..to live as nature requires. To investigate and analyze, with understanding and logic, the principles we ought to live by.
- Marcus Aurelius
‘It is my bad luck that this has happened to me.’ No, you should rather say: ‘ It is my good luck that, although this has happened to me, I can bear it without pain, neither crushed by the present nor fearful of the future.’
I purchased my Tesla Model 3 (Performance) earlier this year, taking delivery on the last day of February. After driving it daily for the past three months I am ready to describe life with this exciting but controversial car. To summarize, I have been nothing but impressed and excited.
When asked about the car, something I have gotten used to over the past few months, my initial comparison to owning the next generation iPhone, a few months before its actually released to the public. Every time I drive my Tesla I feel like I am part of a secret that everyone else will learn soon. The interior is clean, sleek and modern without the clutter of multiple gauges, dials and buttons. The central focus of the inside of the car is the iPad like display, which is the control center of the car. Here is where you choose your music, adjust the climate, and navigate your trip. As well, the left side of the screen is your car’s avatar, showing you where you are in your lane and what cars are in your vicinity. It may sound like a source of potential distraction, but it quickly fades into the background as a simple tool to use when needed.
The iPhone comparison continues with the software that runs the Tesla. Over the past three months my car has had about four or five updates that load wirelessly in about thirty minutes. This has resulted in increased battery range and efficiency, a new camera-centric security system, pet-based climate control among other improvements to the Tesla experience. These give you the sense you are driving something that is constantly up to date, modern and refreshed.
But what is it like to drive? Well, even after three months, pulling out of the driveway is exciting, as I experience the seamless acceleration, absent any shifting jerks or rumbles common to all non-electric cars. It isn’t long before I look for reasons to test the speed of the car, something that sneaks up quickly and has led to close calls with roadside speed traps. It is simply smooth, fast and handles amazingly well. And did I mention it is fast? You Tube is filled with videos showing the ridiculous acceleration possessed by the Model 3, which doesn’t even have a Ludicrous mode like the Model S. It is nothing short of pure fun to drive.
And if you don’t want to drive in the traditional manner, you can engage Tesla’s Autopilot feature. I have only used this on a few highway trips so far, but it is clear that even paying attention and keeping your hands on the wheel with Autopilot on, my stress level was about half of what it usually is in those situations.
I refuse to be labeled a Tesla fanboy, so I will admit the Model 3 is not perfect. While the battery range is excellent, this car is not for everyone. I have a short commute and live in a moderate climate so do not expect any significant issues with range anxiety. However, I did experience diminished battery charge when it was cold, something that has to be seriously considered for those that live in cold weather states and have significant driving habits. That being said, the ease of charging overnight at home is a joy.
The Tesla Model 3 gives the driver a fun, modern car to experience that makes the daily chore of driving something to look forward to rather than dread. Oh, and it is fast.
“The high ambition, therefore, seems to me to be this: That one should strive to combine the maximum of impatience with the maximum of skepticism, the maximum of hatred of injustice and irrationality with the maximum of ironic self-criticism. This would mean really deciding to learn from history rather than invoking or sloganising it.”
I used to be a huge Springsteen fan. All the boxes checked: seen him live a dozen times across many iterations of the E Street Band, owned all the albums which were bought on their release date, owned countless bootlegs, etc. With maturity I have come to realize that most artists are unable to sustain their original level of excellence. Certainly this is evident with Springsteen’s work over the past decade, highlighted by the subpar and uninspiring High Hopes, his most recent studio album, released in 2014. Later this summer he will release his 19th album, titled Western Stars. Apparently this is a solo album, along the vein of Devils and Dust. The first single “Hello Sunshine” has been out for a few weeks now, and I’ve listened to it several times. So far I am unimpressed. It is an easy listen, and his voice is familiar and it is not a song one will actively turn off as it simply blends into the background. And that is the problem. It offers no challenge, no emotion. The lyrics are simple, and predictable. The music is bland, and the production is uninspiring. Full verdict for the album of course will rely on the whole set of songs after its released, but so far my hopes are anything but high.
Most articles on The Who, when singling out the band’s defining work will point to Tommy. Yes, the rock opera Tommy was groundbreaking, rebellious and beautiful all at the same time. I love listening to it, and the musical journey it takes me on. But ask me what the ‘best’ Who album is, the one that shows who (sorry) they are as musicians, personalities, individuals and contains the most complete work as a group and I’ll choose Quadrophenia every time. From the first sounds of the ocean on I Am The Sea, the listener knows they are in for something special. Its an overture in the purest sense, foreshadowing what is to come but grounded in the power of nature, not guitars and drums. The faint sounds of french horns, piano, and an echo of voices lull you into calm, only to be awakened by Roger Daltry’s voice asking the question every teenager asks himself and the world, “Can you see the real me?” A few beats later and Keith Moon’s drums and John Entwistle’s bass wake you up, shake you up, and let you know the band is going to confront that question head on, holding back nothing. And you should expect nothing less from a band that, through the personal and intimate writing of guitarist Pete Townshend, never shied from asking and answering the questions that lie inside all of us. Who are we for real, what do I mean to those around me, and how can I fit into this world of ours? Quadrophenia explores those questions in seventeen tracks that go from the unrestrained power of The Real Me to the spare Helpless Dancer. Of course highlights well known to any classic rock fan are the more popular songs 5:15 and Love, Reign O’er Me, both well worth their praise. But songs Drowned, Bell Boy, and Dr Jimmy are too often overlooked. But they all are examples of the power of this band, its strength of performance, its cheeky humor (Keith Moon’s vocals on Bell Boy) and the precision of Townshend’s lyrics. From start to finish, from the crashing waves of I Am The Sea to Daltry’s screaming finish to Love, Reign O’er Me the album is a force of nature, and of a band at its peak.
As I tweeted the other day, things like this article are beautiful in their simplicity and directness. Kudos to Dr Elliott Martin for distilling the physician ‘burnout’ crisis down to the core elements. I have written elsewhere that the term burnout is misapplied, and a poor choice to describe what physicians are currently feeling. Although not as headline friendly as burnout, the term “physician devitalization” seems to me more accurate and descriptive. Burnout implies we are working too hard, maybe too many hours, too intense, and that some time off with a little yoga, mindfulness and herbal tea will get us back at it. Bullshit. Read Martin’s article for some of what goes on, and you’ll get a flavor for what it feels like to be a physician (not a provider). And then see how his solutions are so simple and elegant.
Well, actually yesterday, but it was 50 years ago that The Who premiered Tommy to the press. Performing at a London jazz club, they literally blew out the ears of the journalists in attendance. My feelings on Tommy aside, this is again one of those moments that leave me speechless. Can you imagine yourself seeing The Who playing their legendary rock opera in a jazz club? This is one of those seminal moments in rock history, a true innovative work presented in the intimate surroundings of a small club. Unbelievable.
I love Tommy, and see it as one of the most important works of rock music in the twentieth century. However I have always been partial to Quadrophenia when judging Who epics. A work of genius, Tommy is a little too clean for me, too tight and neat in the performances. Quadrophenia to me is the real Who, as it is indulgent, a little over-the-top, frayed and raw, which I feel truly represents The Who at their best. Regardless, seeing them perform this work fifty years ago in a club setting is something only a few were able to cherish.
“It is not the critic who counts; not the man who points out how the strong man stumbles, or where the doer of deeds could have done them better. The credit belongs to the man who is actually in the arena, whose face is marred by dust and sweat and blood; who strives valiantly; who errs, who comes short again and again, because there is no effort without error and shortcoming; but who does actually strive to do the deeds; who knows great enthusiasms, the great devotions; who spends himself in a worthy cause; who at the best knows in the end triumph of high achievement, and who at the worst, if he fails, at least fails while daring greatly, so that his place shall never be with those cold and timid souls who neither know victory nor defeat.”
“Get Up. And. Go. Take the risk, take the gamble, take the first step. Take action. And don’t let another day slip by.”
This article, while on the surface seems benign in its approach and suggestions, is infuriating and offensive to myself, a physician who specializes in critical care medicine. While I would normally hesitate to generalize and doubt how a hospice nurse has the clinical experience to propose such trite recommendations, her essay opens herself to sharp criticism. Ms Brown’s descriptions of physicians as those “who look at patients primarily as collections of individual problems, rather than very sick individuals” is disappointing because it is so lazy and unsophisticated. If this isn’t insulting enough, her next paragraph is a veiled allegation that physicians are keeping dying patients alive for financial gain. Oh, but her wisdom on this subject is so great that she is able to understand the source of problems she was not even witness to. A patient’s family told her they didn’t appreciate how ill their loved one was, so of course Ms Brown knows it was the callous physicians and nurses too busy to care, that the staff ‘didn’t have time, or wasn’t able to make time’. Any medical student on their first clinical rotation quickly learns how little patients and families retain from clinical discussions, especially in an end of life situation as Ms Brown describes. Her ignorance of this makes me doubt what experience she truly has. Any doctor or nurse who has spent any time in an ICU is familiar with the patient or family who, despite repeated careful discussions, still can not grasp the totality of crushing illness and the prospect of death. In addition to being ignorant of this common occurence, Ms Brown is apparently uninformed about the typical discrepancy of prognostic outlook between physicians and families. True to my experience, it is the physicians and nurses who often project a realistic outlook for a patients clinical course, while the family understandably, for many reasons, will cling to an unreasonably positive prognosis (see JAMA. 2016;315(19):2086-2094. doi:10.1001/jama.2016.5351) . But let us not let reality and evidence get in the way of another pointless care algorithm that reduces nuanced medical care to flow charts, arrows and colored boxes. But of course real descriptions of the good care provided in ICUs is not as provocative as describing greedy doctors grinning at the bedside of dying patients, deaf to their patients suffering cries. It is baseless articles like this that can perpetuate doubt in the well meaning doctors and nurses who labor at the bedside of critically ill patients, some who will live and some who will die. Shame on you Ms Brown.
Not exactly on this day in history, but over the last few days of April in 1943 Witold Pilecki escaped from the Auschwitz concentration camp and fled into the Polish wilderness. This escape is amazing by itself, but what is truly memorable is that Pilecki was prisoner at Auschwitz after he volunteered to infiltrate the camp to obtain information that could lead to the camp’s destruction. A soldier in the Polish cavalry, Pilecki continued to fight for the Polish resistance after the German occupation of Poland in 1939. In 1940 he proposed and acted in a voluntary mission to be taken prisoner by the Germans, which led to his internment at Auschwitz. During his three years at Auschwitz he fed invaluable information back to the Polish resistance and Allied forces, while strengthening the resistance efforts within the camp for an eventual combined attack on Auschwitz. This attack never happened for many reasons, and eventually the Germans began executing any suspected resistance members within the camp, forcing Pilecki to undertake his daring escape. His bravery did not end there, as now he worked with the Home Army towards the Warsaw Uprising of 1944 that was an attempt to free the city of German control.
The efforts of men such as Pilecki continue to leave me in awe, as his courage seems unreal to me. In my peaceful 21st century world I am never truly faced or challenged with anything close to what Pilecki confronted, and I wonder if I would have the necessary constitution to act with half the bravery he exhibited. His story is one that should be known to all, so that we can remember his actions and also be inspired to live with similar strength in our own personal struggles.
Reinvigorated by the recent Spotify podcast Stay Free: The Story Of The Clash, the masterpiece London Calling has been stuck in my rotation. While it remains an album I listen too often, lately I have been unable to remove it from at least a brief daily listen. This 1979 classic from the legendary punk rock band The Clash has remained as relevant and powerful as when it was released forty years ago. Listen to Episode 5 of the podcast for the great story of how this album was recorded and then put the album on. Though it spans two records it only is sixty six minutes long, but what a glorious hour. Power, energy, protest and snark all come through on the albums nineteen songs with highlights being the title track, Clampdown, Death or Glory and of course the radio favorite Train In Vain. Here is a brief taste of what truly is one of the best rock records of all time.
“When you want to help people, you tell them the truth. When you want to help yourself, you tell them what they want to hear.”
Not sure I have much to add to this recent controversy . The statement made by Washington state senator Maureen Walsh is at its best inaccurate, at its worst insulting. Entering the hospital as a third year medical student over 25 years ago, it did not take long to realize how essential nurses are to the outcomes of patients, and how unbelievably hard their job is. And it is only become harder. Patients are more complex, shifts are longer, charting is unreasonably demanding, and stress levels are unmeasurable. Combine this with a recent rise in hospital work-place violence (who is on the front lines there, you think?) and it is clear that nursing is anything but an easy profession. As a critical care physician, I am fortunate to spend more time with nurses than most physicians, as we are shoulder to shoulder with them during procedures, codes, and intubations. We share in our commitment to the patient, and we share in the trauma, grief and joy in the unpredictable nature of our jobs. However, as a physician I get to walk away often during my day while the nurses are there throughout, at the bedside tirelessly working for whatever the patient may need. They will go hours without using the bathroom, often eating ‘lunch’ at 4pm when their shift started at 7am, and staying hours beyond their shift to finish what is often useless EHR-demanded documentation. Senator Walsh’s statement is uninformed, ignorant and a betrayal to the true frontline heroes of the American medical system.
I recently watched Grizzly Man, likely the third time I have seen it from beginning to end. Even though I knew the story, the details and the outcome, it still remains powerful and maybe one of the most honest documentaries I have seen. It tells the story of Timothy Treadwell, and his time living among the grizzly bears of Alaska, and the complicated events that led him there. A significant portion of the footage was shot by Treadwell, as he spent months at a time among the bears and was able to capture unique and amazing footage of the grizzlies and other wildlife of the Alaskan wilderness. But the footage also reveals Treadwell’s frustration with society, and the contemporary stress we all choose to live with every day. He knew he was not meant to be a part of this modern society, and convinced himself that the social network of the grizzlies was more simple and forgiving than that of the human race. It is difficult not to be inspired by his independence , as he is brave enough to set out on his own and leave the chains of the modern world. But this was what led to his death, giving up the knowledge of boundaries and rationality that the modern world forces us to accept. The way Werner Herzog puts this on the screen, raw and for the viewer to judge, makes us need to decide where we fit in our world, and judge the decisions we make. While it is clear Treadwell’s decisions were not all well thought out, there are moments of beauty and inspiration in his footage that demonstrate that he was at least on to some of the value of living as one chooses, which in the society of the 21st century becomes harder every year.
About a month ago, senior medical students across the country were celebrating Match Day. This is the day they discover the next step on their path to becoming a physician, when they are ‘matched’ with a residency program in their chosen specialty. Many will feel relief, believing realization of their goal is now clear. Complete the journey through their training and they will become the physician they set out to be when they first applied to medical school. If it were only that easy. As the college one attends does not determine someone’s intellectual ability, the residency program does not guarantee who will be an excellent doctor. This led me to think about what actually does make a good physician? What are the qualities needed, no matter the training or academic pedigree, to be an outstanding doctor in the twenty first century?
Pride. A doctor, or any one for that matter, needs to have pride in what they do. You have to believe what you are doing is important, that you are doing it well, and when looking back on your work that it is the best you could have done. For a physician, that will mean it demonstrates thought, caring, and sound medical decision making. It will mean that at the end of the day you can look back and say that you did everything you knew to do for your patients to the best of your ability.
Humility. While pride is needed, it can become a negative quickly. Early in my career I recall pride overwhelming me after a series of good patient outcomes I mistakenly attributed to myself. It was right about the time I could feel myself walk a little taller, buttressed by my unique ‘doctoring’ genius, that I was confronted with a call about a patient of mine not doing well despite my best efforts. It did not take but a few times for this lesson to quickly sink in, that medicine is a humbling practice. We can do the right things, follow the correct protocols, consult the appropriate specialists, provide the correct interventions, and yet the patient will still not recover or survive. It is essential to remember that as a doctor we are working in an unpredictable service, one with great feelings of joy, but with opportunity for great disappointment as most of the outcomes we seek are out of our control. Humility also teaches us to ask for help, that we do not have all of the answers. The old training message that it is weak to ask for help is misguided. It is strength that allows the physician to ask his colleagues for their assistance and expertise, and the physician who fails to do this will be also be failing their patients.
Perspective. Many may use the term empathy, but I am not sure that empathy serves a physician. That term implies too strong of a relationship with a patient’s suffering, and that is a dangerous thing for a doctor as it could negatively impact their decision making. I choose to think of perspective as a more appropriate characteristic. We need to remind ourselves, every day, what it is like to be that patient we are seeing at 1015am while we have two pages to return, a drug rep waiting for a signature for samples, and dreading a 1030 phone call to dispute an insurance company’s refusal to allow a PET scan. That 1015 patient is going to see you today because they need you, and they rescheduled work, or arranged childcare, or had their cousin miss work to drive them to your office, all for these fifteen minutes of your time. They need your attention, your expertise, and your focus. All too often we will fail at this, but we have to recall why we do what we do, and who we truly serve.
Curiosity. Physicians have to be intellectually curious. We have to want to learn constantly, and that does not end when our training ends. Medicine is in constant evolution, faster now than ever. We have to keep up the best we can, and be curious about what we can do better, what treatments serve our patients better, and how to provide the best care possible. (And this can be done without Maintenance of Certification activities, but that is the topic for another essay. Don’t even get me started.)
Communication. The ability to communicate is essential to an exceptional physician. Talking to nurses, letting consultants know specifically what we need from them, asking the right questions of referring physicians. Most of all we need to learn how to clearly speak with patients, to explain to them what is wrong and what we are going to do to help. Or those tough times when we have nothing to help, but we need to let them know we are not giving up or have stopped caring. An often forgotten element of communication is listening, probably the most essential part of this exchange. So much is learned from listening to the patient describe what is wrong, and this is the most essential component of their visit. If we just let them speak and tell their story we can most often learn why they need us and how we can help. If we listen to the ICU nurse who has spent the past ten hours with their patient we will gain more knowledge than staring at a screen of lab results and images. If we listen to a family member we will learn what really has been going on at home that led them to needing our help.
Courage. More than strength, physicians need courage. Every decision we make is out in the open, exposed in the medical record for all to see. Now more than ever, those decisions will be examined and criticized. By the family member who disagrees due to what they read on the internet. By the insurance company who disagrees with your choice of test, or medication, or procedure. By another physician, who you have asked for help and may either internally or externally critique the care you have provided. It takes courage to be able to do this every day, to expose your work to others and be able to stand behind your decisions and defend them to all who question. But this is needed, and what is truly the point of the training we endure. This is what we are learning during those endless rounds, when we are postcall and exhausted and our consultant is drilling us on why this patient (the sixth one you admitted that night) is short of breath if their chest xray is normal. This is what we learn when we are drilled with questions during our surgical conferences, being asked to defend every step we took to take the patient to the OR, and then every decision we made during their procedure. This is what we learn in the ICU, hearing distraught and frustrated family members ask us why we are failing to save their loved one from the horrors of ARDS.
But it also takes courage to examine our decisions and acknowledge when we could have done better. This is an essential part of the practice of medicine. We have to look back and know when different decisions could have been made in the service of our patients. To learn what we would do next time, who we would ask for help, what test or procedure should have been done earlier. Mistakes will be made in the care of our patients, and it is the courageous physician who will acknowledge those mistakes, learn from them, to better serve those who will put their trust in us.
The first album released by the new Rolling Stones Records label, Sticky Fingers made its mark on several historic fronts. The new label introduced the new logo for the Stones, the licking-tongue and lips which would be their infamous trademark image for the next fifty years. As well, another infamous image is the album cover itself. The image of a male crotch and prominent penis certainly showed that the Stones were declaring their independence from their previous album cover controversies. However, as usual, the main impact from the Stones was the music. The first single from the album, Brown Sugar, was released on April 13 1971 and made its impact immediately. This song is the Stones. Bluesy, trademark guitar riffs from Keith Richards, lyrics alluding to illicit sex, girls, and giving off imagery that is dirty, seedy and dark - this song had it all.
Watching the movie Magnolia is a commitment. Clocking in at just over three hours, this is not the film you casually put on at 9PM wanting to kill time before bed. This involves scheduling and planning, to give the time and energy demanded by this long and complex masterpiece. Briefly, the movie is the intertwining stories of seemingly unrelated characters who all eventually overlap in their search for love, truth and forgiveness. This is not a happy film, it is not light, it is not bright. But its message is powerful, and can leave the viewer feeling better about themselves, and life in general. We are all here together, struggling through this complex and difficult life that despite our planning and intentions surprises us with conflicts and gifts.
The performances are stellar. If you were to pick Tom Cruise’s best dramatic performance, most may go right to Rain Man, but this is the one you want to see. He is incredible, sealing his reputation as one of this generations great actors. Philip Seymour Hoffman is outstanding as well, coming across with tenderness and strength in a character that at first glance suggests otherwise. All of the actors are strong, impressive and rise to the challenge of the script, but Julianne Moore needs to be singled out for her performance. She shows vulnerability, anger, fear and loneliness in a way only she can.
Honestly, this is one of my favorite movies. Every scene is shot to draw you in, every actor is worth the words they are given, and the music is legendary in how it meshes with the images on the screen. Go watch it, but make sure you have the time to give this true work of perfection.
Led Zeppelin seems to be the band that makes up the classic rock background of radio, always there, always consistent, but often forgotten. The Who in their current form still tour, as do the Stones (until Jagger’s recent health issues), but Zeppelin shut it all down with the death of drummer John Bonham in September 1980. Except for a few celebratory performances, Zeppelin’s music is limited to a furious twelve year span from 1968-1980. And it all started with this album, Led Zeppelin, released in 1969. Can you imagine listening to the Beatles’ Abbey Road or the country rock tones of the Stones’ Let It Bleed and then hearing the first few notes of Good Times, Bad Times blast from your speakers? If you made it through that that onslaught, you may have thought you had some time to recover with the acoustic strumming that begins Babe I’m Gonna Leave You. Well, you would be wrong as by the second minute of that song the fury of Bonham’s drums form the platform for Robert Plant’s wailing and John Paul Jone’s bass line. Never mind that it wont be until two songs later when you hear the full brilliance of Jimmy Page in the bombastic, indulgent classic Dazed and Confused. What isnt confusing is the power of this whole album, start to finish. Go back, listen, and I dare you to disagree.
“Get after it”
I enjoy reading Jocko Willink, be it his tweets or his books. As the world seems to get more complex every day, it is easy to get bogged down in all of the data and noise thrown at you. But reading Jocko reminds me to keep it simple. To focus on what is important. To find meaning in doing what is right, and being the best person you can. To get after it.
I am constantly working on improving the focus and content of Resolute Inquiry. Please reach out to let me know your thoughts.
stevec21@protonmail.com
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