Sump pumps at 6 AM on the coast of Maine

EB_White_tumblr_ln72twZxC91qztcnqo1_500Living on the coast of Maine is very special. It is a constant battle with the elements even when the sun is shining and the wind is calm. I began my day, which is cool and foggy, with a visit to the basement to explore the (disturbing) absence of noise from my sump pumps.

An E. B. White morning?

I found their pores clogged. I opened one pump’s inlet pores to make it operational for the impending showers. Then I put it back online. It worked, although the disrupted connections now leaked a bit. Still, I felt accomplished with my male version of The Happiness Project and even happier with my subsequent decision to call the plumber to muck out the drains and professionally reattach the pipes.

All of this before six in the morning. I love calling the local businesses at 6 AM and finding them open and ready to work. Do I sound like E. B. White yet?

I came back from the World Domination Summit with a renewed sense of self worth, even without a professional title. As part of the trip back, we paused for a night at the home of a childhood friend. He is a plastic and hand surgeon. He was late to greet us because of an add-on case involving the loss of three digits [aka fingers] to a band saw.

We had a great dinner and he left earlier the next morning than expected when he was called to the OR for an abscessed finger. I envied his energy and his professionalism. But I am still savoring my new freedom.

I also reminded myself that he has carved out a part-time practice, and although busy at the time of our visit, he generally works only four days per week and takes four months of vacation per year. I never figured out how to do that. A professional, caring, gastroenterologist had to be more available than that to keep a practice alive in Washington, DC.

What the word “profession” means

Medicine is a profession and should be practiced as such. The definition of a profession varies from dictionary to dictionary. The most common definition describes a profession as an occupation requiring rigorous and prolonged education and training. Another common definition refers to profession as “a calling” because of its earliest usage as a “profession of faith”. Finally, some definitions include the concept that a profession is an occupation with standards and obligations that its practitioners accept and meet.

This is what used to separate practitioners of law, medicine, and journalism from the average businessman.

In the course of a business transaction two parties will come to an agreement. If one party benefits more by the agreement than the other he is considered a good businessman. Both parties came together willingly and with equal standing in the transaction.

In the true professions (law, medicine, education, journalism) the relationship between the professional and the subject is asymmetric. The doctor or lawyer has a vast knowledge base that the patient or client does not. The patient or client relies on the doctor or lawyer to exercise judgment in the treatment or recommendations rendered. They pay for the expertise with the understanding that the professional will exercise restraint and in no way abuse the position of power and authority that they hold.

Journalists have power over their readers that requires the exercise of judgment and restraint in reporting events. In this asymmetric relationship the reader relies on the writer to tell the truth.

We all know how teachers have power over students. We expect teachers to inspire and stimulate students without abusing their position or teaching a misguided perspective.

My lament: professions have turned into businesses

Over the last few decades we have seen professions turned into businesses. In the realm of education we have seen for profit schools take federal loan money and churn out workers unable to find jobs.

We all know lawyers who complain that the business aspect of their firm’s activities must be satisfied first. One elderly lawyer has said to me that when he started practice the best legal advice he could give was independent of cost considerations. When he left practice the “best” advice was that which made the most money for the firm.

Journalism is a difficult profession to contain by ethical standards because it is so easy to slip into a PR mode or to shade the truth to sell a product. It is also easy to confuse rumor and opinion with news. The growth of the cult of celebrity in our culture compounds the problems in journalism as celebrity journalists become more influential than thoughtful journalists and the distinction between journalism and entertainment is blurred.

As I pour out this sanctimonious rant on professional behavior I remember Professor Wilmott Ragsdale’s favorite expression, “Journalism, a profession? I don’t think so. Boxing is a profession!” So, I recognize shades of gray in all professional activities. [Ed note: Rags, as we called him, was my journalism professor at the University of Wisconsin in the mid-1970s. He was the best teacher I ever had.]

Yet, I lament the loss of professionalism in medicine. For in medicine the business model has become paramount. Whatever makes the most money for the practitioner is the best medical care. It is sad to see and as I wrote about the use of propofol delivered by anesthesiologists for routine colonoscopies, it is a disgrace.

The largest group of gastroenterologists in the Baltimore/Washington/Northern Virginia region took a vote about the use of conventional sedatives (as recommended by the professional societies that guide subspecialty care) versus the employment of anesthesiologists that would allow them an additional revenue stream and more profit. The majority voted for the added revenue even though this does not improve quality of care. Do they discuss this with patients? No, they tell the patients what “is best” and the patient accepts the advice.

I am advised by other colleagues that whole hospital systems have adopted this use of propofol by rationalizing that they are standardizing treatment across a spectrum of care but the real reason is to increase cash flow in a world of increasing hospital costs and decreasing revenue.

Anything goes in a business transaction but revenue should not be the driving force in a professional consultation or treatment. As Dr. Steve Nissen, of the Cleveland Clinic said in the documentary Escape Fire: the Fight to Rescue American Healthcare: “When we made medicine a business, we lost our moral compass.”

Bless those who have the moral fiber to stand up to the commercialization of medicine.

I am going back to the basement to check my sump pumps.

Photo is of E. B. White writing in his boathouse in Allen Cove, Maine. Courtesy of Andrew Romano.


Q. & A. with Debbie and Sam on “collaboration”

GapYear_June2013_croppedDebbie: Is this really our first collaboration? What about our three children?

Sam: That was different.

Debbie: You’re right; it was.

Sam: This is doing creative work together.

Debbie: And you don’t mind me being your editor? It’s not that easy.

Sam: You mean because of our different approach to quotation marks and periods and spaces at the end of sentences?

Debbie: No, because sometimes I don’t love every word that you write. Your prose is generally very, very good. But sometimes you are a little repetitive and not entirely clear.

Sam: What?!!

Debbie: OK, never mind. I shouldn’t have said that. You are an amazing and prolific first-time blogger. I only want to encourage you.

Sam: That sounds better.

Debbie: I take this blog very seriously, you know.

Sam: I do too.

Debbie: I have high standards.

Sam: I’ve noticed.

Debbie: I’m not entirely sure where the blog is going but I think it’s important to articulate what we’re experiencing.

Sam: How honest do you think we should be about how we’re really feeling one month into our Gap Year?

Debbie: Giggle.

Sam: Seriously, how much should we reveal?

Debbie: Well, as the resident blogging expert I would advise us to be authentic… but not to reveal everything. I don’t want people to know how discombobulated I feel, for example.

Sam: That will probably pass when we have established a better routine.

Debbie: But isn’t that the point? That we’re breaking out of our familiar routines?

Sam: Yes and no. Once we’re properly unpacked and settled on the coast of Maine we’ll feel better.

Debbie: What if I miss DC?

Sam: I don’t miss DC.

Debbie: I do sometimes. All this traveling (back and forth between DC and Stonington, ME; to Portland, OR for the World Domination Summit) makes me unsettled. I’ve been talking for years about how cool it is that my work is “location independent.” But so far I haven’t adjusted to a nomadic lifestyle.

Sam: Give it time. Imagine how I feel giving up my daily routine with patients at the office and the hospital.

Debbie: I worry about that a lot. Sometimes I think I’m worrying for you; that you might miss it too much.

Sam: OK, enough with the touchy feely.

Debbie: Yes, and… 

Written 33,000 feet up on Alaska Air #35 bound for Portland, OR.

The luxury of time; the challenge of structuring it

Time For ChangeI am one week into my Gap Year. One friend emailed to ask how it goes.

Of course a gap year in the usual sense is for a young adult to gain perspective on life, blow off the initial energy of post high school freedom, explore the world and return to university with a more mature focus.

A gap year after 60 is quite different. It is not about focusing but about refocusing.

It is not about blowing off energy but about marshaling energy anew.

It is not about looking forward but about looking back, analyzing, then looking forward again – but with a less distant horizon.

Without a daily load of patient appointments and hospital visits, the first challenge for me is to structure my days.

I was a slave to punctuality

One of the rewards of medicine is the knowledge that your work is valued and valuable. Even if unable to heal, a physician can guide and comfort a patient. To replace that structure of appointments and procedures (and I was a slave to punctuality) I plan to impose a schedule of blocks of time to allow for more free reading, some exercise, writing, studying, and whatever errands and projects need to be done.

From the point of view of restructuring my day, Milwaukee might not have been the best first choice. To visit a 92-year-old man for the sake of catching up and reminiscing is to be a slave to his schedule. Meals, naps, treatments, etc. dictate the general rhythm of the day but the idiosyncrasies of the nonagenarian supply plenty of unexpected interruptions.

Of course, the point of the trip was to maximize face time so when he called I responded, dropping whatever mini-project I was working on. It was well worth the time. I hope to get back soon.

Time, what a luxury

Today is one of the first when I can set the schedule I have outlined above. Write, clear my desk, read, exercise, study, do errands and leave the evening free. Repeat tomorrow.

Clearly, if I were an exceptional person and physician I could have done this over the last few decades, but I didn’t have the energy or bandwidth. I never found the time. My work expanded to fill the gaps and I never blocked out enough time to grow in other areas.

Time, what a luxury for me.

Today’s project is to select our first load of furniture for the new rooms on the coast of Maine. It will be a test of my new relationship with Debbie, vis-a-vis time, space, and each other. [Editor’s note: ha! the new relationship is going well. Yet I fear that Sam is so organized… and I am not. – Debbie]

Parking permits, moving trucks and the D.C. government

Yesterday we went to the local police station to obtain a parking restriction permit for the moving truck, which is scheduled for later this week. What a farce. In years gone by the desk officer would simply handwrite the request and advise you to give your neighbors 72 hours advance warning.

Now the police station houses a terminal for the DDT (District Dept. of Transportation) that prints out the red parking restriction signs – for a hefty fee of course. You pay by credit card. The police have nothing to do with the new process and the desk officer is quite happy to tell the petitioner that she can’t help at all.

It took two college grads (with three post grad degrees between them and 31 years of experience with the D.C. government) an hour to work through the program. We came out with the wrong request (a moving container instead of a moving truck) and the wrong dates (five days of restrictions versus the intended two days).

If we hand modify the sign we are threatened with a fine. So goes it in DC.

You can see I like to get things done.  Doctors tend to be that way.  We see the patient, institute therapy, push for a cure and move on to the next.  More about that later.