and heal the body in which you reside?


Too much of this thread is dominated by a juvenile Ayn Randian rhetoric that treats the modern world of resources in purely zero sum terms.  As if provision of food necessitates breaking into Dr Leonard's pantry in the middle of the night or armed bandits raiding the neighborhood grocery store.  (How about simply paying the populace----in the era of 3% unemployment--- a living wage so they can afford to buy their own groceries.) As if doctors are remanded by state police and forced to perform procedures on the unworthy, the lazy, unentitled. (How about instead legislating universal care, whether in the form of single payer or one of the hybrid systems used by Germany, France et al) This world of abundance and wealth is both a blessing and a curse.  Our lives are enriched and made comfortable by its spoils but it is also the dark mirror that reflects our basest, most selfish instincts.


I would urge many of you to break out of your cloistered intellectual dead ends.  Put down the Atlas Shrugged. Read about alternative solutions. Expand your minds.  Your hearts will follow.

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 jparksmd@gmail.com

jcp

Work History

I always find myself asking a new patient what they do or, for the elderly, what they did for work.  All this stuff about heart caths and gallstones and knee scopes and the gout acting up is numbing and disconnecting. Abstract collections of fact.  Case studies in a stack of medical journals.  Where am I?  What is this place?  Why are we in this room together?  Why are we sharing this space?

If you aren't a doctor you wouldn't know exactly what I mean.

The contrived forced intimacy.  One on one, the one way sharing of embarrassing secrets and frailties. Enough of the unmentionables.  Let's discuss something else.  What kind of work did you do when you were younger?  As if knowing Stan ran a hair salon or Sue was a third grade reading teacher would somehow bridge the gap of absurdity that brought us together here in this small room.  Remind me I'm not alone in here, brightly lit, all the gauze and tape, antiseptic steel. Something to interrupt the piercing gaze, to start again to feel.

The old woman snoozed during the initial interview.  A daughter answered all the pertinent questions.  The colitis.  Bedridden.  Recurrent urinary infections.  Confined.  Early dementia. But what did she used to do?  And the old woman heretofore ignored, sprung to life, as if plugged in, visage brightened.  I used to teach Sunday school.  You know my granddaughter says I have squishy skin.  She likes to pinch the skin on my arms between her fingers like this and she says I have squishy skin and I tell everyone I am an old woman with squishy skin.

And just like that her smile faded.  Her eyes went dull and she turned away toward another blank wall.  That was it.  The lady with "decreased skin turgor".  I put my hand on her forearm.  I didn't pinch, just a light gathering of loosening elastic flesh.  I could see what her granddaughter meant.

Charlottesville Thoughts

I grew up in Massillon, Ohio--- an ethnically and culturally homogeneous small rural town with a foundering manufacturing base. I was raised by a single mother, visited my father in Arizona in the summers. We lived in relative poverty for years after the divorce. We barely scraped by, to be perfectly honest. (We ate a lot of tuna casserole on Wednesday nights). I was always loved and supported but something always felt amiss. I had grandparents and relatives who casually dropped the "N" word at family gatherings. I was told that mixed race children were bad because "they get rejected by both the blacks and whites" as if one needed a certain skin tone for admission to a tribe. My high school was 98% white. I never really had an actual conversation with a black person until medical school.

I was also blessed with a certain unearned, undeserved intelligence. I did well in school and was able to go off to college and then to medical school. Today I am surgeon in Cleveland and 1980's Massillon seems eons ago, and millions of miles away, even though I could drive to my childhood home in less than 90 minutes if I wanted.

But events like the violence and hatefulness demonstrated in #Charlottesville yesterday bring it all rushing back. The notion that White Supremacy is baked into the essence of America cannot be easily dismissed. As Ta-Nehisi Coates has more eloquently stated in his magazine pieces and books, America is built upon the idea of plunder. Plunder of land, of labor, of life by the "more deserving" Anglo-Saxon elite. In this reprehensible worldview only the White Christians of Western European origin are fit for power. For the racists and white nationalists, subjugation of Africans, of Native Americans, of Hispanics, of the non-Protestant religious is not only justifiable but even morally desired for the betterment of all humanity. As Robert E Lee (the man for whom the Alt Right protesters were ostensibly marching to defend yesterday) said: "The blacks are immeasurably better off here than in Africa, morally, physically, and socially. The painful discipline they are undergoing is necessary for their further instruction as a race, and will prepare them, I hope, for better things. How long their servitude may be necessary is known and ordered by a merciful Providence. Their emancipation will sooner result from the mild and melting influences of Christianity than from the storm and tempest of fiery controversy."

Today I live in an ethnically diverse part of Ohio. The majority of my patients are African-American. My colleagues in medicine are Black and Jewish and Asian and Muslim and Hindu. My medical assistant is a strong African American woman who works her ass off and treats my patients with dignity and respect. For all this I am eternally grateful. My life has become far richer with the experience.

It started with medical school, intensified during surgical residency in Chicago and then blossomed here in Cleveland. Something happens to a mind and a body when you are able to escape the arbitrary constraints of provincial narrow-mindedness. There's a wide wide world out there. And the the further you venture out, the more you find that the extent of the world can be found in the heart of your own soul. You never knew the secret was wrapped up inside, that you needn't go far to find it. In sickness, in pain and suffering, we all cry out with similarly pitched wails of protestation. White or Black or Asian, we all suffer. We all are loved. We all err, we all rue lives lost, chances missed, paths neglected. We all have parents who mourn our failings or falls. We all wish we were better, more loving, more understanding. Life for all of humanity is a series of failures. If we are lucky, we rise from bed each morning with the yearning to maybe make things just a little bit better, incrementally. In medicine, the facade falls away and you see people without any of the obfuscatory bullshit. The authenticity available to a physician is the greatest of all privileges. It may have saved my soul, in particular. Too easy it is, in this fallen, inadequate, craven world to succumb to an overwhelming cynicism and despair.

And so today I say, unequivocally, that I denounce in no uncertain terms the UniteTheRight protests in Charlottesville yesterday. It wasn't "both sides". It was one side promulgating the absurdist notion that one's skin color is a marker of human superiority. This "side" has no place in 21st century America. Beneath the relative melanocyte content of your skin, beyond the arbitrary nature of one's parents' provenance, there resides a commonality shared by all the living. We all have had our hearts broken, we all have faced the sudden pre-dawn stifling fear of our own imminent mortality. Life is a shared experience lived through a seemingly singular consciousness. After all these years that's the only thing I have really ever known to be true. All else is up for interpretation......

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 its population.....

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.

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....