Fear Not the Future

“Be of good cheer. Do not think of today's failures, but of the success that may come tomorrow. You have set yourselves a difficult task, but you will succeed if you persevere; and you will find a joy in overcoming obstacles. Remember, no effort that we make to attain something beautiful is ever lost.”
- Helen Keller

I’ve been traveling a fair amount lately, both in business and personal realms. Sitting in one place allows the luxury of time and contemplation. Some of my most creative thoughts and blogs have come while riding the train from New York, or watching the planes depart from the vantage point of the rocking chairs in the Charlotte airport. Physical travel is the metaphor for our own life journeys and with it, the contemplation of the future. The physical and symbolic transformation in going to Haiti was reinforced recently when I was on a plane listening to a blog Ben sent me.

http://www.thisamericanlife.org/radio-archives/episode/408/island-time

It speaks of the importance of some structure for future success in Haiti, and that money alone won’t solve, and may in fact worsen, the problem. There are also uplifting stories of self determination and the balance between providing help and creating dependency. In my mind it spoke both to optimizing the present and setting a course for the future.

These have been a difficult few years for many. Economic upheaval, job loss, environmental catastrophes, and personal struggles with change – it makes one wonder what the future will look like. But then I meet amazing people doing remarkable things. I’ve recently visited a patient centered clinic model that has blurred silos and truly aligned incentives for providers and hospitals; I’ve met a woman in her 50’s with a PhD in Child psychology– she works as a flight attendant weekends to supplement her income so she can do what she loves - treat disabled children, some with little if any insurance; I’ve watched parents with newborns and tight budgets still putting something away for college- and the belief in the future.

Helen Keller never planned to be blind, deaf, and mute. It is likely she has no memory of those senses. But her story, and the lessons it teaches us, transcend mourning current loss and instead focuses on the new opportunities of tomorrow.
So while we have concerns for the future of Haiti, and issues in our own lives and those around us, it is the future that keeps us toiling in the now. I have mentioned “The Right Stuff.” John Glenn, the first American to orbit the earth summed it up beautifully.

“People are afraid of the future, of the unknown. If a man faces up to it, and takes the dare of the future, he can have some control over his destiny. That's an exciting idea to me, better than waiting with everybody else to see what's going to happen.”

Let's raise a bottle of Prestige beer for the people of Haiti and for ourselves with a toast. "Anvi!" "To the future!"

A Leg Up

It’s always nice to start the week on a light and positive note. I’ve just returned from a bike ride along the East Bay, enjoying the late spring weather and the paths along the water. Although thinking about the New York Times article this morning regarding the Haitian prison uprising was disturbing, I also found some uplifting news from my colleagues in Milot regarding our patients and their continued recovery.

The prosthetics lab had arrived.

Many of you have followed my observations of the difficulties in getting the right supplies to the right place in a timely fashion. Our patients that survived the quake had complex orthopedic injuries that required multiple procedures, and often amputation. It would be impossible to for them to return to Port au Prince with any degree of independence if they were still on crutches or in a wheelchair. The CRUDEM foundation, working with the Order of Malta coordinated the design and construction of a prosthetics lab on site at Sacre Coeur. The picture shows Tom, wearing the first prosthesis fabricated, throwing his crutches to Patrick Etienne, one of the translators we discussed Friday. Over the next few weeks, the amputees will be fitted, trained and will be able to return home. We fully expect to see an influx of other amputees from Port au Prince and other parts of Haiti as word spreads. Beyond the humanitarian benefit, the lab will provide an economic boost to the region, as local workers will be employed. I would hope that over time, operations will be transferred to the Haitians.



Clean water is always key to public health. During my time in Milot, we went through thousands of bottle of water daily for staff and patients. The waste plastic created was gathered and burned in open pits, or ended up in the trenches I showed you. Again, working with partners from the States, a solar powered water filtration system has been installed, generating 6800 gallons daily of potable, safe water. There will also be significant cost savings that can be used toward other urgent needs.

I am hopeful that my own transitions will move forward, so that I can return to Milot in July. You see I want to go to the 3 pm dance party and see the pediatric amputees up and moving with their new prostheses, quenching their thirst from cups of safe water, and smiling now that they have a future more clearly in sight.

Not Lost in the Translation

My French is rudimentary, my Creole is worse. I recognized that much of our success in dealing with the patients and staff at Sacre Coeur was due to an incredibly committed and available group of Creole translators. When I asked why their English was so good, the answer was always, “Oh I spent some time in the States.” But there is more to that story.

CRUDEM board member Dr. Bill Guyol forwarded a link from the Miami Herald.

http://www.miamiherald.com/2010/04/24/1595742/in-haiti-skills-of-deportees-from.html.

It tells of these men, most who came to the US as youngsters, were raised by friends and relatives, and in many cases, excelled. But as is common for teenage boys, impulsivity and peer pressure led to some bad decisions with regard to the law. Many of their offenses would have been treated with probation or counseling if they were American. But instead, they were deported to Haiti, endured time in jail, and had little hope. They made their way to Milot, and with it, the opportunity for a new life. Many volunteer their time, hoping at some point to be hired by the hospital, at $15/ day. Even without pay, they are available 24 / 7. My night as charge nurse in the ICU would have been impossible without them. They go beyond just the hospital – if we wished to walk to town, they would come along on their own time and translate or negotiate for us – we would buy them lunch and compensate them. They were appreciative. They never looked back or complained about their past. They were grateful for a second, or third chance, and realized that this service was vital to their countrymen.

I admire people who have excelled despite difficult circumstances. The most remarkable say little about their journey, and are able to find strength both within and outside of themselves. I often wonder if we as Americans are too eager to blame our pasts or others for our present situations. We have so much, yet focus on what we don’t have. This is not to say that it is selfish to aspire to a goal, as it is that hope for the future that keeps the fire burning in our bellies. But even as our translators clearly felt loss on being deported, they refocused, found their core and achieved a different level of fulfillment. With that came the ability to reenergize and move forward to find the important parts of their past. I am trying to learn from them. On my next trip to Milot, in a quiet moment, I’d like to ask if they now felt able to bring back those vital pieces of their past, while leaving the bitterness behind. I’ll bet the answer will be a smile and a nod.

And I won't need a translation for that.

From Milot to San Francisco

Today’s thoughts don’t involve a discussion of Haiti. However, as I look back over the last 2 months’ postings since I first left for Milot, there is a clear theme of findings one’s core, and experiencing life from different perspectives. From the feedback of others, I realize we are all on various journeys of self discovery, at different rates, and dictated by our circumstances. So it was with this past weekend’s trip to one of my favorite cities, San Francisco. The plan was to see Adam and Sarah, visit with my Uncle Dick and Aunt Jackie, as well as run in the Bay to Breakers.

Some of you know that I’ve been on a Sabbatical this past year, and have taken advantage of the time to further my education, travel a bit, and explore new directions as my children have grown and career opportunities are evolving. There is both uncertainty and excitement, so in many ways, the chance to watch Adam navigate his transition as I experience mine is somewhat symbolic. It is also a wonderful perspective to spend time with my Uncle, the only one of my father’s siblings that left the Midwest to head to California in the 50’s. After a PhD and stint in academics at Berkley, he moved to real estate, was a single Dad to 2 daughters, and established a thriving practice in the Bay area. He’s still selling houses in his 80’s, has an extensive network of colleagues, a wonderful wife, and an optimistic attitude that’s infectious. He encouraged me to come to California after medical school and on numerous occasions subsequently – for a variety of reasons I haven’t. Yet both of my boys headed West with their girlfriends after college - Ben to Los Angeles and Adam to San Francisco. They didn’t have jobs, but they had dreams, support, and the enthusiasm to take the risk and follow their passions. So far it’s working. Their hours are similar to my residency, the pay is also low, and there are moments of doubt, but you can see it all coming together. And I admit that I enjoy living vicariously through them.

While we try to plan for the future, it’s vital to experience the now – you never know when circumstances will change. I’ve always enjoyed the open and someone outrageous attitudes of Northern California. The Bay to Breakers is an embodiment of that spirit. Originally created in 1902 to help citizens celebrate and recover from the earthquake, it is now in its 99th running. There are the elite athletes, of course, they would be close to being finished by the time I made it over the start line and past the second mile. But the great majority were people out to enjoy each other’s company, the beautiful city, and to have the chance to let their hair down. For you New Englanders, here’s a group of running lobsters. I also loved seeing families out together. I am not enclosing pictures any of our Bare to Breakers runners – there were plenty – everyone smiling and living the credo of being comfortable in one’s skin. I was alone, Adam and Sarah dropped me off and went back to sleep (it was Sunday morning at 7am). I met a group from the Chicago area and we started off the race together. The pace was fairly slow which was great for pictures and sightseeing. Cresting the Hayes Street Hill at 2.5 miles, the crowds spilled over and our pace quickened as we headed into Golden Gate Park, smelling the flowers from the gardens, and rounding a curve to the waterfall. The wind picked up and you could hear and feel the ocean. Just beyond the windmill was the Pacific. A left turn and suddenly the finish was in sight. I wasn’t tired, and looking at my watch, was amazed at how my time was faster than usual, without trying. I realized I was truly in the moment.

Yet my most memorable moment was earlier in the weekend. Sarah, Adam, and I had gone out for dinner Saturday night. Although they now live in Oakland, when they first moved out, they stayed with my Uncle and Aunt in SF, about 6 blocks from the marina. We were staying there again that night. After dessert, we were down by the water. Adam asked if I could drop them off so they could sit by the Bay, and then walk back up to the apartment. It seems that when they first came out, with no jobs, and only dreams, they would walk down to the water, sit, and talk. They hadn’t had that chance to do that in a while.

And as I watched my son take his girlfriend’s hand and disappear into the darkness toward the foghorns, I once again simultaneously felt joy and sadness, hope and pride.

Fear and Loathing in Health Care

“There’s no need to fear – Underdog is here!”

Before I started my surgery internship in 1982, a resident told me to read 3 books: House of God, by Sam Shem, a semifictional account of his first year as a medicine resident at a Boston teaching hospital; The Right Stuff, Tom Wolfe’s portrayal of the test pilots who would subsequently become the Mercury 7 astronauts; and Hunter Thompson’s drug fueled, gonzo journalism missive Fear and Loathing in Las Vegas. My resident wanted me to understand the culture that I was about to immerse myself in – one of high energy, hard work, the need for confidence, living a bit on the edge, and the recognition that all this would be scary.

In House of God, the protagonist learns how to keep his patients alive and avoid being chastised, deals with his fear that he’ll hurt someone, loses his idealism, has a few memorable adventures in the call room, and subsequently changes specialties to psychiatry. The test pilots in the 50’s and 60’s had tremendous skill and bravado, and recognized that they could well be killed doing their job. But they were the best of the best. Their fear was covered by the attitude that if someone augered in – it was because they didn’t have enough of “The Right Stuff.” But when you got inside their heads, not only was there drive to succeed, but also fear and doubt. Alan Shepard was heard muttering “God, please don’t let me screw this one up,” prior to the first Mercury launch. Such studied confidence is vital in any high risk profession, and for those that combine that with skill and realistic insight, the results can be spectacular. The late Hunter Thompson was the National Affairs editor for Rolling Stone. His books involve completely immersing yourself in an experience, usually while under the influence of numerous drugs. He traveled to Las Vegas to cover a convention of District Attorneys dealing with the “The fear and loathing caused by the drug problem in America.” The combination of polarized attitudes, in the backdrop of a Las Vegas, leads to an interesting study of pushing limits.

Fear, even if we don’t recognize it, pervades health care. Patients are afraid – they cede control to others and are uncertain of their future. They may not openly acknowledge it, until something triggers it (see blog “Self Determination.”) As a provider, before I went to Haiti, I was asked if I was afraid of the violence or if I could handle the extent of the disaster. Perhaps because I am older, and my children are grown, I didn’t fear as much for my own safety. I’ve also shared with you that by working with other remarkable volunteers, we were able to deal with whatever we saw.

The adversarial nature of our tort system creates anxiety and fear, and impacts on the patient /physician relationship. Politically, as the health care reform debate played out, both sides used fear to influence their support base. “Death panels” vied with “Losing my insurance because I have cancer.” Because fear is a basic human emotion, just like joy and passion, it can powerfully influence behavior. How we chose to handle fear can define how we live our lives.

We all deal with fear differently. Some become overly arrogant, never admitting to a second thought, and subsequently forging forward to a disaster. Others are paralyzed by fear, and do not take any chances, achieving and experiencing little. Perhaps the best tactic is to recognize that the fear you feel is a sign to be a bit more aware, a bit more prepared, and a bit more willing to reach out for advice, enlightenment, and support. When you are able to integrate fear, both your own and others, into the overall experience, and balance it with planning, confidence, and a little bit of faith, the rewards outweigh the risks.

…or you can call Underdog.

Joy

We laughed in Haiti…a lot.

It didn’t really hit me, until today, when a journalist asked me if all the suffering and injuries were upsetting to me. It was in the context of a report on the experiences of Brown faculty, students, and staff that have worked in Haiti both before and after the earthquake. I tried to recall how I dealt with the extent of what I saw. As a surgeon, I’ve learned to compartmentalize my emotions, (this blog none withstanding). But for many of the others, I realized that they hadn’t been exposed to this sights, sounds, and smells. Yet when I looked back at the pictures, and think of the people with whom I worked, I didn’t see sadness or pain, I saw joy.

Joy is not the headiness of first love, or the feeling of accomplishment when completing a task. Joy is the recognition that you are in the moment, experiencing the world around you, and finding that it resonates with your core. And laughter can be an expression of joy, even when the situation seems difficult. The children were injured, certainly, but their smiles and their eyes took away any doubt we had that we could do what we needed to. We could have been upset by some of the working conditions, until we laughed every day at the room 3 gecko report, our friend by the air conditioner enforcing the “no fly” zone near the operative site. We laughed when asked what was for dinner- “tonight something new – rice and beans, unlike last night’s beans and rice…” We dressed up the pet goat in scrubs, and took him to the tents to make rounds - you could hear the laughter back at the compound.

How do we still find joy, when back “in the world” and dealing with the complexities of work, family and relationships? It is easy to focus on what we may not have, or jobs that have been eliminated. But if we allow ourselves to ruminate, we lose opportunities at joy in the present and hope for the future. And it doesn’t have to be some major humanitarian effort to find it.

This weekend, I am going to California to see my middle son and his girlfriend, as well as my Uncle. The other reason is to participate in one of the most unique happenings of May – the Bay to Breakers Run. You nonrunners out there already think we’re a bit crazy, but imagine 40,000 people out for a seven mile jog from the San Francisco Bay, across the city, through Golden Gate Park, finishing at the beach on the Pacific. Oh, and many will be in costume, some will be naked (the Bare to Breakers – not sure where you pin the number), others will rope themselves together as human centipedes, and a separate group will dress as salmon, start at the finish and run upstream, against the crowd, to spawn at the start line. Why – it’s pure joy – no reason, no redeeming social value, just a group of people sharing the energy of the moment.

And at some point during that run, I’ll be laughing, and expect it will feel a lot like Milot.

Passion

We all know people who bring great energy to their work, their relationships, and their daily existence. They move forward in the face of adversity, and draw others in to follow them. When we feel passionate about a cause, we work to share that emotion. Ideally, we are able to follow our passions or reawaken those that are dormant. In my work in Haiti I was able to recapture the passion of practicing the core of medicine. Since my return, I have felt some loss and emptiness.

In many ways this is appropriate. “Passion” has as its root, “pathos” or the sense of feeling of pity or sorrow. In the classic definition (I did learn something from the nuns in Milot) “passion” is the suffering of a martyr like Jesus. This feeling can subsequently be expressed in artistic works. When we are feeling passion, we are really feeling strength and energy that magnifies an emotion.

People know I am passionate about flying and patient safety. Most recently, I had the privilege of meeting with the second year medical students prior to them starting their clinical rotation. I’ve done this every year, discussing lessons from aviation as applied to medicine. It is both fun and serious. I could see them becoming engaged in the process of recognizing where errors occur and what they could learn to be better and safer doctors. I felt that good tired at the end. Still I wondered if despite my energy and passion, any of it would stick.

Afterward, as I was getting a sandwich, I overheard one of the second years talking about the session to a fourth year who was there to orient them. “Oh yeah,” the senior said. “Maintain situational awareness.”

Passion trumps textbooks every time.

Goal Congruence, Incentives, and the Need to Blog

It's been 4 weeks since returning from Haiti. As I take my last chloroquine tablet to prevent malaria, I am in Boston for my weekend with my classmates at the School of Public Health Masters Program in Health Care Management. Here I am surrounded by brilliant people and many of the world's greatest and most sophisticated hospitals. We just had our final session on organizational control and management, with an exam focusing on aligning mission, goals and incentives in complex systems. It is a tremendous difference from last month, when my concerns were antibiotic dosages, mosquitoes, and providing basic medical care. Yet the concepts for a simple hospital in Haiti are similar. If we are to provided care for each other, how do we do it within the constraints of our resources? I would venture to say, that on a dollar for dollar basis, the impact on health by expenditures is far greater in Milot.

I have learned that more is not always better, and that in many cases we create incentives that inhibit, rather than encourage us to meet our mission. As we anticipate providing more coverage and expending more of our GNP, we must assure that the improvement in health and function is commensurate. The WSJ discussed a new immunotherapy for prostate cancer that will cost $90,000 for 3 doses. There is a statistically significant increase in survival of several months. If it's you, and you're not paying for it, why not use the therapy? But on a broader societal basis, is this appropriate? We need to take a hard look at what the goals are, and make sure that how we support and incent those behaviors is congruent with those goals.

So after 4 weeks back, what goals am I trying to reach, and why do I continue to post new blogs? I acknowledge that I do not have fresh stories from Haiti to tell, and appreciate that there are still some of you out there reading my thoughts. We all write for different reasons. As I continue to integrate these experiences and make decisions about the future, sharing these observations with you gives me some clarity and I hope gives you some new perspectives. I know that I have been touched by your own comments in Facebook and other venues about your lives. By writing our thoughts down to share with others, we each gain new understanding of the world around us.

And in the end, it is that feeling of the human connection, even if via a blinking cursor, that makes our lives richer.