A selfless rhythm

I remember there were times during football games in high school where I seemed to function independent of conscious thought.  My body was in rhythm with it's environment and acted without restraint.  I had the the perfect economy of motion.  I was invincible.  (You may cite my several concussions as a counterargument to my claims of invincibility, but my response would be that I have no recollection of these purported concussive events.  No really, I don't remember them at all.)

Oddly enough, I was reminded of this economy of motion at the VA hospital the other day.  To briefly acquaint you with the Vets, they are a wonderful group of guys (mainly guys anyway) who performed a remarkable service for the rest of us and are now suffering the mental and physical consequences of their efforts.  Diabetes, heart disease, obesity, hypertension, depression and numerous other ailments run rampant throughout the system.  Despite the seriousness of their disease states, the Vets are oddly robust.  They seem able to survive an acute decompensation of their physical status much better than most of the rest of us could. And when I ask a Vet what type of medical problems he has, the majority of the time he will respond with "none".  True, certain diseases in this group are so common they almost seem like they are not diseases at all (if everyone had diabetes, would we have a name for it?), but they appear truly unaware that anything could be wrong.  Or maybe they are ware but just don't care, brushing me off with "do what ya gotta do doc."

It makes me wonder if they have a certain economy of motion to their lives.  Having experienced an intensity that is not replicable, life now simply comes to them.  They move through it with a rhythm that lacks self-awareness.  Life comes and goes and they accept and release it.  The question that follows is, does this lack of self-consciousness effort strengthen an individual?  Is a lack of a self-concept and thus a fear of loss of that self, the key to prolonging life?

Death panels for pundits, mortality navigators for the rest of us.

Death and disease are commonplace for most physicians.  The tubes and wires and beeps and machines are familiar to us.  We know their function and, more importantly, we know their meaning.  We speak in statistics and are comfortable making life and death decisions based on "chance".

As non-pysicians, you are not comfortable with any of it.  Tubes and wires and beeps and machines are added complexities to an already too deep unknown, mortality.  You don't know their function nor their meaning (even if you do, you really don't just like I "know" the function of a carburetor but have never had my hands on one).  They are symbols to you.  A ventilator means life when death is eminent.  The identity of your love one merges with this symbol of life-sustaining medicine.  This places you are in an inadequate position to make death decisions: the medicine is no longer external but instead an intimate part of who your loved one now is.  But we make you do it anyway.  We make you decide on chance.  And, consciously or unconsciously, a piece of us resents you when you make the "wrong" decision.

We also make the wrong decisions.  Sometimes from the perspective of hardened practitioners who seen innumerable loved ones die and expect to see innumerable more.  Sometimes it's from the perspective of scared individuals who see their own mortality in you or your loved one.  And sometimes it's from the perspective of people hopped up on adrenaline and unskilled in the art of inaction, like a soldier in the heat of battle incapable of lowering his weapon. 

The point is, individuals - patients and physicians alike - are not equipped to decide on death.  You can't do it when a piece of you dies with your loved one.  We can't do it when a piece of us dies with them either.  Nor can we when that piece of us stops dying with them.

Decisions of futility need to be made at a policy level.  We need to take it out of the hands of the individual.  We need to free up the family to be the family and not the caretaker/decision-maker.  And we need to free up the physician to be the physician and not the perceived hand of God.  I don't suggest we make a death policy on all illnesses, only the most extreme, the ones where mortality is all but given and futility is obvious.  The institution of medicine needs to start navigating patients and family through the maze of morbidity and mortality and not simply construct definitions which they are expected to piece together themselves.

Complexity as a disease

I was thinking about chaos today.  Chaos theory, complexity theory, emergence theory, all that shit amounts to patterns within chaos (at least it does to those of us with brains incapable of accurate mathematics).  Things as we see them are not the sum of their parts.  I am not the sum of atoms and electrons and molecules and proteins and cells and organs and whatever.  I as an entity emerge from those things.

Complex entities have two important properties.  First, they are robust: they can handle a lot of shit (like the crazed, Kali wielding Scotsman of "Cats in a Sack") without apparent dysfunction.  The second property is called the tipping point: the complex system that hides the dysfunction from our eyes/ears/nose/throat/touch becomes saturated.  The dysfunction then becomes immediately apparent.

The key is things as we see them.  There is a lot of ego tied up in concepts of chaos.  I can't comprehend it, so it must be chaotic.  This of course is not the case.  The pattern is there from the beginning.  Our inability to perceive it is a function of our dysfunction: we lack the capability.  Chaos is inherent in us.  It is not external.  

The opposite is true as well.  Coherence is internal.  Patterns don't exist outside our consciousness.  Chaos and coherence are labels like dog, cat, human.  This makes it interesting.  Coherence is in our heads, but lack of coherence is a defect in our heads; it is a limit to our perception and understanding. Following this logic (if you can call it that), we can't figure out our own heads.  My mind labels certain systems as a pattern.  I "can't" label certain systems as a pattern, not because I can't "see" it, but because I can't create it.  This makes us entirely responsible for the coherence of our environment.  I am the master of my own chaos or the lack there of.  

Disease is chaos.  It has a million little pieces that, when confronting it personally and directly, are impossible to grasp.  As physicians, we eliminate the chaos by creating patterns: congestive heart failure, diabetes, arthritis, cancer.  These are all labels and patterns.  And they are created in our minds as physicians.  But the pattern you create as the patient may differ.  Regardless, I direct you through my system of patterns, my coherence.  I make it so you are no longer the master of your own chaos.  

Pity party for my inner hypochondriac

As with all psychopathologies, it is best to place the blame on one's parents.  My father had significant cardiac disease with a heart attack at 38 and 40 and sudden cardiac death at 57.  Since I became a physician, I retrospectively diagnosed him with obstructive sleep apnea, peripheral vascular disease, and metabolic syndrome.  He wasn't on a statin or an aspirin, and he was on an anti-arrythmic that causes sudden death.  In other words, there are six things off the top of my head that could have been done.  (I could have done?  Guilt is our most constant companion.)  Moreover, he ate like shit, smoked, drank too much, and barely got off the couch.  (As an aside, this isn't to berate my dad.  He was a remarkeable man.  He was the most insightful and intelligent person I have ever met and treated me with the utmost love and respect.  He just didn't treat himself with love and respect.)  His disease, although mixed with genetics and bad luck, was mainly due to a lack of action: not taking the proper meds; not exercising; not eating well; not receiving the proper diagnosis; not getting surgery; etc.

So I take action.  I eat (sorta) well; I exercise; and I take a statin and aspirin.  The problem I have is my near obsession with action.  My hypochondria clusters (and they do come in clusters depending on what is occurring in other aspects of my life) are less about the disease process and more about what I have to do about it.  Go to the doctor; make sure s/he does the correct tests; wait it out; not wait it out.  The possibilities are endless.  I start to malfunction because I am convinced there is something that I am not doing.  I often think that it would be easier to live during a time when there was very little we could do with illness (assuming that there was minimal diagnosing; it's worse to have a disease with a name but no treatment).

The problem is, when you look closely at it, there is no "correct" thing to do.  It's all probability.  I am not trying to imply that there is no such thing as preventative medicine.  My grandma lived to 88 as a lifetime smoker, but for everyone like her, I can find 100 smokers that died of a heart attack, emphysema, stroke, or cancer.  Taking control of my eating and exercise simply gives me the illusion that I have control over the possibility of future heart disease.  It certainly puts the odds in my favor, but it is not control.  I have no control over any future disease state.  This is truly an existential dilemma: I have control over what I do now (i.e. not smoke or eat like shit) but have no control over the future (i.e. heart disease or lack of it) despite the fact that I put an enormous amount of thought and meaning into it.

When faced with our mortality, it again comes down to the ability to surrender to the present.  I (we?) need to reposition the meaning and magnitude of our existence within that existence and not in what may be.

Identify with your disease

My guaranteed to read lead in is this: Fuck.

The origin of this lies in the fact that my "Patience" entry is the highest rated.  I am certain that it isn't the quality of the writing but the fact that the word "fuck" reveals itself in the first sentence and has two encores in the first paragraph.  Everybody loves the unnecessarily inappropriate.  I'd love to hear the top ten words that would get you reading (ear muffs everybody: fuck, shit, balls, cock; are you listening Google?).

Now that you've gotten this far, on to identity.  I don't know who the hell or what the hell I am so this will be an oft-treaded topic on this blog. I don't think I'll ever really know who this person who fakes my narrative truly is (there is so much redundancy and feedback in that sentence - I, I, my - I'm getting nauseous; I truly am a strange loop).  I refuse to read The Ugly Duckling to my daughter because I don't want to give her the false impression that we ever figure out who we are.    Maybe that's Buddha and Sartre's point anyway: defining yourself is succumbing to entropy (energy not available for useful work).  If I am what I am, the process is complete.  I am not available for useful work (i.e. the process of becoming).  I am a pinpoint.  I am stagnant.

But that is a topic for another day.  What concerns me here is identity and disease (there is a great book called Human Identity and Bioethics if you’re interested).  My god is the physical process.  I wouldn’t say physics per se because physics is a construct for understanding.  I simply mean that everything as we understand it is an infinitely dissectible set of processes: the unicellular organism driven by physical forces shares work with other organisms forming multicellular organisms that become increasingly more outwardly complex, but still driven by the same basic forces.  We are simple patterns of cause and effect (I don’t actually believe in cause and effect to be honest - blow your mind on this: Backward Causation).  Consciousness, free will, morality, spirituality are all versions of an uninterpretable chaos of physical processes.  I am that zygote in my mom’s uterus (just opened up a shit-can for the pro-lifers).

This means that we could not be anyone or anything other than our diseases.  Whatever the arbitrary classification of disease that my body will eventually degenerate into, that is me.  It is part of the process that is me.  If I were to define myself by the personality that emerges from the chemicals in my brain, I would have to define myself by the disease that shares the same chemicals, cells, and physical causation.  It is the ultimate Catch-22: you couldn’t live without the disease that’ll kill you.

Surrender

I have a friend in the hospital. He is also a physician. When he first arrived, there was significant concern that his symptoms indicated something monstrous (although it continues to be frightening, it is not as bad as they thought). He knew to be scared when he heard the overhead page calling the emergency team to treat his suspected condition. The physician overseeing his care saw his fear and placed a hand on his shoulder. She then said that they will take good care of him. This, he told me, meant the world to him.

As a physician, he knew that to navigate disease is daunting even by experts. Despite the constant push for data and protocol, the art of medicine - action guided by the inarticulable and seemingly imperceptible - is very much alive and well. (The first thing you learn as a physician is "sick" or "not sick" with just a look.) He knew that she had little power to direct his future, but still her words put him at ease.

It is difficult to accept when things are out of your control despite the fact that most everything is. His doctor knew this, so she took control for him. She made it so he did not have to act. He simply had to be (is this true authenticity?). I think, in the end, that is our primary jobs as physicians: to provide opportunities for surrender.

The doctor is ill at ease

When it comes to my mortality, I always think there is something to be done. Go to my doctor, get a test, take a pill.   I mistakenly believe that I have full power over the molecular direction of my body.

Here's what I do with your disease: I take objective measure of it; I evaluate what I may have control over and seize it; and I recognize what I have no control over and surrender to it. This is not to say I don't do everything in my power to help and protect you. What it means is I understand what power I have. I understand when I can't (and shouldn't) intervene.  I am a better doctor because I understand my limitations and the limitations of medical science. I suspect I'd be a "better" person (by better I mean more psychologically at ease) if I took the same approach to my family and myself. My control over my body is limited and there is not way around that.

Patience

How the fuck does one learn patience? (I'm actually not that angry about it. I just like the way the f-bomb implies that I'm impatient about learning to be patient. I love using the word "fuck". It's the Swiss army knife of words: it's a noun, verb, adverb, adjective, preposition, conjunction, everything. In fact, if my entire blog was made up of the word "fuck", it would probably be grammatically correct.). But I digress...

I am not patient. I wish to hell I was. My interaction with our intersubjective world would go a whole lot smoother. (That line reminds me of Matthew McConaughey in Dazed and Confused when, confronted with a freshman not bearing weed, he states "you'd be a whole lot cooler if you did...") When I expect something, time expands. Seconds are minutes. I am patient in relation to my new perspective of time, but certainly not to everyone else's.

At first glance, impatience seems to expose a love for the present. I have no interest in future gratification. The present is king. On further inspection, however, it is the opposite. When I can't wait for something, I am focussing my attention on the future. I am not or have not what I want. The present is in fact distasteful. This also works for those things that we don't look forward to. I'm in Mexico right now and have zero interest in going home tomorrow. The possibility of a future event (there's that damn probability crap getting in the way, affecting my actions despite it not being a real entity) alters my respect for and attention to the present.

Time and the present have obvious and enormous implications in death and disease. Both are inevitable and, as Ernest Becker suggests in his book Denial of Death, the knowledge of this possibility (the probability being 100% on a long enough timeline) constantly affects our self consciousness. The inevitability of my death - which, I would argue, I have infinite patience for (against?) in that I hope to forever avoid it - alters my respect for the present.

Back to the question, though, how the fuck does one learn patience? Seriously. I'm asking you. I have no idea. In fact, I don't have the patience for this fuc...

Probability

I'm having trouble with probability. It seems simple enough: you have a fifty percent chance of getting heads with the flip of a coin. There is a 25% chance of flipping heads twice and so forth. Where I get stuck is that although there is a 25% chance of flipping heads twice, if I flip heads once, on the next flip there's 50% chance of flipping heads on this go around. Mathematically it makes sense and is almost childish in it's simplicity. But the point of probability is not only mathematical prediction, but a way to describe and understand our environment. Unfortunately it goes against the value I place on it. Past probability has no impact in present probability. Although I can predict a 25% chance of heads twice, it has no bearing on the moment of action.

How does this affect me? Let's say that there is a 25% chance of your head exploding if you drink a pint of Jaeger mixed with espresso and hot sauce. This is based on observations of things that occur in the past. Based on this percentage I think, well shit, there's 3/4 of a chance my head won't explode so pour me a drink! Although rationally I know that this bit of "science" carries no protection, irrationally I don't act this way. I use percentages as a protective guide as if these past events shape the present.

The thing that really gets me is what are my chances? My father had a heart attack at 38 and died of heart disease at 57. I eat differently, don't smoke, minimize time on my ass but I have a high stress job. If 5% of people in my situation have an MI, does that mean I have a 5% chance? Or do I have an X% chance that in the grand scheme of things only carries meaning as a single mathematical point in thousands observed from afar?

In the beginning...

I'm scared shitless of death and disease. I say this as a practicing physician. Mortality is a bug up my ass that won't go away. Why am I so afraid? There are probably a million reasons but one stands out, mainly because it is an intriguing sob story that may lure you in if only out of pity.

My parents divorced when I was five. I am an only child so it had to be my fault. I must have done something heinously wrong to drive the wedge between my parents. I didn't know what that thing was, so everything I did or felt was subject to scrutiny. If I was to prevent them from the obvious next step - divorcing me - I had to change. Whatever concerns or emotions I had needed to be kept in check.

The problem was that I was a stressed out 5 year old who was sad as hell. I don't have the emotional maturity now at 35 to make sense out of my feelings. How could I possibly do so as a 5 year old? But as far as I could tell, I was being blamed for my emotions so I must have control of them. I didn't feel like I did, but I must given the catastrophic consequences (I was a bit dramatic as a kid) my emotions elicited. Although I was confused about my ability to control the health of my emotions, I was astute enough to realize that I definitely did not have control over the health of my body. When I got sick, I got sick. There was nothing I could do about it. So instead of being sad, I became sick. My body became my emotional dumping ground. Aches and pains in lieu of tears, fear of death in lieu of fear of abandonment.

Like all healthy American males, I chose not to address this quirk in my being and chose instead to pretend it did not exist. So it grew like the nasty emotional fungus it was into a near hypochondria. (Although an anesthesiologist and not a psychiatrist, I know enough about psychiatric diseases to hide behind technical definitions: I don't meet all the criteria to be considered a true hypochondriac. Of course, tell this to my pediatrician wife who will follow with eye rolling acrobatics.)

Today I have an enjoyable yet stressful job that resides in an enjoyable yet stressful life. Stress is an emotion we all have difficulty dealing with, both psychologically and physically. So, as you can imagine, when the pressure builds in my head, I displace it on my body. When I'm stressed, your disease becomes my disease. Whatever medical or surgical dilemma my patients face, I worry about having the same. And unfortunately, I take these "diseases" home with me.

It is time for me to face mortality; to understand it as much and to fear it as little as one can. It is time to be what I truly believe a doctor should be: a guide, leading patients through the seemingly conflicting meanings in objective disease and subjective illness. I have been doing my patients a disservice by not coming to terms with my own being and the inevitability of its demise.

So here it is. My journey to understanding my mortality. I'm not a religious man although I appreciate the philosophical aspects (not the dogmatic!) inherent in the major religions I have encountered (all seem to have as their goal a loss of self, the pinnacle in coming to terms with mortality). Nor am I a traditional scientist. I believe science to be a habit like religion with as much dogma and politics. I will primarily look to philosophy, the tradition that asks the same questions as religion, but uses the techniques of science. (It, of course, has its own bullshit too but I enjoy it's brand of bullshit.) But, in the end, what the hell do I know (that's the point isn't it?). I'll just figure it out along the way.