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John Kennedy O'Toole, A Confederacy of Dunces

Dante, The Divine Comedy

C.S. Lewis, Mere Christianity

Jeffrey J. Selingo, College (Un)bound



The contents of this website are for contemplative purposes only. No medical advice will be given, and emails asking for medical advice will be ignored.

Although patient vignettes are based on my experiences with real individuals, I liberally change details to maintain patient confidentiality.

I also reserve the right to change old postings to correct errors, and to delete comments that include obscene language or that I deem abusive to me or other commentators.  If you are looking for a open mind, I suggest you consult a neurosurgeon.

Katrina Blog Project

New Year’s Resolutions Already in the Dumpster? Good. Here’s How to Turn Them Into Something Useful.

By mid-January, most people have given up on, or are about to give up on, their New Year’s resolutions.  It’s an American tradition more predictable than a drunken New Year’s Eve. And that’s a good thing. Attempts at self-improvement can’t succeed until they first become failed attempts. You don’t succeed by succeeding. You succeed by failing and resolving to try again.

But how to try again? This is the challenge of failure — when you fail, aren’t you right back where you started? It is hard to regain focus and purpose when you made an effort and have nothing to show for it. But the truth is, failure is rarely empty. Most of the time, if you achieve nothing else, you at least learn from the experience. Failure isn’t total failure if something has been learned.

If you haven’t achieved your goal, and especially if you haven’t come close, consider the possibility that the goal may have been all wrong in the first place. Not that your intentions were wrong, but the goal may have been. The first step back from failure to achieve a goal is often to throw the goal away.

The problem with goals is that they are black or white — you either achieve them or you don’t. This leaves no room for flexibility, for the small successes, failures, setbacks, and rebounds that are substance of most human endeavors. Goals leave no room for commonplace improvement.

An example: I run regularly. My commitment to running, however, took years to establish. I would run for a few weeks, maybe even a few months, and then fall back into months of inactivity. I would set goals: Run 5 miles, run a 10K, run a marathon. I always had a goal. And I didn’t achieve any of them. Finally, I did what any sensible person does in the face of constant failure. I surrendered. I flushed all my goals down the toilet and decided that instead of worrying about goals, I would just decide to be a runner.

What does it meant to be a runner? It means I go out 3 or 4 times a week and run. Five minutes, five blocks, five miles, no matter. It's all running. Just as long as I put on my shoes and go out, it counts. And the interesting thing is that this simple change in approach worked.  

Before, when I ran, I was not able meet any of my goals, and so my passion for exercise lessened with each failure. I would quit. Then, I would feel guilty in couch-potatodom and set up the goals again. And the cycle would repeat. In this cycle, there was no chance I would ever succeed as a runner. Why would I keep doing something if I kept failing again and again? By simply telling myself I would run for the sake of it, for the heck of it, and that there were no goals at all, I was able to change my frame of reference. If my only criterion was to run — any distance, any place, any day — that was something I could succeed at. This thinking replaced long-term goals that I might never achieve with small, simple ones, achievements that formed a modest base that I could build on.

One might object: What good does it do to run for five minutes? Five minutes is nothing. Yes, it is nothing if your attitude is “Boston Marathon or bust.” But that is not my attitude. My attitude is, five minutes running is not everything, but it is five minutes better than nothing. It makes me a runner. I may not be as good an athlete as someone who runs five miles, but I am still an athlete. I don’t stop being an athlete if I can’t run five miles. I stop being an athlete if I stop running altogether.

And with that I had uncovered a secret that, while new to me, I have since heard other writers allude to. Rather than goal setting, it turns out that it is often more useful to change your personal story. Rather than saying, “I will achieve X,” it is better to say “I am now Y.” In other words, improvement is not an act of will, picking a goal and driving towards it, but an act of identity, deciding to be a changed person.

Let’s look at how this works. You can set a goal of writing a hit song. Or you can just choose to be a guitarist. You can set a goal of bench pressing 500 pounds. Or you can just choose to be a weightlifter. Setting a high goal sets you up for failure: if you don’t have a hit song, or if you never bench press 500 pounds, you have not succeeded in your mind. But if you choose to rewrite your story, you can turn repeated failure into sustained success. You may never bench 500 pounds, but if you spend as little as five minutes in the weight room three days a week, you are a person who lifts weights. Who has a right to say otherwise? No one can take away your identity as a weightlifter. You can only fail at that if you stop lifting.

Nike had it wrong. You don’t just do it. You must be it.

Need some more examples? Consider some common New Year’s resolutions.

Lose 10 pounds. What kind of person loses ten pounds? Someone who is a healthy eater. So instead of trying to lose weight and being disappointed when you can’t, just choose be a better eater. Decide to have a vegetable with every meal. Choose to drink plain water with your lunch. You can do that every day even if you never lose weight. And one day, it might help you lose weight.

Travel to Paris. What does it take to travel to Paris? Money. How do you get money? By saving. So instead of setting the goal of Paris, choose to be someone who saves. Any amount is fine. Like running, if you save anything, you are a saver. Recently someone showed me a very simple weekly savings plan. For one year, every Friday you set money aside. On week one, you save one dollar. The next week, you save $2. At 52 weeks you will set aside $52, and have $1,300 in your bank account. That’s enough for a plane ticket to Paris.

Get a promotion at work. That isn’t up to you. But doing a better job at work is. So pick a simple habit that will make you a better worker. Choose to be someone who is always at work on time. Being at work on time might not get you a promotion, but it won’t hurt. Or maybe choose to be someone who dresses well. Too simple? Choose to be someone who listens at meetings.  Prove you have been listening by reflecting back what people say to you before you make your opinion known. Everyone values a listener.

Learn to play the piano. Consider being a musician instead. What does a musician do? A musician listens to a broad range of musical styles, and learns about them. That’s easy. A little harder: A musician sits at the piano every day, even if it is just for a minute. Every minute counts. Do that, and the skill will eventually follow.

When I started writing this blog fourteen years ago, there were hundreds of doctors hosting blogs across the internet. We had a network, and we linked to each other’s blogs and even had a weekly online Grand Rounds that served as the “best of” posts among blogging docs. Now, all of them are gone except me. I don’t have the most popular blog on the net, and probably not the best one either, but I have been here 14 years and counting, and have no plans to stop. The difference between me and the dropouts is that the other guys wrote for a goal. To vent their spleens. To call attention to their medical practices and attract patients. To make money. To pass on medical knowledge (or show it off). Those are all goals. You either meet goals or not. If you do, your reason for blogging goes away. If you don’t meet your goal, you get frustrated and quit.
But for me, blogging is a way to be a writer. That’s what I am, a writer. What does a writer do? He writes. Every day. So I write every day. Some says I only write a single sentence, and sometimes a write for an hour or more. But I write.

And the reason my blog lives on is because I write to be a writer, and not for any particular goal. I do it because writing is what I want to do, and because a writer is what I want to be. One day, I expect to find myself on my deathbed ginning up another article for my old blog. And I will do it because writing is an expression of my being, not the fulfillment of a goal. Goals are for quitters. If you want to succeed and keep succeeding, you have to do something because you have made a part of what you are, a part of your personal story, and not some arbitrary finish line.

And that, my friends, is how you keep a New Year’s resolution. You ask yourself not what you are trying to achieve, but what you want to be. Do you want to be a writer, exerciser, healthy eater, spiritual thinker, saver, friend, spouse, father, doctor, teacher, mentor?

It is not possible to achieve everything. But it is possible to be many things. Choose to change your identity, and you will find your life changed in ways that you did not think were possible.

I am telling you: it works. I have been running regularly for eight years now. I am still terrible at it. But it keeps me fit, it keeps my mind sharp, and I will keep doing it as long as I can, not because running will take me anywhere, but because running makes me what I am, right here.


2018: My Year in Books

My list isn’t as well polished as Barack Obama’s, but keeping track of books read isn’t just a job for ex-presidents. This year’s crop includes thirty-four complete books, plus innumerable short stories and essays that I don’t have time for here.

I am embarrassed to say that the self-help genre is over-represented. I have a weakness for these kinds of books, especially titles about personal productivity and organization although I seldom get true wisdom from them. But sometimes I do, and it makes all the digging worth it. Among these, Outsmart Yourself, which is an audio lecture collection from The Great Courses, was probably the best.

1. The Two Towers by J.R.R. Tolkien
2. The Aeneid of Virgil by Elizabeth Vandiver (Audiobook)
3. The Untethered Soul: The Journey Beyond Yourself by Michael A. Singer
4. Northward Towards Home by Willie Morris
5. The Moviegoer by Walker Percy
6. White Trash: A 400 Year History by Nancy Isenburg (Audiobook)
7. Nausea by Jean-Paul Sartre
8. Runaway by Alice Munro
9. The Science of Energy by Michael E. Wyeesion (Audiobook)
10. White Rage by Carol Anderson
11. Morte D’Urban by J.F. Powers
12. How Democracies Die by Steven Levitsky and David Ziblatt
13. Just Friends by Shirley Glass
14. Every Single Day by Bradley Charbonneau
15. Return of the King by J.R.R. Tolkien
16. The Soul of America by Jon Meachum
17. Ask the Dust by John Fante
18. How to Change Your Mind by Michael Polian
19. The Unbearable Lightness of Being by Milan Kundera
20. The Procrastination Cure: 21 Proven Tactics by Damon Zahariades
21. Outsmart Yourself: Brain Based Strategies for a Better You by Peter Vishton
22. The Benedict Option by Rod Dreher
23. Fire and Fury by Michael Wolff
24. Beautiful Ruins by Jess Walters
25. Hyperfocus by Chris Bailey
26. Fear by Bob Woodward
27. The History of Jazz by Ted Gioia
28. The Joy Luck Club by Amy Tan
29. Aware by Daniel Siegel
30. Atomic Habits by James Clear
31. My Man Jeeves by PG Wodehouse
32. The Prince of Tides by Pat Conroy
33. Joy to the World by Scott Hahn
34. Classic Philosophy for the Modern Man by Andrew Lynn

Best Book: Close race, very close. I will go with Runaway, by Alice Munro, a beautiful collection of short stories about rural Canada. But also, Morte D’Urban was wonderful, and the Moviegoer.

Most Surprising book: I stumbled on Ask the Dust accidentally. It is a rarely read book these days (as is Morte D’Urban), but it deserves better. Read it, please.

Most Disappointing Book: Fear by Bob Woodward. It had some interesting information about the Trump White House, but there was no arc to the story, no narrative drive. It was like, “Hey, let me tell you a bunch of crap I learned about the White House.” I would have preferred Woodward had kept his notes to himself.

Worst Book: Fire and Fury sucked. Wolff’s book was was like Woodward’s book, except that Wolff can’t write well enough to keep wet on a fish. I hope the book made him so rich that he will never bother to write again. Every Single Day was a short read but very shallow. The title is all there is: To establish a good habit, do it every day. It was good cheerleading, but that’s it.

Rereads: The last two installments of Lord of the Rings were even better than I remembered them. Better than the movies. Unlike the movies, where good and evil simply pose against one another for the purpose of conflict, in the books evil was a real thing, sinister, purposeful. Evil written by a man who understands what sin is.

Anything else? The History of Jazz was very good until the 2/3s mark. Up to that time Ted Gioia told the life stories of many of the great jazz pioneers. But towards the end, there were so many names piled in that the book became nothing but a catalog of one jazz musician after another. It seems that Gioia had a story to tell, a great one, and at the beginning kept is personal enough to make it the compelling story of a few innovative musicians. But towards the end he panicked, and, afraid to leave anyone out, packed so much into the last part that there were no human stories left in the last few chapters. I understand the impulse, but it weakens the book.


Happy New Year!


Christmas 2018

Christmas Eve, and I am on my way to work. I haven’t been counting, but in my medical career I have probably worked between fifteen and twenty Christmases. The way the big holidays work in the medical business is that you either get Thanksgiving or Christmas off, and most years, New Year’s Day (as a somewhat inferior holiday) is thrown in as lagniappe with Thanksgiving to balance things out -- something like the way when a star player is traded in a professional sport the exchange usually includes a low draft pick or a minor player as an extra. Just to make things look better on paper.

I don’t mind working Christmas. When I signed up to be a doctor, certain things were included in the deal. Some of them I am not good with, like having to interact with insurance companies, or to deal with hospitalized patients who are angry that their food is cold, or patients that complain that they need to stay until tomorrow morning because they don’t like driving in the dark. But working Christmas is one of those things I knew I would have to do going in and feel is part of the sacrifice. Not only is there nothing to be done about it, it is, unlike some of the other unpleasantries of medicine, absolutely necessary. People get sick every day of the week. Somebody has to be on hand when they do.

No job is worth anything if it is not worth sacrificing for. Not that working Christmas is a massive sacrifice, but it is a minor one that can add up over the years. In this sense, I wonder about my colleagues who I never see on Christmas — dermatologists and allergists and plastic surgeons who paid their dues in residency but never have to work a major holiday ever again. There may be great value in these fields of medicine, but there is a certain honor in knowing your job is necessary enough that it has to be done every single day, no exceptions.

The original Christmas story is the Christ story, which is a story of sacrifice. Sacrifice adds something to the value of every job. It adds meaning, a sense of purpose. Nothing in life matters to me quite so much as the search for meaning, and sacrifice, even small sacrifices, like going to work when almost no one else has to, brings meaning to work. Nothing has value if never demands anything. When something or someone makes a demand of me, I must ask myself, “Is this thing worth a sacrifice? And if so, how much?” And when the answer is in the affirmative, not only have I decided that the thing is valuable, but I have now made a new commitment to it.

It is this decision, that practicing medicine is worth working Christmas for, that makes medicine more valuable to me.

The many people who go to work on Christmas make the holiday possible for everyone else. People are safer at home because there are firemen and police on call. They are able to enjoy Christmas morning because the electricity comes on. They are able to call their families because someone at the telephone company showed up for work.

Sacrifice makes the world go around. My sacrifice on Christmas will be small — probably 8 to 10 hours of work. But it is what I am able to give. I give it gladly — because my job would be worth nothing to me if it didn’t require that I put something into it. To give it meaning.


Books: The Joy Luck Club, by Amy Tan

The Joy Luck Club is a cycle of short stories more than a novel. This has become an increasingly popular way to write novels, but Amy Tan seems to have been ahead of the curve, since this book is now more than 25 years old. More recent books such as The Lord of Misrule, Olive Kittridge, and A Visit from the Goon Squad come to mind. There are older examples: Alice Munro has played with this concept for years (various stories in Runaway have related or recurring characters), and Ray Bradbury’s The Martian Chronicles is an even older example.

The idea is to use recurrent characters or places in a series of freestanding short stories. It is an efficient way to write a novel, because it allows the writer to complete and polish each chapter as a separate entity without having to worry about transitions between them. It also makes timelines easier to create, since the independent short stories can have overlapping time frames or be years apart. And flashbacks, which require some linking to the overall plot in the traditional novel, can be executed by simply ending one story and starting another at an earlier time. No explanation necessary. A flexible concept.

The Joy Luck Clubis a collection of sixteen short stories about a group of four women who emigrated from China to San Francisco right after World War II, and about their often strained relationships with their daughters. Each of the mothers gets two short stories, and each of the daughters gets two. This presents us with another characteristic of the novel of linked short stories — since each story can have its own protagonist, the book can have multiple protagonists.

For this book, that would be eight protagonists. One might assume, and would be correct in assuming, that eight protagonists would make a novel very crowded and confusing. This was the case with Joy Luck, at least for me — I had trouble remembering which daughter went with which mother and who was born where and who divorced whom. Tan seems  to be conscious of this and has occasional asides that help refresh the reader’s memory, but if you are not the kind of reader willing to flip back a hundred pages to remind yourself of previous stories, you may find the book a bit challenging (and prefer the movie instead — faces are easier to attach stories to than names in a book!).

Nevertheless, the book deserves its reputation; it is as popular now as it was when it came out a quarter century ago. (It was even included as one of the 100 great novels in the PBS Great American Read this past year.) Tan’s genius was in putting Chinese cultural thinking at the center of the novel. Not just the Tiger Mom, but the Chinese traditional religious beliefs, the importance of ancestry, and social class. These ides permeated the book and lifted it out of the cliches of typical mother-daughter stories, or immigration stories.

The ending was very affecting. In the last story, one of the daughters returns to China after her mother dies, not in place of her mother, but, in a spiritual sense, as her mother. This sense of ancestry, that future generations do not just succeed the previous ones but actually embody the hopes and dreams of their forbears, is a very powerful concept, an argument convincing even to the Western reader.  It clarified the other mother daughter relationships in the novel, which mostly seemed antagonistic, but in light of the final chapter appear more to be a misunderstanding between the mothers and the children. The mothers simply want to transfer their hopes and dreams to their children, just as they accepted the hopes and dreams of their parents. Trying to do so in a new country proves to be almost impossible -- with the emphasis on almost. The book emotionally resolves when the daughters re-interpret the aggression of their mothers as a desire to pass on hope and love.

I can see why some Chinese-Americans would feel the book promotes Asian stereotypes. (Search the internet for “hate Amy Tan” and see what you get.) The mothers are traditional Chinese and their voices and life stories resemble the the views and stories Americans might expect traditional Chinese women to have. And the daughters seem to react to their mothers in typical California Valley Girl ways — dismissive, rebelling, and with a shrug. Surely not all Asian mother-daughter relationships are this way. Although in Tan’s defense — and this isn’t just a defense, it is the final word — as an Asian-American herself Tan has a right to write about the Asian-American world as she encountered it. If the stories here aren’t legitimately her experience, that’s a different matter, but I assume that they are. And if so, she has every right to express them.

But the stuff about one daughter saying her mom came over from a “slow boat to China,” another daughter being a chess genius, two of the mothers working in a fortune cookie factory when they arrive in San Francisco, and all the talk about how Americans don’t have discipline…well, I can see the problem.


The Midterms

The midterm elections are over, at long last. The Democrats managed to secure the House, which is a good thing, since if they hadn’t I am not sure we wouldn’t have had riots. I am no advocate of violence, but we live in a democracy, after all, and a democracy can only survive as long as the majority is allowed some say in the government. As things stood the day before the midterms, a marginal majority of Americans either identified with the Democratic party or were sympathetic to many of its aims.

This is particularly true in the areas of health care and gun control, and I would argue that a narrow majority also supports the Democratic attitude towards immigration. (Which is not to swing the gates wide open, as many irresponsibly allege, but instead to recognize that our economic and cultural growth depends on a steady influx of immigrants, and that basic immigration policy ought to acknowledge that fact.)

That we could have a president that was not elected by a majority (Trump received 48% of the vote in 2016), a Senate that does not represent the makeup of the majority (it is white, male, and religiously and economically conservative), a Supreme court with 5 of 9 members clearly identifying as Republican (and several declaring themselves Originalists, the legal equivalent of Fundamentalism), and a House of Representatives that is much more Republican than the nation the nation at large (House: 55% Republican in 2017; the general public averaging 30% Republican, 40% Democrat, and 30% independent in most polls), the situation as it was on election eve could not possibly hold.

No matter how conservative you are, or how liberal, if you truly believe in democratic government, you must believe that our elected officials ought to approximate the center of gravity of society at large. When the makeup of government is significantly different from public opinion, there is great social tension. If it goes on long enough, there must be either be civil war or dictatorship. Either the public will cast the government aside entirely, or the government will close out the right of the public to a say in politics. But as long as there is tension, government and society will constantly disrupt one another.

My views tend Democrat, but as a lifelong Southerner I have mostly lived under the political leadership of people more conservative as I am. For me, this is acceptable, as long as the conservatives in charge don’t act like liberals don’t matter, and as long as the conservative leaders govern with a sense of responsibility to everyone. The governor we have now in Mississippi, Phil Bryant, is far to the right of me, but for the most part he is milquetoast, so the situation is tolerable.

On a national level, politicians these days seem much less benign, and are more likely to run over the concerns of the opposition. (Think climate change, abortion, and immigration as examples of areas of contention where the party in power tends to ignore the concerns of the party out of power.) Balance is necessary. In fact, the more polarized national politics gets, the more crucial it will be that citizens feel each side is checked by the other. Otherwise, there is real danger of civil unrest.

Divided government means gridlock. Partisan carping. Lots of whining and grandstanding. It might mean threats of impeachment. I used to believe that gridlock was the worst kind of government, but at this point in history a majority that is perpetually under-represented and ignored is almost certainly worse. Democracy has never been perfect, and never will be, but its chief strength is that it is self-correcting. When government goes too far in one direction, the majority tends to pull it back. This results in uneven progress, with government direction lurching from one side to another, but in the end, it keeps us from going into the ditch.  The greatest preserver of democracy is us, and the greatest threat is us unchecked. May we always check ourselves.