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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

President Revenge

“When he gets attacked, he’s going to hit back… He’s not going to sit back and be attacked by the liberal media, Hollywood, elites -- and when they hit him, he’s going to hit back.” — Sarah Huckabee Sanders, June 29, 2017

Among his critics, the usual response to the President’s Twitter posts is to say that they are undignified. Not rising to the level of the office of the presidency.

This is missing the point. Dignity in politics has been dead for quite some time now. The last shred of it, in my view, vanished in the second presidential debate, when Donald Trump brought in several women who have accused Bill Clinton of sexual assault. Others might counter another example, but it doesn’t matter. We can all agree that politics is a disgrace right now.

More to the point is the statement by Ms. Sanders, which obviously represents the opinion of the President himself. His wife repeated the sentiment in almost the exact same words on the exact same day. Hit the President, she said, and he will back "10 times harder."

Consider for a moment what this means. It means that the President’s political policy — in fact, the clearest political policy we have from him since “I will build a wall” — is revenge. His announced plan for handling political adversity isn’t to produce more thoughtful legislation, or to become a more magnetic leader. It isn’t to champion peace or ethics or equality or to lead bipartisan compromise. It’s to knock the crap out of anyone who tries to lay a glove on him.

Revenge. That’s it. That’s what his dialog with the press is all about. Don’t you dare say anything I don’t like or I will slap the skin off your face.

His defenders will probably use the more-sinned-against-than-sinning argument, but here is the problem with that: He is the President. Although his behavior in office suggests that he thinks the Oval Office is his own personal property and pleasure palace, this is not the case. There were 44 presidents before him, and there will be, God willing, many more presidents after.

He didn’t create the office. He didn’t win it in a contest. He didn’t earn it as the last man standing on a reality television show. The presidency is not his to do with as he sees fit. The powers of the presidency belong to the people. It is defined in the Constitution, the first three words of which are "We the people." A president acts on behalf of the people, exercising powers that the people confer upon him. Powers that can be revoked at any time. He no more owns the Oval Office than I owned the public park bench I sat on the other day.

The point is this — since the powers of the office are not his, and he has no right to use those resources to settle personal scores. His "hit and I will hit back harder" mantra is an illegitimate and illegal use of the office.

Indeed, why is he spending any time at all tweeting out personal attacks? The reason most past presidents have been restrained in their public remarks is that they understood this. While Barack Obama may have been upset by the birthers, he didn’t spend time on the clock raging about it. Ronald Reagan got pretty harsh treatment about his age and supposed memory lapses and he shrugged it off. There are certainly examples of presidents who have settled political scores on the job. But there is a big difference between political conflicts, which are part of the job, and personal conflicts, which are not. Chris Christie is about to be unemployed for exactly this reason.

When you are the President, you don’t get to use the office to get even for perceived insults, even if they are unfair. It isn’t about dignity. It is about using the resources of your office on behalf of the people, not on your own behalf, as if the Oval Office were a newly acquired wing of Trump Tower.

Some would defend him by saying Twitter is not a public resource. Bull. He has millions of followers because he is President. And when he says something outrageous, his press secretary and many other government officials find themselves having to defend what he said. As Ms. Sanders did, on the public dime. Or as the First Lady did, through her own spokesperson, another public employee.

If the President wants to settle personal scores, he needs to quit his job. Then he can attack whomever he wants. But if he wants to engage in personal attacks out of his office, he is abusing his powers.

So, you ask, is the President just supposed to take it on the chin? Actually, yes. A big part of being President is knowing when to keep your mouth shut. When you are President, you speak for the American people or you don’t speak at all. This isn’t too much to ask of someone who could, with unguarded words, trigger a war.

Revenge is not acceptable public policy.


Out of the Paris Accord

To me, this is an impeachable offense. Considering the danger climate change poses to the American people, it is a crime to back out of the most important environmental agreement ever. Climate change is not a debate. The only debate about climate change is in the minds of people who have been paid off by oil companies.

But forget about oil companies. Forget about coal. Remember this: The days of oil’s supremacy are over, and I say this as someone who grew up in the oil patch of South Louisiana. All of Donald Trump's whining and foot stomping about what's fair for the American worker won't make a minute of its slow collapse any different. You can change politics, but you can't change facts.

Solar and wind power are advancing rapidly, and the third world will adopt them rapidly, because third world nations aren’t stupid. They will want technologies that do not cause dependence on oil-producing countries. Technologies that won't ruin their environment and make their droughts longer, and won't pollute their cities with impenetrable smog.

Oil has had its day. The future belongs to other technologies. Don't believe me if you want, but I know where I am putting my retirement money, and it isn't in oil. And coal? Please, don't make me laugh. Coal was cutting edge in the eighteenth century. Tell me about all the eighteenth century technology you used today.

I am driving a 12 year-old car and have no intention of buying a replacement that doesn’t get at least 40 miles per gallon. What I really want is a plug-in hybrid -- no, what I really want is an electric car -- but I am not sure if the ones on the market are right for me. So I will wait until I get the car I want. My car still runs. I have time. And I won't be waiting all that long, either.

This is a metaphor for world society. A good chunk of the world economy is using older fossil fuel technology and is waiting for the moment when it can install cheap renewable energy. The time is close. I saw a news story the other day about roof shingles that have solar cells in them. Another company is developing solid glass hexagonal bricks that can pave roads and generate power at the same time. There are now a few countries in Europe that can fulfill their entire energy needs with windmills alone. And we are just beginning to build out the infrastructure.

More solar panels appear on the roofs of houses every day. Cars are being sold with gas mileage rising into the 30s and forties. Not 5 years ago the Prius was the only car that boasted a 50 plus mpg; now there are at least a dozen. Natural gas, a less polluting fossil fuel, has displaced coal and oil as the main source of indoor heating in this country and is serving as a stopgap that has helped level out emissions temporarily.

No, it won’t be long. We all saw the computer revolution. In 1985 all we had were massive desktop machines that could do little more than word processing and organize your list of CDs. Now we have iPhones that give us directions to the movies and buy us the movie tickets in advance. Computers drive cars now. Is anyone so stupid as to think that this revolution won't sideline fossil fuels?

It would be intelligent for the most technologically advanced society in the world to commit itself to new energy technology. But our leaders are not intelligent. Instead, they seek to damage the long-term competitiveness of our nation.

There is nothing to be gained in backing out of the Paris Accord. Of all countries signing, we have the most companies poised to make money off of this. We have the research facilities, the open land for wind farms and solar farms. We have the knowhow and universities willing and able to commit all resources to clean energy development. We have the world's largest nuclear program. (No, I don't think nuclear energy is out of the question. Fusion energy is the Holy Grail of clean energy. No time: Go look it up.) No other country has so many resources.

The only resource we lack in this new technology race is rare earth metals. Most of these are in China. Which is another reason not to back out of the Paris Accord -- China has signed, and if we pull out, China might retaliate by restricting our access to the rare metals needed for advanced computer and battery technology. That would be an ironic price to pay for being stupid, wouldn't it?

There isn’t a way we win with this. In backing out we commit ourselves to obsolete energy technology. We throw the door open to our competition to take the lead in energy advances that could revolutionize poverty in the third world. We lock our universities out of going all in on new discoveries that everyone in the world will be adopting soon.

And we will be saving the environment. I almost forgot about that one.

Let’s just say for the sake of argument that you believe climate change is a hoax. Even so, consider that every one of the 190-plus nations who signed the Paris Accord feels differently. A smart nation is a nation who understands where everyone else is going with this and decides to get there first.

The city of Lynchburg, Tennessee is home to Jack Daniels Distillery, possibly the world's most famous bourbon manufacturer. It is also a dry county, which means it bans the sale of alcohol. Despite this local opposition to alcohol, Lynchburg has no objection to allowing Jack Daniels to make whiskey and sell it elsewhere. After all, the people of Lynchburg may not like alcohol, but they aren't stupid. They will take the money they make from selling Jack Daniels even if they won't drink it. And they have been cashing the checks for over a century.

You don't have to sell what you like. You sell what makes money. Clean energy is a huge business opportunity, maybe the biggest one in the whole world right now. Most countries in the world have little or no oil, and would love to have energy without creating dependence on countries who have. That's what this is all about. Even if you are one of those who doesn't believe in climate change.

There is a rumor around, hinted at by many people who know him, that our current president was never a birther. That he never at any time believed that Barack Obama was born in Africa. The rumor goes that he only said so because he knew the Republican base would buy what he was selling. If so, this may display an alarming lack of moral principle, but a keen business mind. Here was a man who knew he could profit from selling to others an idea he thought was bunk himself.

In the same way, wouldn’t it be smart for the U.S. to promote or at least encourage thinking that drives every country in the world into buying more of our stuff? How do we lose from this? Only Big Oil loses. And Big Oil will lose anyway, because if it won't help the world develop clean energy sources, someone else will. If Big Oil would take the untold trillions it has made selling oil and use it to develop solar, wind, and battery technology, it could profit, too.

All we are doing by exiting the accord is alienating our friends abroad, and crippling our domestic businesses in their efforts to compete in potentially the most lucrative business venture of all time: cheap energy for everyone.

Oh yes, and saving our planet from environmental devastation. I keep forgetting about the devastation part, but hey, that's the grandkids' problem. We'll be dead by then, right?


On Writer's Block

Waking up in the morning, my mind swirls with all sorts of things: turns of phrases, essay and novel titles, images -- whole paragraphs leaping out intact, sometimes even whole essays, complete-form.

Between the mind and the page there is a speed bump. It's not all that high, but that's the genius of speed bumps anyway. They don't have to be high. They don't have to forbid. They just have to discourage.

If I understood the speed bump, it would be easy to defeat. My sense is that it is a problem of organization, not of fluidity. It is easy to think of lack of fluidity as the heart of writer's block, the misery of squeezing for that drop that just won't come, but at least for me, that is not it. I am fluid all the time. I slosh from one end of my house to the other.

No, the problem is organization. Which is the opposite of fluidity. You can pour water into an ice cube tray, confining it and compartmentalizing it, and it will freeze and take shape easily enough. But there is the patient work of deciding to pour the water, of taking a moment to interrupt a non-structured day and do something structured -- pour water right now into a structured container with the expectation of enjoying an ice cube some time in the undefined future. It is easier not to be organized now for the sake of later, and so I leave my tray empty in the freezer rather than filling it up.

With writing, there is this ever-so-mild resistance to shape. The words flow, but you have to submit to limits and pour -- you decide this goes here, that goes there, that over there goes in the trash. We who flow are not amenable to that.


Jimmy Kimmel and Pre-Existing Conditions

Late night comedian Jimmy Kimmel delivered a powerful and important message last, an argument I have been making for years: There are some people who will never be able to afford their health insurance obligations. They lack the financial resources to pay for their treatment, and they always will. But society at large can afford to pay for these treatments, and should.

This seems self-evident. I don't have to go far on my daily hospital rounds to run into people who have medical problems that will cost more to treat than the patient can ever earn. Many stroke patients and most cancer patients fall into this category. Almost all children born with serious congenital diseases fall into this category as well.

This was Jimmy Kimmel's point. That children with serious medical problems will never be able to pay back their medical bills, and shouldn't be required to. Everyone has a basic right to life -- after all, the Declaration of Independence argued for the basic human rights of "life, liberty, and the pursuit of happiness." I do not think it was accidental, either, that the Founders put life first on the list.

No one can be faulted for wanting to live. Survival and the avoidance of pain, both goals of medical treatment, are the most basic instincts humans have. As a free society, we ought to be all about helping people to live when they want to, since all other freedoms depend on the right to live. After all, a dead person can't have rights. To have other any other right -- speech, religion, or voting -- you have to be alive first.

So, since all human rights flow from life itself, it makes sense to argue that the right to live -- that is, the right to life-saving healthcare access -- should be one of the chief goals of a free society. The fact that it costs a lot to insure everyone doesn't seem like much of an excuse. Defending the country is expensive. Educating children is expensive. Incarcerating millions for the maintenance of civil order is expensive. This hasn't stopped us before.

Critics of Kimmel and of health reform in general have argued that no person should be forced to pay for the health problems of another. That forcing a free individual to pay for another's health is a violation of liberty, just as it would be unfair to force me to buy my neighbor's shoes, or repair his car. In a free society, the argument goes, every individual should be responsible for himself.

This philosophy makes sense in theory. We are, after all, a free country. Why should I be required to pay for someone else's medical problems?

The problem is that the theory breaks down when faced with reality. If I don't pay a police force to protect someone else's home, there will be no police to protect me when my home is threatened. If I don't pay to educate other people's children, who will be educated enough to be my doctor, fix my computer, fly my airplane, educate my own children?

If I don't fund a health care system to take care of others while I am well, what reason do I have to expect it to exist when I get sick? Hospitals don't just pop into existence when we need them, like scenery props in a cheap movie. They need to exist all the time, so they can exist when rich people are in need.

And then there is the problem of consequences, which was also Kimmel's point. It is one thing to stand for the theory that the government shouldn't tax me or force me to buy health insurance, but it is another thing to face the outcome of that decision: A newborn baby with heart disease who must die because his parents can't afford the operation.

Kimmel was speaking out of experience. This is what we need in the health care debate, more people speaking out of experience. More people who have been denied care, who have had their care limited, or who have been frustrated by the shortcomings of the system that we have now. Healthcare reform cannot be about pie-in-the-sky political theories. Healthcare is about what happens to real people, in real situations.

One of the things that attracted me to medicine in the first place was its practicality. Medicine is conducted in the real world and is concerned with real people. No patient cares if an antibiotic will work on her disease in theory. She wants to know when she takes the antibiotic, if it will make her feel better. This is what medicine is all about. It is all medicine has ever been about.

As a doctor, I don't give a flip about constitutional arguments over health insurance. I don't care whether Mr. Jefferson thought it was fair or unfair to tax one person to treat the illness of another, or if Mr. Madision thought health administration should be a federal or a state responsibility. I care only that the system works, and that it works for a price that my patients can afford. My concerns are purely practical. Will it help me to take care of patients, and to help heal sick people?

For this reason, I think it is wrong to deny people insurance because of pre-existing conditions. As a doctor, it is my job to discover medical problems, which means I am in the business of finding pre-existing conditions. It is not acceptable that doctors do what they are trained to do, and in doing so, exclude patients from further care. It is, to say the least, impractical.

There has been a pitched debate over the funding of health care in this country for as long as I have been an adult, and it is ridiculous. American citizens don't want to think about their health insurance any more than they have to think about electricity, or roads, or running water. They just want to have it, and pay a reasonable price for it. When an intersection needs a stoplight, citizens expect government to put one in. When there is a fire, they expect the fire department to show up. What they do not expect when a fire breaks out is for a carload of politicians to drive up and lecture them about the constitution.

This should not be so hard. The only reason it is hard is because the discussion is dominated by people who can afford good doctors and who have adopted the principle that everyone else should be as rich as they are, not matter their age, genetics, or social condition. These people of high priniciples will raise taxes to put the poor in jail, but not a finger to help them with their doctor bills.

This is and always has been about money. About who has to pay what and when. For once in my life, I'd love to see the U.S. government grow up, make a fair estimate of what it would cost to insure everyone, figure out how to pay it, and then move on without further whining. This is not about "us" and "them." There is no "them;" it is all "us." Everyone wants health insurance.


Book Catechism: Colorless Tsukuru Tazaki and His Years of Pilgrimage, by Haruki Murakami

Describe this book in one word.

Can't do it. I hate reductionism, anyway.

But on the topic of reductionism: There is a great passage in this book about the massive Shinjuku train station in Tokyo. It describes a photograph that was taken at the station in the 1990s that was widely published in the United States, with an accompanying article that said, "Japan may be affluent, but most Japanese look like this, heads downcast and unhappy-looking." The main character of the novel, Tsukuru, disputes this observation: "The real reason that most passengers descending the stairs at Shinjuku Station during their packed morning commute were looking down was less that they were unhappy than that they were concerned about losing their footing."

That is to say, the station was so busy that in rush hour the crush forced people to look down to avoid being run over. It had nothing to be with being unhappy.

This is the non-reductionism at the heart of this fine novel. Murakami never allows us to settle into easy judgments. Tsukuru isn't really colorless. But in a way, he is. He goes on a long pilgrimage, but in the end he finds himself back where he was at the beginning. In many ways, at the end of the story he is the same person he was. But in another way, he undergoes profound change.

Well, that's awfully vague of you.

Ok. How about suspense as a one word description? It doesn't entirely fit but it's as good as a reductionist is going to get.

Now we are getting somewhere. Why suspense?

The book starts out with an inciting event and then slings the reader forward from big scene to big scene. It is very well plotted. It begins with Tsukuru being kicked out of a very close group of five friends he had in high school. His friends shun him from then on, with no explanation whatsoever. This completely unexpected event leaves him in shock.

After a few months of suicidal depression, Tsukuru rebounds with an unexpected friendship with a college student. This relationship ends as unexplicably as the loss of his high school friends. Years later, at the urging of Sara, his rather enigmatic girlfriend, he begins to look into his past, to find out what happened. One by one, he encounters his old friends, and has he does, the revelations mount. Each encounter with an old friend pushes Tsukuru on into the next one. And each encounter drives the reader forward as well.

I kept asking myself, What will happen when he meets the next one? To heighten the suspense, Murkamani sets the final encounter in rural Finland, making the last interview a spiritual and physical encounter. It is nicely done, a simple setup for an intensifying series of interactions, the stakes rising each time. I was surprised to find that the book was a real page-turner, not something I expected at all.

So the book is a mystery novel?

In a way. But some mysteries were never solved. In fact, several of the biggest questions raised by the plot were never answered.

In the hands of an inferior writer, this would be a real problem. But Murakami makes it clear that answering all the questions is not Tsukuru's quest. His quest is to learn to live with unanswered questions.

That is something we all must do. Learn to live with unanswered questions.

If that is true, why bother to read the book at all? In fact, why bother to write a book if you don't intend to answer questions?

It would be grossly unfair to the book to say it didn't answer any questions. It answered many. Just not all of them.

For example, Tsukuru inherits a Heuer watch from his father. It is an old watch, expensive. It doesn't keep perfect time, although it is pretty accurate. It has to be wound all the time or it will stop. Slightly temperamental, impractical, not at all like the rest of Tsukuru's life. Somehow this odd watch says something about Tsukuru, and about his father who wore it before him, but we never really understand what. But this is all right. We are not supposed to understand all of the vagaries about our lives. Tsukuru likes the watch; it is not like him, but not entirely different either. We can assume the same was probably true about his father, whom we never get to know.

And that is fine. Every loop does not have to be closed. Every watch does not have to run exactly on time.