Point Yourself into the Wind

Last week, I wrote about the Goldsmith and the analogy to human struggle. That truly resonated with me. But reflecting on it, I remembered an early lesson from my flight instructor that had a similar message.

While taxiing to the runway, one one of my first flights, he told me, “Make sure you always face into the wind when taking off.” I look at life in the same way: the challenges and difficulties that we face in life are what lift us up high into the sky.

Why the Goldsmith Stokes the Flames

There is a historical element that, in combination with metallurgy and materials sciences, gives rise to the age-old practices of goldsmiths. Why is it that goldsmiths take precious metals and place them into the hot, dirty coals?

The goldsmith might retort, “I use the heat of the flames to purify the gold – to turn an imperfect piece into the most precious metal.”

Perhaps the glowing blaze of the forge, the rising embers from the ashes, the swirling heat that distorts our vision, represents far more. Perhaps the goldsmith’s retort is the answer to the primordial question, “Why do we struggle?” It is the flames of the coals that purifies the gold. Likewise, it is struggle and hardship that purifies the human soul.

Two Types of Love

There are two types of love.

One that makes you enjoy the fact that you’re in love. It’s the one everyone knows about, the one that you look forward to.

The other is much heavier. It makes you feel sad that you love. It’s one of responsibility. A love that makes you go out of your way to care for someone. One that makes your life difficult but only because you want theirs to be easier.

In English we don’t have too many ways of expressing this dichotomy, though we find ways around it. Does this affect the way we think, as proposed by Sapir and Whorf?

Perhaps.

The Tree of 40 Fruit

This is a project I heard about years ago and fascinated me. It was not only a piece of artwork, but also a living example of the beauty of biodiversity.

I remember my elementary school having a tree drive where families could pick up fruit tree saplings and plant at home. We went there and brought home three apple saplings and planted them in our backyard. Over the years I would watch them grow from my window on the second floor, watching them slowly grow taller and taller.

While I was a bit sad that they blocked the prime sledding tracks on our little hill, I later learned to love these trees as a part of our home. When they finally started blooming and growing fruit, we quickly realized that these trees were in desperate need of pollination.

Those were the years where the sudden collapse of beehives was propagating like wildfire through the news. It was then that I recognized the central duality of nature — that of its frailty and its resilience.

Hilarious Improvisation at TED

I recently came across this TED Talk in my YouTube subscriptions. I’ve always enjoyed improv, especially since the cafe nights in my time at Mass Academy – shoutout to Freitas and the SJ Improv club!

It’s a bit of inside joke about the style of TED Talks, but it’s nonetheless humorous for those outside as well!

Statistics Have Biases Too

Today I noticed that Glassdoor recently published their annual top-earners report. Immediately, headlines were all over the place describing that physicians are once again the highest-paid professionals in the United States. However, I think that the claim is slightly misleading, especially given the exponential increase in stratification in today’s society. While physicians are still paid well, there are disparities that hide in the data and underlie important social aspects that touch the lives of all Americans.

The first misconception arises from how people identify their careers. Almost every doctor in every specialty identifies as a “physician.” A cardiothoracic surgeon, in these surveys would likely qualify as a physician. If you were to ask them in person, however, they would likely first say “surgeon.” Professionals in other fields often don’t have the same level of unity in titles. IT professionals, for example, have multiple titles for essentially the same job: software engineer, process development engineer, development manager, etc. While there are certainly some nuances between these, they are no different than the nuances between, say, a neurologist and a neurosurgeon.

Professionals of other fields are often much higher paid than physicians, yet because there is no unifying title that dominates, the statistics fall short of the truth simply due to our categorical nature. As such I think it’s worth surfacing these issues in discussions about top-earners. At least, then we’re inching closer to the truth.

Dossier

“The Highest Paying Jobs in 2019,” by Glassdoor, September 17, 2019. https://www.glassdoor.com/research/jobs-companies-2019/ . This is an annually compiled list of the 25 highest paying jobs and companies, with some additional insight about their respective industries.

Intention vs. Perception in Linguistics

Weirdly enough, I spend a lot of time thinking about linguistics.

Because the way we use language to communicate ideas is critical to understanding the way our cultures have evolved, a lot of studies have examined it in great depth. While such a macroscopic viewpoint can be useful for studying change on a global level, it rarely manifests meaningfully in the day to day interactions that define the human experience.

Instead, I’ve realized that the minutiae we use to subtly inject meaning into words and phrases has a profound impact at that individual level.However, even that analysis is slightly flawed. Rather, I argue that we should study these minutiae from the influence that they have on the way our messages are perceived. This shift in analysis forces us to communicate with a more rhetorical approach.

By definition, a rhetorical approach requires careful understanding of the relationships that define that communication. This emphasis on audience manifests itself everywhere, whether interpersonal as is on the level of normal conversations, or analytical as is through these essays.

Some of the factors include tone, word choice, inflection, emphasis, etc. And even the slightest change can radically alter its perception, regardless of the intended meaning. During conversation, we have the luxury of immediate feedback from the listener. Thus the act of responsiveness is facilitated. I reason that a more intricate understanding of a conversational mode of communication will therefore apply primarily towards speech. And yet with the advent of textual communications on that conversational plane, such as texting, messaging, etc. people have found workarounds that allow them to inject the same level of meaning into the text.

This becomes fraught with misinterpretation, hence my emphasis on perception.

At Long Last: End of Life Care for Dementia Patients

Advances in medical technology have resulted in substantial gains in life expectancy, especially in developed nations (Roser 2016). However, the healthcare system in the United States is not effectively prepared to handle the massive influx of patients with age related cognitive deterioration and their goals to live comfortably at home and be free of pain. Not only does the current healthcare system stress quantity rather than quality of care, but it also is heavily biased towards acute medical intervention and short term increase in life instead of comforting patients and relieving their pain (Meier 2015). Doctors and hospitals are incentivized to provide more treatment, even if it is less beneficial to patients. However, patients with terminal illnesses do not want aggressive treatment to prolong life, but rather to enjoy their remaining time in comfort (Delude 2015). These issues become more evident in the context of dementia and its underlying diseases, such as Alzheimer’s, which are currently incurable despite the considerable improvements in medical technology and treatment.

Alzheimer’s disease, a progressive neurological disorder that afflicts about five million Americans today, affects the entire body (Mitchell et al. 2012), leaving patients incapacitated and bedridden. Patients gradually lose track of where they are, what is happening, how to dress themselves, who their family is, finally becoming immobile, incontinent, incoherent, and catatonic. As a result, an Alzheimer’s diagnosis is extremely emotionally distressing because it constitutes a loss of identity and of personhood. However, the long trajectory of cognitive decline means that many patients who are diagnosed with Alzheimer’s disease will likely continue to survive for many years, and sometimes even decades (Delude 2015).

When asked, three out of four people say they would prefer to die at home, receiving comfort care only and with no intrusive interventions. Yet most people fail to discuss end-of-life wishes with their families, and only one in four actually prepares advance directives. So when the end nears, most families don’t know what their loved ones would want. Meanwhile, doctors are trained to defeat death, not allow it to happen. In addition, the current payment system creates perverse incentives for sending dying patients to hospitals, where the default mode is acute care. As a result, many people receive unwanted and expensive end-of-life treatments that exacerbate, rather than alleviate, pain and suffering (Delude 2015).

The purpose of the healthcare system should be to best use medical technology to help patients with dementia achieve their goals of comfortable, at home care that provides relief from pain. End of life care is supposed to be supportive and less intrusive in nature. Though dementia is terminal illness, the process of eventual death takes an exceedingly long time. Consequently, patients are more likely to pass away due to the clinical complications from interventional care and being bedridden rather than from the disease itself. In contrast, hospice is a more effective form of treatment because it provides a refuge from unwanted end of life interventions. In hospice care, patients forgo curative treatments but receive care focused on comfort, managing symptoms, relieving pain, emotional support, and enhancing the quality of the time they have left (Delude 2015).

Though hospice seems ideally suited to providing the type of care that advanced Alzheimer’s patients need, it can be a challenge to be admitted. A physician must certify that death will come within six months, a requirement that stems from the early days of hospice when it was primarily designed for cancer patients. However, it is significantly more difficult to predict with reasonable accuracy when a patient with dementia will likely die than it is for a patient with cancer, a disease that has a relatively well understood trajectory towards death. “Alzheimer’s prognosis is so variable that most people who need hospice care won’t get it because it’s not clear they are dying until the last week of life,” says Diane Meier, a geriatrician at Mount Sinai Hospital in New York City. In addition, patients are also required to show ongoing decline in order to continue to receive hospice care. Patients who live longer than six months must reapply; those who stabilize and stop getting worse are no longer eligible for hospice. Ironically, hospice patients often do improve, because palliative care alleviates medical problems caused by the side effects of intrusive medical interventions. By providing loving and meticulous care, patients lives are extended and, in a cruel paradox, their eligibility for hospice is jeopardized (Meier 2015).

The hospice Medicare benefit was set up in 1980s for terminally ill patients. As a result, Medicare considers hospice only as a short term solution and has implemented a cumulative benefit cap per patient. The inherent problem with financing hospice care for dementia patients specifically is that their “end of life” care often lasts far longer than the six month period that Medicare will reimburse. The majority of expenses are taken up only in the beginning of care, when the patient is first admitted, and at the end, when the patient is dying. In between, however, daily expenses are typically lower. Despite the expense curve, hospice benefits are paid out at a constant rate, which eats into the benefit cap. Consequently, hospices must discharge long term patients once the benefit cap is reached. This ineffective administration of funds severely limits the care that patients wish to receive. Many patients who outlive their prognoses and would have benefited from continued palliative care provided by hospice services are forced to resort to invasive hospitalizations and aggressive medical treatments as families struggle to pay for or provide comfortable, at home care consistent with the goals of patients (Meier 2015).

Unfortunately, the current healthcare system does not offer a clear way to continue to care for patients who have been discharged from hospice (Delude 2015). In order to make palliative care more accessible to the ballooning aging population, the hospice Medicare benefits program must be revised such that benefits payments are not paid at a constant rate. Rather, benefits should be reduced during the period when the patient is in stable condition and hospice expenses are lower. This allows patients to remain longer in hospice care and in the comfort of their own homes.

As clinicians become more reliant on the technical aspects of care, less attention is given on supporting patient and their families. Adjusting doctor training protocols and reimagining the home as a place of medical treatment are key aspects in changing the healthcare system for the better. It is imperative that doctors in medical school be trained to take the time necessary to explore the goals and values of patients and best utilize their expertise and medical technology to help patients achieve their goals. The medical system is primarily built around hospitals and clinics and the payment system mirrors that. Though a growing number of hospitals now provide palliative-only care to dementia patients, most who need that care are not actually in hospitals, but rather in their own homes, nursing homes, and retirement communities (Meier 2015). Because reimbursements are predominantly given to hospitals and clinics, most doctors do not have any financial incentives to provide at home care. Reaching these patients will require new federal policies that include the home as an effective location of health care and reward doctors for meeting patient needs where needed (Delude 2015).

References

Advanced Dementia: State of the Art and Priorities for the Next Decade,” by Susan L. Mitchell et al., Annals of Internal Medicine, January 3, 2012.

A National Study of Live Discharges from Hospice,” by Joan M. Teno et al., Journal of Palliative Medicine, August 7, 2014.

Fixing Medicare’s Hospice Problem,” by Cathryn Delude, Proto Magazine, January 28, 2015.

Long Last Moments,” by Cathryn Delude, Proto Magazine, January 28, 2015.

Troubled Passage,” by Diane Meier, Proto Magazine, February 15, 2015.

Alzheimer’s Disease and Dementia Are Different,” by Angela Lunde, Mayo Clinic Expert Blogs, September 27, 2007.

Alzheimer’s and Dementia,” no author listed, Alzheimer’s Association, nd.

What is the Difference Between Alzheimer’s and Dementia?,” no author listed, Alzheimers.net, nd.

Medicare Hospice Benefits,” no author listed, Medicare.gov, nd.

Life Expectancy,” by Max Roser, Our World in Data, 2016.

Important Terms and Definitions:

  • Dementia: a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning.
  • Alzheimer’s Disease: a progressive mental deterioration that can occur in middle or old age, due to generalized degeneration of the brain.
  • Palliative Care: care designed to relieve pain or alleviate a problem without dealing with the underlying cause so patients remain in comfort.
  • Hospice: a home providing palliative care for the sick, especially the terminally ill.
  • Medicare: the federal health insurance program for individuals who are 65 years or older.

Aviation Checklists in the Operating Room

Imagine you’re a physician walking through the halls of your hospital. You come across a nurse ordering pizza for her colleagues over the phone. Just as she’s about to hang up and put the phone down, she hears something and raises the handset back up to her ears, just catching the person on the other end reading back her order to make sure it’s correct. Two days later, walking down the same aisle, you see the nurse on the phone receiving medication orders from your colleague. She writes down the order and at the end, she says, “Alright, doc. I’ll get that done.” and hangs up the phone to finish her work.

While this situation seems absurd, John Nance, the author of Why Hospitals Should Fly, recounts this exact exchange in his interview with Proto Magazine. As a pilot since the 1960s, flying for the Air Force and for commercial airlines, his work in connecting the disciplines of aviation and medicine were instrumental in paving the way for Gawande to write his own book, The Checklist Manifesto. While Nance’s work attempts to convince hospital administrators, Gawande takes a different approach in order to help those actually in the medical field to recognize their own humanity.

Physicians, and particularly surgeons, often think of themselves as the infallible commanders of the medical world. The “Miracle on the Hudson” is an excellent case study in team dynamics, and Gawande contrasts how aviators and surgeons deal with unexpected problems. Captain Sullenberger and First Officer Skiles had never worked together prior to that fateful flight. Yet, in the face of a dire situation, they were able to work as a seamless team to address every issue that arose. That seamlessness was no coincidence. Before every flight, the pilots brief each other as to what their specific roles are: who is the pilot in command, who will handle radio communication, etc. The checklist that they followed to ensure that everything was taken care of before the start of the flight was instrumental in the successful outcome of the flight, despite the flock of geese that knocked out both of their engines.

One of the key takeaways can be beautifully summarized by this, “The fear people have about the idea of adherence to protocol is rigidity. They imagine mindless automatons, heads down in a checklist, incapable of looking out their windshield and coping with the real world in front of them. But what you find, when a checklist is well made, is exactly the opposite. The checklist gets the dumb stuff out of the way, the routines your brain shouldn’t have to occupy itself with… and lets it rise above to focus on the hard stuff.”

Gawande masterfully weaves this thread of “immense complexity” through anecdote after anecdote describing a diverse set of disciplines where checklists have made an impact. Importantly, he doesn’t forget to mention that checklists are simply tools – they can’t replace a surgeon after all.

Gawande opens the first chapter by contrasting the “dry prose of a medical journal article” with the miracle it describes. Immediately, he builds credibility by reassuring the reader that this book isn’t that. Rather, it shows exactly how he approaches the rest of the book. His linguistic style shows no signs of purple prose. Rather, he seems approachable and conversational in tone. It seems like he’s talking directly to you and just telling a story.

Gawande’s argument that the point of checklists is to help reduce cognitive strain resonates with me. Whenever someone asks how hard it is to fly a plane, I respond by saying that flying the plane is the easiest part of being a pilot. The hard part comes actually from doing all of the other things that the pilot needs to do, while flying the plane.

I remember one particular flight with my instructor that I think readily  illustrates the value of a checklist. My instructor asked me what I would do should the radios fail in mid flight. Immediately I begin to go through all of the possible modes of failure of the onboard radios in mind. I begin to panic. What would I do if the radios failed? The obvious thing to do, I say, is to check if we’re transmitting and receiving on the correct frequency. It could have somehow been changed accidentally. He says that it looks good – nothing amiss there. I ask if there are any other electrical issues; are other instruments behaving strangely? No, he replies, just the radios. I tell him that I would reset the electrical system anyway just to make sure. I think to myself, is anything wrong with the antenna? Did it shear off as a result of high winds or a rock during our takeoff roll? Not likely; we probably would have noticed earlier if that was the problem. I move on to explaining that we should squawk 7600 on our transponder to let air traffic control know that we have radio issues and have lost communication. I glance down at the paper below me, frantically looking for the light gun signals. That’s how the tower can communicate to aircraft without two-way radios. But no one bothers learning these anymore, not when modern electronics have become so reliable. I don’t find them, and so I sheepishly tell my instructor that I’ve forgotten what the light gun signals mean. He laughs it off and asks me, “Did you check if you’re headset is still plugged in? It might have come loose from the turbulence and bumpy ride we had earlier!”

That’s what a checklist is for. It’s so that we don’t overlook the stupid little things like checking if our headset has become unplugged from the intercoms. It’s so that we can focus on flying the plane. When you learn to be a pilot, you’re not learning how to fly a plane. Rather, you’re learning how to deal with the plane when things go completely wrong — and things do go wrong. Likewise, surgery itself isn’t too difficult. However, the training of a surgeon is to know how to deal with everything when it goes wrong.

Most people don’t realize just how easy it is to actually get lost. I was flying back towards Mansfield after a cross country flight to Keene, New Hampshire. Before I left, I noted that a Temporary Flight Restriction would be in effect surrounding Gillette Stadium around the time I would be flying back. I called ATC to ask them if the TFR was currently active, and after a brief pause to double check, they let me know that it was indeed active. In order to avoid the airspace, I flew a couple miles further south than the direct path, not even that far, but just enough to skirt around the edge. That little change completely threw off my sense of direction. I now had no idea what I was looking at and I couldn’t see where the airport was. I had a GPS, so I wasn’t too nervous, but in that moment I realized that without my tools, I would have no idea where I was. I searched outside to see if I could spot 290 snaking its way around. After a few minutes of flying straight ahead and double checking with the GPS, I finally found it. I knew that if I continued following the highway southwest, I would eventually come up to the airport, which just happens to be right off the highway and next to a lake on the other side. Airports tend to look like large clearings in the normally wooded landscape of Massachusetts.

As a pilot, being able to see the value of checklists firsthand is an invaluable convincer to support the use of checklists wherever possible.

While the overt premise of the book appears to be exalting the value of the checklist through anecdote after anecdote, the true reason that this book succeeds is through the masterful use of the connecting thread that ties those anecdotes together and shows how so many diverse disciplines, all with the commonality of immense complexity can greatly benefit from a well designed checklist. Gawande’s poignant reminders serve to show that surgeons, although in a role apt to believe in their infallibility, can also make mistakes and likewise benefit from a checklist to help guide them.

The Social Nature of Humanity

We all get hit with a bout of nostalgia every now and then as we remember and reminisce at the halcyon days of yore. Yet as human beings, I don’t think that our nature can allow us to ponder these things for long without thinking forward at what is to come. Obviously, we are finite creatures and will one day perish, not only as individuals, but also as a part of the collective identity of humanity. It is indeed a disturbing thought, however we must realize the beauty in the ephemeral. The fact that things wilt and weather makes them all the more precious.

As much as I love delving deep into philosophical discussion, it’s just as important to consider the implications of what goes on at the surface of human life. We are by nature social creatures and crave contact with others. Coupled with the fact that we love being in the company of others who share our opinions, the rise of social media was inevitable. It allows us to connect with an immense number of people who are just like us. These groups are commonly referred to as “echo chambers,” where our opinions, whether correct or not, are amplified. These are essential for advertisers looking to make a meaningful impact, but are even more useful when spreading ideologies. Politicians and news organizations constantly tap into social media to influence the beliefs of people all over the country. What I think is particularly dangerous about this is the degree to which social media has infiltrated the opinions of uneducated people. It is essential to the function of the country that we elect competent politicians. When poorly educated and highly opinionated people are responsible, the results cannot be good. When one company is able to use its algorithms to control the influx of news to the population, when they show more conservative news to right wing voters and more liberal news to left wing voters, the echoes are further amplified. Today’s political scene is the most partisan since World War I started in the early twentieth century. Rather than spreading people apart, it is our duty to bring them together, to unify the public into one cohesive America.

I recently read Eugene Wei’s excellent (although I may say, quite lengthy) post about the fundamental nature of humans — that of status seeking monkeys. His theory of why people use social media is really able to explain why some networks succeed while others don’t, and why the demographics of each are the way that they are.

Dossier

“Status as a Service (StaaS),” by Eugene Wei, February 19, 2019. https://www.eugenewei.com/blog/201—9/2/19/status-as-a-serviceThis lengthy blog post goes in depth into the rise of social media and how it adapts to our fundamental being as “status seeking monkeys.”