July 21, 2023
Dear Interested Readers,
Let Go and Hang On If You Can
I recently passed my 78th birthday. Because of many factors like the pandemic, the fentanyl epidemic, increased gun violence, and probably somewhat due to increasing difficulty with accessing care, life expectancy for males in America has fallen to about 73 years. Life expectancy for every American is at its lowest point since 1996. I could not find current data for white males only, but it is probably a little higher than for men from minorities because of the differential racial impact of the social determinants of health across racial groups.
I would hope that the recent fall in life expectancy might generate the same sort of distress within the general public as inflation, but that is not happening. Still, I am getting used to the idea that what I hope for is not necessarily high on the list of what politicians talk about and what concerns voters after they have been bombarded with misinformation to stir up their cultural concerns.
Having survived COVID and persisting five years longer than the average American male, current actuarial data suggests that as a man of 78 who is in relatively good health, I might hope to live 9.43 more years. If that’s true, and I do make it to 87, then the tables suggest a bonus of 6.07 years, which would bring me to 93, which is almost the age my mother achieved. She died two months shy of her 94th birthday. This way of thinking does not produce immortality, but there is some encouragement from this exercise if your goal is to make it to 100.
To become a centurion I must avoid the error that precipitated my father’s death a month and a half before his 98th birthday. His oft-stated goal was to live to be 100. He failed in his effort because he made the mistake of submitting to unnecessary diagnostic testing when he presented with evidence of a GI bleed while on aspirin for slow AF. The doctors in the emergency room of his local hospital did not deny him any billable diagnostics. The hospital had been recently acquired by a very large profit-oriented nonprofit healthcare system. I was called after their plans nearly put an end to him. The alternative management that I would have favored would have been to stop the aspirin and observe him. With either approach, he should have been transfused. The diagnostic testing that seemed more important to the physicians taking care of him who did not know him was not necessary since he may not have been a candidate for intervention.
After being scoped from both ends under anesthesia without the discovery of a source of bleeding, he had aspiration pneumonia, was essentially comatose, and had a permanent decline in mental and physical function as he faced six months of continuing harassment with feeding tubes and daily humiliation in a chronic care facility where he spent most of his remaining days. That was a big step down in function for a man who had previously had an inquiring mind, exercised regularly, enjoyed socializing with family and friends, and ventured into a second marriage at the age of 94. If Dad had been lucky enough to have encountered a physician who could have exercised some restraint and treated him in an age-appropriate way, he may have achieved his goal of living to 100 because his life expectancy at 98 was 2.37 years!
One of the joys of being 78 is that by the time you reach this age, you are loaded with lots of data that allows you to make numerous “what if journeys in your mind.” “What if journeys” are pleasant and enlightening if you avoid “woulda, coulda, shoulda” follow-up thoughts. One must remember that the past has passed, and the key to going forward is accepting and learning from what has occurred.
Perhaps the reflections above were precipitated by the fact that I am reading a delightful little book, The Book of Charlie: Wisdom From The Remarkable American Life of a 109-year-old Man, written by the Washington Post journalist and author of several books of history, politics, and culture, David Von Drehle. The book was an unexpected birthday present from one of my sisters, and we agreed to discuss its deeper meanings once I finish reading it. For full disclosure, I must tell you that the little exercise in life expectancy is almost an act of plagiarism because Von Drehle did almost the same exercise while introducing Charlie in chapter two.
If you don’t know the book or have not heard anything about Charlie, he was an anesthesiologist who had a very remarkable and positive outlook on life that enabled him to survive adversity and live with a very high level of personal joy. At the end of the second chapter, Von Drehle gives his take on Charlie’s philosophy of life which he believes in combination with good genes and better-than-average health habits enabled Charlie to live for so long. He condenses Charlie’s philosophy to “Let it Go and Hold On” and then writes:
Let It Go and Hold On! In the way of so many great philosophies, those apparent opposites prove to be two sides of the same coin. To hold securely to the well-formed purposes of your own will, you must let go of the vain idea that you can control people or events or the tides of fate. You can’t change what was, nor entirely control what will be. But you can choose who you are and what you stand for and what you will try to accomplish.
I ruminate on many things besides healthcare. At my age, it should not surprise you that with curiosity and without fear I spend a lot of time thinking about what might come next. The result of those ruminations so far is the conclusion that I must accept what is and not fear what might come. Since I can’t understand how all that I see in the natural world came to be, it is unlikely that I will ever be able to figure out with certainty where it is going. I am comforted by my father’s conclusion that he would not want a God that was so simple and small that He/She could be understood by a mortal, or at least him. I have added to his thought by saying that the creation of all that is is far beyond my capacity to understand, and that I am better off not fretting about what may or may not come, and being content with just accepting whatever is to come and hoping that what might be will be at least as good as “what is” has been for me.
At his trial for “misleading” the youth of Athens, Socrates said that he did not fear death. He told his accusers that he believed in two afterlife possibilities. One possibility was a deep dreamless sleep. The second possibility that he anticipated was a state of great pleasure, engagement, and comfort in an environment ruled by “just judges.”
It is not that I have not tried for greater understanding, or that I am unwilling to proclaim certainty founded in faith when I have doubts. I am just accepting of whatever might come and expect like Socrates that whatever it is, it will be good. I am comforted in my ignorance and ineptitude by knowing that the brighter people of theology, science, and philosophy are not much closer to universal certainty or a “Theory of Everything” than I am. I have accepted that despite the advances of cosmology and advanced physics, the answers will not be forthcoming in my lifetime, and if they are, I will not understand the conclusions, and would also have to exercise some sort of faith in the declarations of others. The “Big Bang” does not answer any important questions for me. Science as we know it seems to be so riddled with uncertainty, think Heisenberg’s principle, that the dream of some overarching scientific explanation “of things” seems unlikely. It confuses me when astronomers and physicists talk about “singularity” which in my small mind should represent some unifying truth, but what they really are referring to is something that for me is mostly still theoretical and devoid of emotional comfort.
Singularities are regions of space where the density of matter, or the curvature of spacetime, becomes infinite. In such locales, the standard concepts of space and time cease to have any meaning.
Singularities are predicted to occur in all black holes and also in certain models of the Universe. For example, open Friedmann models of the Universe possess a singularity in the finite past, while the closed models have both an initial and final singularity. In general, cosmic censorship hides singularities behind event horizons, the exception being the initial singularity of the Big Bang.
What does that mean? It is just as hard for me to accept as it is to imagine someone walking on water. Charlie’s down-to-earth philosophy is a better fit for me. I like the idea of “Let it Go,” but in letting go I must remember, review, and analyze what did happen with the hope that what I might learn from what I can’t change will be of use as I attempt to “Hold On.”
Among the things that can’t be changed are the ideas and feelings that drove decisions that were made in the past. Who we are is some combination of genetics, nurture from family, and external influences. The Greeks called it fate. My parents believed, lived by, and impressed on me the idea that every life has a purpose and that the quest to discover that purpose is a personal responsibility. I have enjoyed reading the recently deceased theologian, essayist, and novelist, Frederick Buechner, whom I discovered by reading his obituary in The New York Times and the salute that David Brooks gave him. In the tribute, Brooks quotes Buechner:
“Listen to your life. See it for the fathomless mystery that it is. In the boredom and the pain of it no less than the excitement and the gladness: touch, taste, smell your way to the holy and hidden heart of it because in the last analysis all moments are key moments, and life itself is grace.”
I was surprised to learn when I mentioned Buechner to some of my friends that they had all known of him for years, and most of them had read one or more of his over thirty books. One gracious friend gave me her copy of Listen to Your Life which is a collection of daily meditations which I have been faithfully reading since the first of the year. The short entry for July 18 is entitled “Vocation” and you can read it below.
Vocation
It comes from the Latin vocare, to call, and means the work of a man is called to by God.
There are all different kinds of voices calling you to all different kinds of work, and the problem is to find out which is the voice of God rather than of Society, say, or the Superego, or Self-interest.
By and large a good rule for finding out is this. The kind of work God usually calls you to is the kind of work (a) that you need most to do and (b) that the world most needs to have done. If you really get a kick out of your work, you’ve presumably met requirement (a), but if your work is writing TV deodorant commercials, the chances are you’ve missed requirement (b). On the other hand, if your work is being a doctor in a leper colony, you’ve probably met requirement (b), but if most of the time you’re bored and depressed by it, the chances are you not only bypassed (a) but probably aren’t helping your patients much either.
Neither the hair shirt nor the soft berth will do. The place God calls you to is the place where your deep gladness and the world’s deep hunger meet.
I bolded “The place God calls you to is the place where your deep gladness and the world’s deep hunger meet” because it connects very nicely to last Sunday’s (July 16) podcast of The Daily which was the reading of a recently published article in the Sunday Times magazine by Eyal Press entitled The Moral Crisis of America’s Doctors: The corporatization of health care has changed the practice of medicine, causing many physicians to feel alienated from their work. I hope that you might find time to listen to the 31-minute podcast or read the article. To summarize its point there are many physicians and nurses who may not say that they were “called’ to their profession, but consciously or unconsciously they became medical professionals because providing care is what they were “called” to do because (a) it is was what they needed most to do and (b) it was the thing that they could do that was what the world most needed to have done. Now, they are faced with the reality of working in a system that frequently operates in a way that violates the principles that drew them to practice, and that creates confusion and “moral injury” for them as they feel they are forced to be a part of the problem.
As many of us chose to go to medical school, we were not worried about what it would cost in dollars or effort. We were buoyed by our desire “to help people” and most of us did not give much thought to the sacrifices that would be necessary to realize the place where “our deepest gladness met the world’s deep hunger.” We were excited about a life of service and care for others or about the opportunity to solve problems that would advance the science and understanding of medicine to the benefit of all.
The article goes on to describe how for many physicians and nurses those expectations were dashed by the current ways by which medicine is financed and delivered, and the crashing impact the process has had on the “souls” of many providers who now suffer from a deep moral injury as they realize that they are trapped in a system that violates the principles that they thought would define their professional lives. Some of those in our profession have not been able to “hold on” like Charlie and the result has been to leave practice or in extreme circumstances, commit suicide.
I first wrote about “moral injury” in a letter to you back in June 2015. In that letter, I described the moral injury suffered by a colleague and close friend. He had Charlie’s ability to “Let Go and Hang On” and for the forty years since he suffered his injury he has been able to do what he needed most to do in life, and what he needed to do has been what the world needed of him. The article is worth your attention because not every doctor or nurse is able to Let Go and Hang On.
I do not mean to imply that those who can’t Let Go and Hang On are morally inferior. Indeed, I am sure that for many of them their “calling” has been such an intense process that they can’t imagine continuing to be a part of a system that harms many and neglects others that it never sees while focusing on profits that seem more important than outcomes. As Eyal Press writes deep into his article:
…more and more doctors are coming to believe that the pandemic merely worsened the strain on a health care system that was already failing because it prioritizes profits over patient care. They are noticing how the emphasis on the bottom line routinely puts them in moral binds…when a person’s sense of what is right is betrayed by leaders in high-stakes situations. “Not only are clinicians feeling betrayed by their leadership,” she says, “but when they allow these barriers to get in the way, they are part of the betrayal. They’re the instruments of betrayal.”
I feel very fortunate that during my many years of practice in the same organization where my friend experienced his moral injury, I never had a similar experience, but things can change. The organization that I worked in for my entire career experienced a deep financial injury during the pandemic and is now part of a large for-profit system. I have no idea what practicing there is like now, but as a patient, I have the same concern now for its providers that I have for all of our healthcare providers.
I fear that because there is so much money for some to make in healthcare, those with a vested interest in the status quo will make sure that America’s healthcare system will be able to continue on the path that it is on for a very long time as more and more damage to patients and providers accrues until a critical mass has been injured. Eventually, change may come when the number who have been injured as patients or providers becomes a concern that generates enough outrage that there is a political demand for deep change. Until then we should continue to Hold On and anticipate the day when young people can be assured that if they feel “called” to service that service will not be in an environment that presents them with the risk of moral injury. While we wait perhaps we should ponder what David Von Drehle told Elizabeth Eagan who reviewed his book about Charlie in The New York Times.
“…we can only control our own selves, our own will, decisions and actions. We don’t control people; we don’t control the world; we don’t control the future…
Those are good thoughts to remember as we let go of all the misery that we have seen and have experienced in an environment that is a threat to our sense of calling and an origin of injury to many while we hold on and yearn for, and work for, better days to come.
Broiled, Washed Out, and Temporarily Drying
When do we become concerned? The concept of global warming has generated contentious conversations for at least three decades now. It’s been seventeen years since former Vice President Al Gore became the champion of efforts to reverse the process of global warming with his video production and book “An Inconvenient Truth.” How are we doing?
Perhaps the presentation which warned us of rising sea levels from the melting of the global ice caps and glaciers was sugar-coated by its focus on melting without enough emphasis on being broiled, blown, and washed away. Gore’s data produced a lot of jokes about inland properties becoming beachfront bonanzas, but perhaps he did not warn us enough of the possibility of those new vacation homes being ripped apart by high winds.
In 2017, Kim Stanley Robinson wrote a successful science fiction novel about life in New York when all of lower Manhattan was underwater, New York 2140 (read The New Yorker review) after two huge rises in sea level. The first in 2050. That picture of the consequences of global warming was not so bad although he does reference a few billion people dying on the way to the new reality.
Perhaps Robinson applied deeper thought to his peer into the future because his 2020 novel, Ministry For the Future, begins in 2025 with a deadly heat wave in India with temps at the level of those being now experienced in Phoenix mixed with a little more humidity which kills millions as air conditioners fail. After a horrendous night of heat across India, the local lakes and rivers are filled with the dead bodies of those who sought relief from the heat in the water. More than 15 million people are dead. The disaster produces a worldwide militant reaction against the producers and users of carbon-based fuels. Billionaires and politicians are assassinated, and their private jets are bombed.
Robinson is an optimist, as the New York Review of Books review says, “…climate change [in the book] is the crisis that finally forces mankind to deal with global inequality.” It is interesting to see global warming as yet another manifestation of inequity not only for now but for the experience of future generations who will inherit the burden. As the song says, “Oh, when will they ever learn?”
What is becoming more and more obvious with each passing season is that before things work out for our great great grandchildren, some of whom may be citizens of New York in 2140, or God forbid for ourselves in 2025 if Robinson is a prophet, we have much pain and suffering to endure and some lessons to be learned if we are to “Let Go” of our current wayward political divisions over climate and together attempt to “Hang On” until enough of us see the writing on the wall and demand change.
Phoenix has had three weeks of temps above 110, and I have heard that not only is there more to come, but it is going to get even hotter. In the Midwest and South, violent weather with tornadoes has wiped out towns. In the Northeast, floods have ruined businesses and left many homeless. In an ironic piece of local news, I read that Vermont’s cannabis stores are not eligible for relief from federal disaster funds.
Here in New London, we have been relatively lucky. As you can see from today’s header, heavy rain filled our lake and its outflow washed out the road where I walk and ride my bike. The damage was temporarily repaired in about three days, but it will be impassible again for a few days when they close the road to put in a new and larger culvert that will be capable of handling the next “100-year” deluge. It has never happened before, but the road has washed out twice this summer.
I guess it is human to hope that we have seen the worst and now things will be better, but it is more than possible, it is a reality, that we haven’t seen the last of our climate-related surprises. What surprises me is that even as we predict more wild weather in the future, no changes to substantively reverse the process seem to be on the horizon despite the international climate agreements that are probably going to be too little too late.
Living with it, or “letting go and holding on” seems to be an emerging strategy. You might be interested in listening to an interview with David Hondula, the director of heat response and mitigation for the city of Phoenix. Mr. Hondula’s position is a “first in the nation” public position. His job is not to make the heat go away. He was hired to help the citizens of Phoenix live with the heat. I guess that is progress.
Things have been looking up here. We had heat, humidity, and a little air pollution from the Canadian fires and more heavy rain earlier this week, but no meteorological disasters to match Pheonix or Vermont. The last two days have been beautiful. There has been a little rain overnight and the possibility of a more violent front coming through later today has already washed out our plans to attend a concert this evening on the lawn of the old Bradford Center Meeting House, but we will hold on for a better Saturday. I hope that wherever you are that you will have a wonderful summer weekend or find some comfort from an excellent air conditioner.
Be well,
Gene
