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.

Does anyone know how to fly this thing?

Flying freaks me out. Never used to but, since the advent of my daughter, the almost nonexistent risk is magnified. Am I really going to risk not being able to see my daughter grow up so I can rock out with Soungarden at Lollapalooza (top five shows of all time by the way)? The answer is of course yes because I know I am an irrational jackass. My friend is more of an irrational jackass than I am. She is remarkably courageous in my opinion because she flies despite her fear (courage is not a lack of fear but what you do with that fear).  We shared a flight from LA one time.  We started out in a torrential rain and she asked one of the stewardesses if it was safe to fly.  The stewardess said yes and that they too had an interest in living and would therefore not taking on any unnecessary risks.  

This is a very important concept.  The pilot and staff on the plane assume the same risk as the passengers: we all go down together.  It is not as obvious in medicine that we share the same risks as our patients.  I would argue, however, that this is absolutely the case.  There are questionable statistics on the limited life spans of physicians.  I can't honestly say what's right.  But it is clear we have stressful jobs and the burnout rate is astronomical (think about how this affects patients).  I can say from experience that if you do poorly under my care I am affected whether its my fault or not.  There are anesthetics that have changed my life, for both better and worse.  In addition to the baseline empathy we non-psychopaths share with other humans, we are tied to our jobs (and thus you as the patient) through the exceptional amount of time, effort, and sacrifice we put in.  My identity is inextricably linked to my profession (think about how you answer the question 'who are you'; I'm a father then a husband then an anesthesiologist then some other shit I can't remember, but I only mention the anesthesiologist part).  Consider also the patient who comes in who is nearly identicle to me except with a life threatening disease.  I am unconsciously tied to his outcome if only to protect my fragile concept of my own mortality (if it can happen to you, it can happen to me).

When you come under my care, we take the journey together.  We share risks. My say is equal to your say.  We forge a path together, neither of us directing the other.  I have the most knowledge of the controls so I'll be flying the plane.  I won't, however, drop you off in Minnesota when you're expecting Kansas City.  I'll do my best to avoid the uncomfortable bumps that are familiar to me but terrifying to you.  And I hope that you respect me and my stake in this journey enough not to force me to land in a pile of shit.

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.

Babies and suicide

Probably an unfair title.  There isn't much literature on babies committing suicide oddly enough.  What I mean by it is I never understood the concept of suicide until I had my child.  Strange to think the concept of mortal self limitation should arise out of my blonde haired, blue-eyed bundle of joy but it did.

I always thought that if I hit rock bottom somehow (whatever rock bottom is) then, in the very least, I'd be the world's greatest stuntman or the best war photographer of the century or the first man to eat 10 gallons of cookie dough a day.  Rock bottom would, in a sense, be freeing (another topic altogether already well put together by Chuck Paluhanakanaksanahun [possibly misspelled] of Fight Club fame).  If I truly examine this, then freedom to me was no longer caring about my mortality.  My life and death was the meaningful base from which all sprung.

With the advent of my daughter, that base changed.  She added a dimension that trumped my mortality.  Her physical safety; her emotional and intellectual growth; her potential role in society; my future enjoyment in watching her grow up; her present and future dependence on me; and much, much more all represent a richer, more immediately present meaning to my existence.  In other words, although the I've always enjoyed my life and am quite fond of who I am (contrary to the self-reflective brow-beating I give myself in this blog - you hurt the ones you love), the fall to rock bottom was not truly a long one.  I was standing on the 3rd floor veranda of a beautiful summer home in San Sebastian.  With my daughter, I am standing on top of 100 Burj Khalifas ).  I'm so tall now, everything I used to know and care about is microscopic.  I understand suicide now because I could not tolerate any other view than the one my daughter gives me.  My life became richer but more fragile with the birth of my daughter.

Camus said that the one philosophical question worth asking was why not commit suicide.  It is a brilliant question that, if you truly think about it, is a difficult one to answer (the question of course being the unanswerable "what's the meaning of life?").  I say flip it on it's head: why commit suicide?  What could you have in your life that truly means more than your life?  What would die over?  (Napoleon suggested that he can make a man die over a piece of ribbon.)

Chuck: [http://chuckpalahniuk.net/]

Burj Khalifa: [http://en.wikipedia.org/wiki/Burj_Khalifa]

Camus: [http://www.tameri.com/csw/exist/camus.shtm]

Philosophy and the Meaning of Life: [http://plato.stanford.edu/entries/life-meaning/]

Napoleon Quotes: [http://www.military-quotes.com/Napoleon.htm]

Faith

My wife and I had a discussion yesterday about religion and faith. We live in an area where the dominant religion has an enormous impact on the government (of course, that area of religious dominance is a mere subset of a larger area of religious dominance, i.e. the U.S.). We have our grievances with this particular religion because it's dogma infringes on our lives and beliefs. Unfortunately, our irritation extends beyond the boundaries of this religion's politics into it's philosophies. In other words, because some religious asshole shits on my parade, I hate the religion.

But my system, whatever that may be, is not perfect either. And if I hope to achieve what Tyler Durden would call the "instant of perfection", I need to consider the value of other people's ...well... values.

As I said before, I am burdened by mortality. Not to jump ahead and ruin the ending, but I think it unlikely that I'll ever find an answer to my burden (hopefully just some relief). Because of the weight of this burden, I wish (if i am truly areligious, to whom or what do I wish to? So many contradictions...) I had faith. True faith provides an answer by not giving one. It says it's there but you just can't "see" it. Just trust whoever or whatever it is you have faith in. Pulling it out of the dogmatic, politicalized, business entities that we deem religions, it is quite beautiful. We are perceptually imperfect beings. We can't know everything. If there is something we need desperately (i.e. meaning, order, purpose), maybe it does exist. And if it doesn't and we have to make it up, why not create it in the hands of an extraterrestrial? Who cares where it comes from, as long as it does it's job. I wish to whatever god I believe in (we all believe in gods - the providers of truth - whether they be in the form of a white male, a multi-limbed elephant, or the scientific method), that I had faith. It would give me a reason for my mortality and lessen it's burden.

I think Kierkegaard explained faith beautifully. He dismissed the dogma and piety surrounding his beloved Christianity and boiled religion down to faith: subjective faith that can't be understood by anyone other than the practitioner him/herself. In essence, the god is you. Quite beautiful and empowering.

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.