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Herman Melville, Moby-Dick, or the Whale

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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

Health Care Reform, by William Shakespeare

The battle over the repeal of Obamacare is in a ceasefire, but it is hardly over. And there is still immigration reform, and a Supreme Court nomination, and who knows what other political melees pending.

This time, rather than expound my own views on politics, I thought I would allow a few words from an old friend.

The quality of mercy is not strain'd,
It droppeth as the gentle rain from heaven
Upon the place beneath: it is twice blest;
It blesseth him that gives and him that takes:
'Tis mightiest in the mightiest: it becomes
The throned monarch better than his crown;
His sceptre shows the force of temporal power,
The attribute to awe and majesty,
Wherein doth sit the dread and fear of kings;
But mercy is above this sceptred sway;
It is enthroned in the hearts of kings,
It is an attribute to God himself;
And earthly power doth then show likest God's
When mercy seasons justice....
Though justice be thy plea, consider this,
That, in the course of justice, none of us
Should see salvation: we do pray for mercy;
And that same prayer doth teach us all to render
The deeds of mercy.

          -- William Shakespeare,
              The Merchant from Venice
              Act IV, Scene 1, ll. 182-200

Here Shakespeare, in one of his greatest speeches, makes a heartfelt case for justice tempered with mercy.

But he is after all Shakespeare. Which is to say, messy. Shortly after the character Portia delivers this sparkling speech, she uses the law to strip the Jew Shylock of half his fortune and force his conversion to Christianity. To make things worse, Portia is not even a judge, but instead a wealthy heiress fraudulently posing as a judge. Any legal decision she renders as a fake judge is illegal, and thus hardly an act of mercy.

Shakespeare's audience would have found this hilarious, but today the humor is tempered by the cruel and anti-semitic treatment Shylock receives. Yes, Shylock is a villain and yes, he does try to kill one of the main characters. But for all their boasting about superior Christian values, the Christians in the play do not exactly live up to their Christian values when they mete out punishment.

Portia admits as much in the first act, when she says, "I can easier teach twenty what were good than be one of the twenty to follow mine own teaching." That is, it is easier to teach others right from wrong than to follow the teaching yourself.

But then, that is the point of mercy, isn't it? "In the course of justice, none of us should see salvation" in Portia's speech means that if God is just, we have no chance of escaping punishment. Justice has very little meaning without mercy, because if all of us were punished fairly every time we did wrong, we would all be in jail -- or worse.

As Shakespeare argues, far from being a sign of weakness, mercy is a sign of strength: "Mercy is above this scepter sway; It is enthroned in the hearts of kings, It is an attribute of God himself."

If I were in charge of health care reform, I would, like Shakespeare, be more concerned with mercy than justice. And should I fail, I should seek mercy myself, and then make a second attempt.


On Illegal Immigration 

Undocumented immigrants are breaking the law by remaining in the U.S. So, many conservatives ask, what is wrong with enforcing the law by removing them?

I've thought a lot about this lately, and here's what I've come up with.

As a physician, I have a job that permits me to see into people's private lives. I see people who do drugs, who cheat on their wives, who commit fraud of various kinds. Who beat their wives or abandon their children. Who abuse or horribly neglect their elderly parents.

All of them are citizens. Citizens who daily break the law. And none of them are in jail.

If you ask me who has done more wrong, an alcoholic who continues to drive drunk or an illegal immigrant who cuts grass so his family can eat, there is no comparison.

Illegal immigration may be a crime, but it is just one of many. It needn't be singled out as uniquely bad, because it isn't. The idea that we should marshal para-military assets to combat a crime that hasn't been proven to cause serious harm to our society seems excessive at least, totalitarian at worst.

Where is the proof that undocumented immigrants harm our economy? They mostly take jobs no citizens want. They replace roofs, wash dishes, cook fast food, clean houses, babysit children. They aren't CEOs, or stock brokers, or welders, or certified electricians. In fact, by doing work no citizen wants to do, they add to our GDP by producing tangible products that create jobs for Americans. When an illegal helps build a house, an American can sell it. When an illegal picks peaches, a farmer sells the produce. When an illegal mops a floor, an American gets a job making, shipping, and selling cleaning chemicals.

An economy is complicated. One person chops down a tree. Another mills the wood. Another makes furniture from it. Yet another delivers the furniture to a store. Someone else sells it, and someone else delivers a chair to your house. You buy insurance on your house to protect the chair from loss in a fire. The chain goes on and on. So what if the lumberjack is an illegal? All the other people in the chain could be Americans. So the production of one illegal leads to jobs for dozens of other people.

That is how an economy really works. It isn't millions of people in a pit wrestling each other for a piece of meat. It is millions of people working together, each benefitting the other. Illegals sometimes drain resources from that system, but they are also productive, and the products they make add to the process. In fact, the products illegal immigrants make are added directly to the calculation of the GDP. To misunderstand this is to overlook the value illegal workers add to our economy, and the harm that would arise if they were kicked out of the country.

How serious a crime is it to cross a border in search of a job? Isn't there is a difference between stealing bread so your children can eat and stealing someone's retirement savings? Illegal immigrants don't scam you out of your life savings. Good old true-blue Americans do that, every single day. People who insist on throwing all the illegals out pretend such moral distinctions don't exist. They pretend that a person who crosses the U.S. border looking for work because his family is hungry is in the same moral status as a professional swindler.

This is obviously not true. Most of the people who come illegally into the United States are looking for work out of personal necessity. They are not here to steal from Americans. They are here because they rather enjoy eating and are hoping to continue the practice of eating in the future. And they wouldn't mind if their children could have a chance to eat as well.

To come down on such people as if they are spouse abusers or drug dealers or drunk drivers is ridiculous. They are nothing of the sort, and as long as they follow all other laws and are otherwise upstanding members of society, there is no reason they should not be treated with the same dignity our system accords to citizens who disobey the law in other ways.

Mercy is an important aspect of the law. If we were prosecuted to the fullest extent of the law for every illegal act we ever committed, we would all be serving jail time. If drivers got a ticket every single time their speed drifted up to 67 mph, every single driver would be bankrupt from recurring tickets, and the roads would be empty.

Laws have to be enforced intelligently, not blindly. The purpose of law is to maintain social order, but the dirty little secret of society is that good citizens break the law from time to time, and social order is not disrupted. A wise government knows this, and often turns a blind eye to "crimes" that do not harm society deeply, like accidentally drifting above the speed limit or the occasional experiment with illegal drugs, and instead focuses on those that clearly disrupt order, like intentionally running red lights or dealing illegal drugs.

Blind enforcement of the law is tyranny. The goal of government isn't to throw every single transgressor into prison. It is to correct people who drift outside of the lines and get them back on track. And to be tolerant of people who are breaking the law for understandable reasons, and who are not causing significant harm when they do.

I don't think undocumented immigrants are causing nearly the harm some politicians want us to think they do. Yes, they are breaking the law, technically, but many of them bring more value to the economy than they take away, and most of them have good reasons for doing what they are doing. We need to let mercy and understanding take its place in governing, as it is supposed to.


Change Is the Only Constant

For the last few years, I have practiced mindfulness meditation. For those who don't know, mindfulness meditation is a style of meditation that focuses on being in the present moment, awake and alert as possible. I find it a necessary antidote to our hyper-distractible world. It is impossible to spend five minutes in today's world without someone tugging on your sleeve: Buy this! Look at me! Spend your money here! This constant stimulation pushes us further and further from self-awareness. Instead of living our own lives and thinking our own thoughts, we end up living someone else's life and thinking someone else's thoughts.

Mindfulness is about quieting the world and concentrating on being in the present. The very opposite of almost everything in contemporary life, which is locked into the concept of escape. Escape into the internet, social media, TV, fast food, sports -- and the complete rejection of being alone with yourself, alive in the present moment.

Since many religious faiths conceive of God as the creator of being and existence (think "I Am Who Am," the name God gave himself when He spoke to Moses out of the burning bush), the mindfulness experience is very close to the Christian concept of meditative prayer.

My attentiveness to meditation has been uneven, and I go thorough cycles of more or less intensity. Most of the time I approach it as a combination of self-observation and Christian prayer. But sometimes I just think of it as a way to quiet the mind, or as a mental discipline akin to working out the body. Just as the body needs exercise to keep strong, the mind needs to practice shutting out extraneous noise to stay fit.

Meditation has taught me many things, things I didn't expect to learn when I first sat down to practice. I think this aspect of meditation is a sign of its power. It is one thing to get out of a practice exactly what you expect from it, but when you learn the unexpected as well, you know you are really onto something.

For instance, one morning this week when I sat down to practice, I found that my mind was spinning. I had made the mistake of looking at social media just before starting my meditation. Something came up that irritated me, and several ideas pinged around in my head even as I sat down and began my breathing.

A racing mind is not compatible with productive meditation. But rather than get up and skip the day's session, something I might have done a few years ago, I chose to allow the racing thoughts to run on, bounce around, and burn themselves out. This is a common technique for calming the mind in meditation. Rather than forcing distracting ideas out of the mind, which is very difficult, you let them run, and observe them without feeding into them. Usually they will fade away of their own accord.

This took more than twenty minutes. So I sat for 20 minutes, allowing these thoughts to spin around in my head, curl and uncurl, exhausting themselves like a hyperactive hamster on a wheel, until I finally got tired and my thoughts began to clear.

And another thing happened. It was an unusually warm February morning, and so I chose to sit outside. When I first sat down, there was a moderate wind, and the sky was completely overcast. But as I sat and struggled with clearing my worries from my mind, the wind swept away the clouds, and the next thing I knew I was looking at a blue sky, sunshine, and cirrus clouds scudding lightly by.

As I sought change in myself, the sky kindly changed for me.

One of the principles of meditation philosophy is that everything changes. That attachments to physical things, ideas, and emotions cause suffering and discontent with life. The goal to good living, the teaching goes, is to allow attachments to pass and to free ourselves of them. Mindfulness teaches that change is life's constant, and that if we wait patiently, most things, good and bad, will pass away.

And so on Saturday I sat, and the sky talked. When I sat down, the sky was overcast, and so was my mind. When I got up, the sky was clear. I was less so, but certainly a lot clearer than I had been when I began. They sky taught me that day that if I am patient, it will change. And that I should expect no less in myself.

This is what meditation teaches. If you sit and listen to the natural world, it will teach you about change, and teach that excessive concern over what is happening now is a form of suffering. To be free, to be happy, one must accept change as the constant. The reward for patience is change and renewal. Only by seeing this truth, can peace, and God, be found.


Child Killers

In the first week of the new Congressional session, Senate Republicans took the first step in making good on their promise to gut Obamacare and replace it with... well, who the heck knows.

In typical Washington style, the Republican Senate (no Democrats voted in favor) passed a budget resolution that would defund most of Obamacare’s initiatives, without setting a specific timetable for doing so. In other words, they voted for what they promised without passing an actual law that would make the promise a reality. It was a perfect example of Washington politics: appear to do something without really doing anything.

That doesn’t mean that nothing will happen, though. The House can approve its own bill based on the Senate resolution and then, with a second Senate vote and a reconciliation process, a final bill goes to Trump to sign. What the Senate did last week was to outline their plans for repeal. What they did not do was accomplish anything. Yet.

Since everyone has come to bury Obamacare, I will not praise it. But let’s at least understand that Obamacare is not a thing. There is no Department of Obamacare. There is not a single insurance program developed under the Affordable Care Act (the real name of Obamacare) that was new. The only thing Obamacare did was increase the funding of certain programs, and change some of the regulations for private insurance carriers. No new insurance entities exist. There are so-called Obama insurance plans, but these are just private insurance plans that are adjusted to fit the new regulations and are sold with government subsidies. All of these insurance plans are issued by standard private companies. Nothing new here.

As a doctor, I often encounter patients who wink at me and say, “I bet you hate Obamacare.” Why would I hate Obamacare? Obamacare authorizes more money to pay me, and the payments come from the same companies and organizations who have always paid me. There is nothing for me to dislike. Most of the doctors who dislike Obamacare do so because ideologically they oppose big government programs and don’t want to pay higher taxes. But in the day-to-day practice of medicine, between 2010 and now nothing is different. Same checks, same payers.

I won’t present an ideological argument with about taxes and government here, but I will say that Obamacare changed nothing about the way I practice medicine. The only difference is that there are fewer uninsured. All of the regulations that have changed the way medicine is practiced over the last 10 years have come from a tightening of Medicare law, which is not Obamacare. These changes would have taken effect even if the ADA had never been passed. Nor will they go away if Obamacare is repealed.

Most of the measures the Senate will take to repeal Obamacare are steps I strongly disagree with. Bringing back pre-existing conditions, preventing parents from insuring their own children to the age of 26, and prohibiting insurance companies from imposing lifetime limits -- all of this is manifestly stupid.

But you know what? I don’t care. I’m a doctor, which means I will always be able to get health care. I have nothing to worry about. I can either get my employer to pay for testing I need, or if worst comes to worst, I can ask doctor-friends to help me out. Believe me, I'm good.

It's the people who voted for Donald Trump and have no "in" with doctors who are screwed. They may not realize it yet, but very soon, they will. And I will not feel sorry for them, not anymore. I am tired of feeling sorry for people who choose to sabotage their own lives. Go right ahead, folks. Blow up the ADA. See what happens. I’ll wait. You deserve what you asked for, and you have no idea what you are asking for.

But one aspect of the repeal has me livid -- the cut in funding to the CHIP program. Defunding CHIP was clearly implicated in the Senate vote because, when Democrats proposed an amendment to the resolution to maintain its funding, it was shot down by a nearly unanimous Republican vote. The Republicans mean to kill CHIP. It is one of their political targets.

CHIP stands for Children’s Health Insurance Program. It is a part of Medicaid designed to provide health insurance to poor kids. Its purpose is to extend Medicaid insurance coverage to all children whose parents make too much money to qualify for Medicaid, but not enough to pay for private insurance. Gap insurance for kids, if you will.

And the Republicans, child killers that they are, are trying to shut it down.

As a doctor, I have participated in the CHIP program. I took care of kids first in Louisiana as a CHIP provider and then later when I was in practice in McComb, Mississippi. Like all federal programs, CHIP was not without red tape. But in my experience, it was an excellent program, the kind of thing taxpayers should hope their money is going to.

CHIP is focused on preventative care. To remain in CHIP, parents had to bring their kids in for regular checkups. The kids had to follow immunizations schedules. They had to be screened for hearing and learning disabilities, and doctors had to follow checklists for health monitoring.

As much as, even more than, any other medical program I have participated in, CHIP adhered to American Academy of Pediatrics (AAP) guidelines for child health care. Most insurance programs are fairly weak-kneed about asking doctors to follow state-of-the-art medical standards. But not CHIP. For a doctor to get paid, he or she had to meet AAP standards at each well-child visit. If a doctor refused to follow guidelines, he could be eventually removed from the program.

High standards, preventative care. It is the very thing you want a health program to be.

And for the taxpayer, the view is even better. CHIP provided insurance to kids whose parents made too much money for Medicaid, but not enough to afford private insurance.

Let me state that another way. CHIP is for kids whose parents WORK, but whose parents aren’t making enough to pay for private health insurance.

From where I stood as a medical doctor, CHIP was a pretty good program. It took care of children. It offered a helping hand to parents who were working but not out of poverty yet. And it adhered to medical guidelines for preventative care as established by the American Academy of Pediatrics.

CHIP represents the conservative approach towards government programs. Keep the program narrow and targeted towards groups that would most benefit from the care. Make them modern and in line with the latest thinking in policy (in this case, pediatric medicine). Make them function as a ladder to help people get out of poverty, rather than a crutch.

The last feature, the ladder out of poverty, is crucial here. Poor parents often can’t get jobs with health insurance. And if they manage to get a job, the income from the job makes them ineligible for Medicaid, because in many states any income at all disqualifies families from the program. CHIP allows parents to get jobs and work and not have to worry about their children losing health insurance.

Where is the drawback here?

And yet, Republican leaders have been gunning for CHIP as long as it has been in operation. The standard complaint Republicans voice is that CHIP is federally run, and that individual states should decide for themselves if they want this type of coverage for their citizens. But mostly, I think, they see it as a wedge issue. Working middle class people see poor people get free health care when they have to pay for it, and they get jealous. Attacking CHIP is a way to play to this sense that too many people are getting a free ride.

No one points out the flaw in this argument. The 8 million kids insured by CHIP don’t choose what jobs their parents get. They don’t get to pick their parents, and they can't make money themselves. They are helpless, and therefore without blame for their situation.

The second flaw is thinking that CHIP (and Medicaid, for that matter) are giving “free money” to the poor. Not a dime of CHIP money goes to the poor. You know who gets the money? Me. Nurses. Physical therapists. Pediatricians. Hardworking people who want to take care of kids. Healthcare providers get CHIP money. The patients get nothing but medical care. No money.

So when you oppose a “free ride” for the poor, you are denying money to health care professionals who work hard to help the patients they see. The children are hurt. Their doctors are hurt, when they have to choose between giving free care and abandoning patients who need a doctor.

Today, the 8 million children in CHIP face life without insurance. Some of these kids have serious asthma. Some have cancer. Some have seizures. Some are kids with learning disabilities who need a doctor’s help to remain in school. If these kids lose their health insurance, many of them will unnecessarily suffer, and some of them will die.

And so I salute you, child killers of Washington, DC. Thanks for hurting and killing defenseless children. May the hurt you inflict on others be visited upon you.

On you, Senators, but not on your children. I may be vindictive, but I would never be so cruel as to try to harm a child. To do that, you’d have to be a heartless bastard.


2016: My Year in Books

Despite all the unfortunate things 2016 brought us (and there have been many), I declare my relationship with the printed word a success. By my count, in 2016 I read 28 books, not counting a few technical medical books, multiple reference books that I haven’t read every word of but have perused heavily, and a large quantity of short stories and essays. I love essays of every form, and would guess that if I could add them all together, the books I have read would make up less than half my total reading for the year.

So, as I said, a good year. Books are a friend to me; I know I have read more books this past year than seen complete movies. The only long form of entertainment that gave books serious competition was football. Probably in 2016 I have seen more complete football games than read books. Maybe.

At any rate, here is the complete list, in the order that I read them:

Bird by Bird, Anne Lamott
All the Light We Cannot See, Anthony Doerr
Hamlet, William Shakespeare
The Now Habit, Neil Fiore, PhD
Revolutionary Road, Richard Yates
Idiot America, Charles P. Pierce
Seven Last Words, James Martin, SJ
Thank You for Smoking, Christopher Buckley
How to Publish Your Book, Jane Friedman
Wherever You Go, There You Are, Jon Kabat-Zinn
10% Happier, Dan Harris
Deep South, Paul Theroux
The Finkler Question, Howard Jacobson
The Art of Fielding, Chad Harbach
Half of a Yellow Sun, Chinamdanda Ngozi Adichie
The Stranger, Albert Camus
Moonwalking with Einstein, Joshua Foer
Talking to Crazy, Mark Goulson, MD
How to Retire with Enough Money, Teresa Ghildarucci
You Are Not So Smart, David McRaney
Lifelong Writing Habit, Chris Fox
Notes from a Small Island, Bill Bryson
Moby-Dick, Herman Melville
The Addictive Brain, Thad A. Polk, Ph.D.
The Revenant, Michael Punke
Writing Tools: 50 Essential Strategies, Roy Peter Clark
Dispatches from Pluto, Richard Grant
The Fellowship of the Ring, J.R.R. Tolkien

For me, the best of this bunch, in no particular order (because I am not the type that ranks everything -- I think equally highly of many books), are Moby-Dick, All the Light We Cannot See, Revolutionary Road, and of course Hamlet.

Moby-Dick was a re-read -- I first read it one summer during high school. It was much better than I remember. Moby Dick, though very long, has to be read patiently. Melville’s prose is not easy to get through, but despite his long-windedness he never wastes a word. It is possible to misunderstand an entire chapter for want of a single sentence, or even a single word. That was the surprise of my Moby-Dick experience, that Melville is so precise. Like the true master he is, he means what he says and says nothing more than he means. My advice: Take it slowly! Rushing through Moby-Dick makes about as much sense as taking Christmas dinner standing up with a 5 minute egg timer and a shovel. You take it at the pace it wants to come, and it rewards that patience with vast treasures.

 All the Light We Cannot See was a luminous joy. Because it was unexpected: I had never heard of Anthony Doerr before, and yet I found that his tale of a blind girl eluding the Nazis in World War II France, despite the dark setting, lightened my heart. Perfect winter reading.

I would also like to acknowledge Dispatches from Pluto, a memoir of a British writer’s experience of moving to the Mississippi Delta. It was funny, and, as a Mississippi resident, I can vouch for its truth.

Finally, as a writer let me salute Bird by Bird, a book that most non-writers will never read, because it is about the craft of writing. Lamott’s memoir/advice book on the art of writing is funny, joyful, harrowing, and most of all hopeful. It put a spark in my pen (or keyboard) this year, and for this I am grateful to Ms. Lamott, a rare writer who knows how to be both harrowing and hilarious at the same time.

I look forward to 2017, and another 30 or so books. I have to finish the last two books of Lord of the Rings (another re-reading from childhood), and beyond that, my nightstand runneth over. Waiting to be read are, among others, My Brilliant Friend, When Breath Becomes Air, The Long Loneliness, The Prize, many splendid things by Michael Chabon, Marilynn Robinson's Housekeeping, Italo Calvino's Invisible Cities, and who knows what surprises life will bring me.

My eyes are ready to behold the world.

Have a happy New Year, and read well and often.

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