Wednesday, November 17, 2010

Agree to Agree for Once

The Co-chairs of Obama’s Deficit Commission, or the National Commission on Fiscal Responsibility and Reform, for those of you who aren’t into the whole brevity thing, recently announced a $3.8 trillion plan that would cut Social Security and Medicare, reduce income-tax rates, eliminate tax breaks including the mortgage-interest deduction and make many specific cuts to different discretionary budget items, including the Defense budget and the National Parks Service. More than likely you are happy about one or two of their proposals and ready to fight tooth and nail about one or two of the other. Indeed, the leftern lobe of the blogosphere has been lighting up my inbox with headlines like “They just declared war on Social Security”. And the gauntlets have also been flying from the rightermost regions, with oaths of “No new taxes!” and “No deals, Mr. ‘Bama.”

If you’re interested in reading a variety of reactions to the proposals, I recommend this article from the Times which I think helps puts some of the issues into perspective.

This is probably the third draft of this blog. The first, especially after reading the list of cuts and changes to the discretionary aspects of the budget, was fairly rah-rah. I said, hey, this is the first time in my political life that I have heard anyone make a set of serious and specific proposals to address our country’s deficit problem so we should get behind it. Then I moved on to an angry WTF-type-of-thing, especially after reading more about the proposed changes and cuts to the entitlements portion of the budget (Social Security, Medicare etc.). I was ready to decry the proposal as another right wing plot to leave the poor and disadvantaged in misery and give money to the wealthy in the hopes that it would some day trickle down. I wanted to remind everyone that in addition to the moral question of social justice, we needed to realize that spending money on people in one way (Social Security, health care, education) would mean avoiding paying even more money for them later when their sh*t really hit the fan.

But these are tough times, arguably extraordinarily tough ones even, and I think they demand some extraordinary measures. So this is third draft (third verse, different than the first). The deal is that there is no way to balance our budget and reduce the deficit through discretionary cuts alone. No way to tax or spend our way out of depression. Anyone offering a simple solution is selling snake oil. A serious solution to our problems will be difficult and complicated--two things that politicians and Americans don’t generally want to say or hear.

Every one of us is will be required to make some sacrifices and decide just what is important, not to us or to our personal interests, but for the future of our country. Not just for or our children and their children, but our neighbors’ children. So the first sacrifice that I’m asking of myself and you, is to let go of our anger and bitterness, our mistrust and ideology. Our next step is agreeing to agree, however disagreeable that may be. Let us agree that the solution to our budget deficit, even the future of our country, is going to entail change. Let us maintain a high index of suspicion for any proposal that makes it sounds like things are going to be fixed with a few small tweaks but that otherwise we will be able to keep on going in the same comfortable way we have become accustomed to. The heat is on and the windows are down, my friends, so let us agree that some serious changes will need to be made to taxes and discretionary budgets and entitlement programs if we are to survive our over 13 and a half trillion dollar debt ($13,736,876,145 right now to be exact). This is something like a debt of $125,000 per taxpayer (watch the national debt clock ticking here).

I don’t see our current legislature, or perhaps any group of people who want to get re-elected, being able to agree on something as difficult and by nature unpopular as balancing the budget and reducing our ridiculously large deficit. Unpopular, why? Okay maybe unpopular is not the right word. Indeed, the idea seems eminently popular. What people don’t seem to like is any of this stuff affecting them, right? And that’s the problem, as soon as we start discussing these proposals, anyone who is or might be affected by any of them are not going to be happy and will start calling their congresspeoples and local radio talk shows. And the result will be a humpty-dumpty collection of disputed and in the end muted proposals that the legislature will never be able to piece back together again into a comprehensive package. So here’s the silver lining, a 14-vote Commission majority on a deficit reduction plan would require Congress to vote on the package unchanged. Still not easy, but at least fathomable. So all we have to do is get this bipartisan commission to agree, just 14 people, not 100 senators and 435 congresspeoples.

It seems clear to me then, and I hope to you, that our best way out of this mess is to throw everything we’ve got, we the people, into making sure this Commission comes up with the best proposal it can be, however much wrangling it takes, and that at least 14 of the 18 members agree to it. Let’s agree that it’s going to be difficult and that nobody will be really happy with it (sound like health care reform yet?), but that we’ve just to got to do it. Maybe it won’t be exactly the right mix of cuts and changes, and more than likely we will have to make some more cuts or go back and change some things that turn out to suck, but now is the time to roll up our sleeves and get stuck in there. It’s going to be a Pyrrhic victory, so let’s put on our Greek gloves and take out some budgetary trash.

What I’m asking you to do is throw away your ideology, not your morality or intelligence or compassion, just your ideology. I won’t push this part, but if you can muster it, send out some New Agey, 100th Monkey-ey type positive vibrations that things are going to change for the better, that a compromise can and will be reached. Finally, and this is important, send the debt commission and your national representatives a message telling them exactly what your priorities are in terms of budget cuts and changes, starting with your number one priority, which is that some intelligent, compassionate and serious changes and cuts must be made. You can contact the commission by email ( or visit their website. Here is a website that allows you to email your representatives, and your local or national media (you have to register first, then look for the links under 'Advocacy 101' on the right side of the page).

Here is what I’m planning on sending:
Dear Deficit Commission,

I beg of you to work hard over these next few weeks to come up with a proposal that you can agree upon and that entails intelligent, compassionate and serious changes to our national budget. Business as usual is no longer an option with a $13.7 trillion deficit, economic depression and another energy crisis around the corner. Not to mention our crumbling infrastructure and lagging educational system. There is no choice but success.

I believe you should focus on cuts to those parts of the budget that are most contributing to our national debt: Defense, Medicare and Social Security.

I’ll start with the hardest job, cutting some little old lady’s retirement benefits. All I can say is that for some people, the difference between getting their Social Security check or not is the difference between having proper food and shelter, and if they can’t afford these most basic of necessities than we are going to have to pay for more food stamps and shelters for them anyway and no money will end up being saved. So please cut carefully. Maybe you can create one retirement age for the white collar who can more easily work at age 70 and another for blue collar workers who aren't likely to be able to lift those garbage cans or crates at that age.

Regarding Defense, we have the most expensive military in the world by a factor of several countries put together. Nothing wrong with having the best, but it should not cost what several other G8 countries put together are paying. Let's get lean and mean. Do we need nukes? Do we need as many subs? Do we need? Do we need? How many megaton bombs and super intercontinental missiles do we currently need or use? Or have we ever used? Cuts should be made based on defense items we actually use and those that we might use in the future (intelligence, so-called “smart” bombs and troops on the ground type stuff). Get in there and cut the rest. Look at how Southwest Airlines saved money: one multipurpose fleet of planes, needing only one set of parts and training. Do we really need F-15s, F-16s and F-35s? Indeed, I’m happy to see some of this addressed in your CoChair report. I urge you to go further.

Next up, the nukes. I think it should be called nuclear encouragement rather than deterrence, because that’s what it seem to be doing, encouraging other countries to build bombs. Have all our nuclear bombs stopped the terrorists from attacking us or anyone else? It would seem not. Do any of our military conflicts present or future look like they will be stopped by the threat of dropping the big one? I think not. So cut away.

Regarding Medicare, decisions need to be made about costly interventions like dialysis (the single biggest drain on the system), organ transplants, end-of-life ICU all out wars against dignity and reality, and expensive new prescription drugs. Any medical device, drug or intervention that has not been proven more effective, and not just marginally more so, in head to head controlled trials than a generic, traditional or lower cost alternative should not be covered by Medicare, or covered at a reduced percentage. And those that are more effective need much tighter protocols on when they are to be used.

Let’s not mess around with the little stuff like PBS and the National Parks. The reason our country is bankrupt has nothing to do with PBS or the parks, and if even it did, their budgets just aren’t big enough to make a dent in the deficits we are now facing.

Taxes, nobody likes to pay them, but the truth is some people can afford to pay more than others. I believe in a much simpler and progressive tax structure. I think it’s clear that budget cuts and freezes alone are not going to do it. If the Commission’s proposal is to have any chance of getting the 14 votes it needs to pass and without which there is little hope of it being approved by Congress in any form likely to do much good, it will have to be bipartisan, meaning more revenue AND less spending. However distasteful to the right or left, revenue will have to be raised. Please keep all taxes and revenue progressive. People or businesses making more money should pay more money as a percentage of their income than those making less. This does not preclude the value or necessity of incentives to our economy and the direction of our growth. Encouraging behaviors through complicated tax loopholes is a game that only those who can afford a CPA can play. Let’s keep it simple. A progressive tax structure with simple and easily applied incentives for behaviors we want to encourage (saving money, education, science, research, small business investment, whatever). When I lived in France I was able to fill out my taxes online in about an hour and still benefited from savings incentives, housing aid etc. The incentives don't have to involve arcane and Gordian knots and loopholes. Simple and progressive.

Thank you for your prompt attention to this matter.

Kevin Lapin
A concerned and voting citizen


Saturday, May 15, 2010

"Stay Hungry, Stay Foolish"... aka Get Stuck in There!

Yesterday, to my complete surprise, I was taking care of 6 patients as a nurse on a medical-surgical floor. Even just a few weeks before, when this final clinical internship was beginning, I thought I would never, ever be able to do this job. Looking back, I see how the dots connect, from classes, to first fumbling attempts to take a blood pressure, to taking care of 1 patient, then 2, then 4...

That was yesterday. A little over a year before, I was applying to nurse practitioner programs with this idea that I loved theater, but wanted to do more (more challenging, more learning, more rewarding) with the rest of my time. So I took a few classes online and applied to Columbia (see "Poison Ivy League Here I Come").

Before applying, I did some volunteering in the hospital to be sure that the whole medical field thing was what I really wanted to do (and, to be honest, to make my application look better). In a weird circular connection of these little dots that make up the course of one's life, I remember watching two brand new Columbia students fumbling with their sphygmomanometer (blood pressure machine) in the hallway, encouraging each other that it would be okay and trying to build up the nerve to walk into a patient's room. And darned if a year later I wasn't standing on that very same unit, wearing the same navy blue scrubs, knees knocking, wondering if I was going to be able to get that BP reading.

Randomly, I remember another Columbia student that I ran into telling me that school was a lot of work and that there was really more reading than you could do, unless you were in your 30's and didn't have a life. And yes, I think she meant that 'and' in its full tautological or redundant sense, as in if you are in your 30's it's implied that you don't have a life so therefore you would have time to read it all.

Step back a few more years and now it's 2005. I've moved back to Paris, graduated from a bizarre little theater school known for physical theater and collaborative creations and am touring around France performing a two-person comedy about math, called "Mad Maths". Looking back another 10 years to 1995 and I'm graduating Dartmouth College with a degree in French literature and education. I'm thinking I'll take a few years then go back to school to become a professor. The connection to what actually happened is tenuous, especially considering the detour via and Slough, but it's there. Looking forward, the idea of leaving Paris for New York could be predicted, but who'd have imagined I would be a paper-thin diploma away from becoming an RN and another year or two down the road to becoming a nurse practitioner (it's definitely an uphill road)? Nothing can be as fantastical and unbelievable sometimes as life. If it were a play, we might reject it as a little too unrealistic. But then, here we be.

It's these little dots that we somehow blindly connect to make a life out of life. My dad always said that "hindsight is 20/20" and that "it's better to be lucky than good". So true. Jeff Bezos, the CEO of Amazon, would often describe the process as "a sprint and a marathon". Correct again. He also, frustratingly, described the first several years of work as "Day 1". More to the point, he described his approach to life as "a regret minimization framework", which is to say he would try and make decisions in the now that would most probably reduce the chance of regretting things (done or not) later. Poker players and business types might add that you if you are not losing some hands and falling on your face once in a while then you are not taking enough risks. You've got to be in it to win it, right? An "old soul" friend of mine created a mantra once that helps temper this advice by explaining that there are, "So many ways to become number one. So many ways to become number one". My signature block says, "Appreciate beauty in all it's forms" and "Get stuck in there!" And aren't these all different ways of saying the same thing? It's all of a peace. It's all one. And if you are a religious, or scientific, type, you believe that it's not only all one, but that it's already been written. Maktub and Amen.

I want to end this moment of reflection, this graduation of thought, with a superlative address given at Stanford University in 2005. It was given at a time when, if you remember, I was blithely and blindly following my path with heart in France. When I was about two or three thousand miles from a medical-surgical floor of a hospital in New York and would never have guessed that each step would somehow lead me here (or is it there?) to today. The speech is from Steve Jobs, a college dropout whose path to the giving the keynote address at one of the most prestigious places of learning in the country seems equally as improbable and beautiful. Here is what he said:

"Thank you. I'm honored to be with you today for your commencement from one of the finest universities in the world. Truth be told, I never graduated from college and this is the closest I've ever gotten to a college graduation.

Today I want to tell you three stories from my life. That's it. No big deal. Just three stories. The first story is about connecting the dots.

I dropped out of Reed College after the first six months but then stayed around as a drop-in for another eighteen months or so before I really quit. So why did I drop out? It started before I was born. My biological mother was a young, unwed graduate student, and she decided to put me up for adoption. She felt very strongly that I should be adopted by college graduates, so everything was all set for me to be adopted at birth by a lawyer and his wife, except that when I popped out, they decided at the last minute that they really wanted a girl. So my parents, who were on a waiting list, got a call in the middle of the night asking, "We've got an unexpected baby boy. Do you want him?" They said, "Of course." My biological mother found out later that my mother had never graduated from college and that my father had never graduated from high school. She refused to sign the final adoption papers. She only relented a few months later when my parents promised that I would go to college.

This was the start in my life. And seventeen years later, I did go to college, but I naïvely chose a college that was almost as expensive as Stanford, and all of my working-class parents' savings were being spent on my college tuition. After six months, I couldn't see the value in it. I had no idea what I wanted to do with my life, and no idea of how college was going to help me figure it out, and here I was, spending all the money my parents had saved their entire life. So I decided to drop out and trust that it would all work out OK. It was pretty scary at the time, but looking back, it was one of the best decisions I ever made. The minute I dropped out, I could stop taking the required classes that didn't interest me and begin dropping in on the ones that looked far more interesting.

It wasn't all romantic. I didn't have a dorm room, so I slept on the floor in friends' rooms. I returned Coke bottles for the five-cent deposits to buy food with, and I would walk the seven miles across town every Sunday night to get one good meal a week at the Hare Krishna temple. I loved it. And much of what I stumbled into by following my curiosity and intuition turned out to be priceless later on. Let me give you one example.

Reed College at that time offered perhaps the best calligraphy instruction in the country. Throughout the campus every poster, every label on every drawer was beautifully hand-calligraphed. Because I had dropped out and didn't have to take the normal classes, I decided to take a calligraphy class to learn how to do this. I learned about serif and sans-serif typefaces, about varying the amount of space between different letter combinations, about what makes great typography great. It was beautiful, historical, artistically subtle in a way that science can't capture, and I found it fascinating.

None of this had even a hope of any practical application in my life. But ten years later when we were designing the first Macintosh computer, it all came back to me, and we designed it all into the Mac. It was the first computer with beautiful typography. If I had never dropped in on that single course in college, the Mac would have never had multiple typefaces or proportionally spaced fonts, and since Windows just copied the Mac, it's likely that no personal computer would have them.

If I had never dropped out, I would have never dropped in on that calligraphy class and personals computers might not have the wonderful typography that they do.

Of course it was impossible to connect the dots looking forward when I was in college, but it was very, very clear looking backwards 10 years later. Again, you can't connect the dots looking forward. You can only connect them looking backwards, so you have to trust that the dots will somehow connect in your future. You have to trust in something--your gut, destiny, life, karma, whatever--because believing that the dots will connect down the road will give you the confidence to follow your heart, even when it leads you off the well-worn path, and that will make all the difference.

My second story is about love and loss. I was lucky. I found what I loved to do early in life. Woz and I started Apple in my parents' garage when I was twenty. We worked hard and in ten years, Apple had grown from just the two of us in a garage into a $2 billion company with over 4,000 employees. We'd just released our finest creation, the Macintosh, a year earlier, and I'd just turned thirty, and then I got fired. How can you get fired from a company you started? Well, as Apple grew, we hired someone who I thought was very talented to run the company with me, and for the first year or so, things went well. But then our visions of the future began to diverge, and eventually we had a falling out. When we did, our board of directors sided with him, and so at thirty, I was out, and very publicly out. What had been the focus of my entire adult life was gone, and it was devastating. I really didn't know what to do for a few months. I felt that I had let the previous generation of entrepreneurs down, that I had dropped the baton as it was being passed to me. I met with David Packard and Bob Noyce and tried to apologize for screwing up so badly. I was a very public failure and I even thought about running away from the Valley. But something slowly began to dawn on me. I still loved what I did. The turn of events at Apple had not changed that one bit. I'd been rejected but I was still in love. And so I decided to start over.

I didn't see it then, but it turned out that getting fired from Apple was the best thing that could have ever happened to me. The heaviness of being successful was replaced by the lightness of being a beginner again, less sure about everything. It freed me to enter one of the most creative periods in my life. During the next five years I started a company named NeXT, another company named Pixar and fell in love with an amazing woman who would become my wife. Pixar went on to create the world's first computer-animated feature film, "Toy Story," and is now the most successful animation studio in the world.

In a remarkable turn of events, Apple bought NeXT and I returned to Apple and the technology we developed at NeXT is at the heart of Apple's current renaissance, and Lorene and I have a wonderful family together.

I'm pretty sure none of this would have happened if I hadn't been fired from Apple. It was awful-tasting medicine but I guess the patient needed it. Sometimes life's going to hit you in the head with a brick. Don't lose faith. I'm convinced that the only thing that kept me going was that I loved what I did. You've got to find what you love, and that is as true for work as it is for your lovers. Your work is going to fill a large part of your life, and the only way to be truly satisfied is to do what you believe is great work, and the only way to do great work is to love what you do. If you haven't found it yet, keep looking, and don't settle. As with all matters of the heart, you'll know when you find it, and like any great relationship it just gets better and better as the years roll on. So keep looking. Don't settle.

My third story is about death. When I was 17 I read a quote that went something like "If you live each day as if it was your last, someday you'll most certainly be right." It made an impression on me, and since then, for the past 33 years, I have looked in the mirror every morning and asked myself, "If today were the last day of my life, would I want to do what I am about to do today?" And whenever the answer has been "no" for too many days in a row, I know I need to change something. Remembering that I'll be dead soon is the most important thing I've ever encountered to help me make the big choices in life, because almost everything--all external expectations, all pride, all fear of embarrassment or failure--these things just fall away in the face of death, leaving only what is truly important. Remembering that you are going to die is the best way I know to avoid the trap of thinking you have something to lose. You are already naked. There is no reason not to follow your heart.

About a year ago, I was diagnosed with cancer. I had a scan at 7:30 in the morning and it clearly showed a tumor on my pancreas. I didn't even know what a pancreas was. The doctors told me this was almost certainly a type of cancer that is incurable, and that I should expect to live no longer than three to six months. My doctor advised me to go home and get my affairs in order, which is doctors' code for "prepare to die." It means to try and tell your kids everything you thought you'd have the next ten years to tell them, in just a few months. It means to make sure that everything is buttoned up so that it will be as easy as possible for your family. It means to say your goodbyes.

I lived with that diagnosis all day. Later that evening I had a biopsy where they stuck an endoscope down my throat, through my stomach into my intestines, put a needle into my pancreas and got a few cells from the tumor. I was sedated but my wife, who was there, told me that when they viewed the cells under a microscope, the doctor started crying, because it turned out to be a very rare form of pancreatic cancer that is curable with surgery. I had the surgery and, thankfully, I am fine now.

This was the closest I've been to facing death, and I hope it's the closest I get for a few more decades. Having lived through it, I can now say this to you with a bit more certainty than when death was a useful but purely intellectual concept. No one wants to die, even people who want to go to Heaven don't want to die to get there, and yet, death is the destination we all share. No one has ever escaped it. And that is as it should be, because death is very likely the single best invention of life. It's life's change agent; it clears out the old to make way for the new. right now, the new is you. But someday, not too long from now, you will gradually become the old and be cleared away. Sorry to be so dramatic, but it's quite true. Your time is limited, so don't waste it living someone else's life. Don't be trapped by dogma, which is living with the results of other people's thinking. Don't let the noise of others' opinions drown out your own inner voice, heart and intuition. They somehow already know what you truly want to become. Everything else is secondary.

When I was young, there was an amazing publication called The Whole Earth Catalogue, which was one of the bibles of my generation. It was created by a fellow named Stuart Brand not far from here in Menlo Park, and he brought it to life with his poetic touch. This was in the late Sixties, before personal computers and desktop publishing, so it was all made with typewriters, scissors, and Polaroid cameras. it was sort of like Google in paperback form thirty-five years before Google came along. I was idealistic, overflowing with neat tools and great notions. Stuart and his team put out several issues of the The Whole Earth Catalogue, and then when it had run its course, they put out a final issue. It was the mid-Seventies and I was your age. On the back cover of their final issue was a photograph of an early morning country road, the kind you might find yourself hitchhiking on if you were so adventurous. Beneath were the words, "Stay hungry, stay foolish." It was their farewell message as they signed off. "Stay hungry, stay foolish." And I have always wished that for myself, and now, as you graduate to begin anew, I wish that for you. Stay hungry, stay foolish.

Thank you all, very much." --Quoted from Free Republic


Saturday, April 3, 2010

How the internet and a little ingenuity saved my life!

Okay it didn't save my life, but it did save a bundle of money and calories... On the heels of our recent magic bullet blow-up, juicer-gate, Kevin Trudeau's Ultra Mega Memory (or what is Super Mega Memory) tapes, and a closet full of exercise implements that would make the Marquis de Sade blush--all As Seen On TV, or more appropriately as seen on late night TV when your faculties of reason and discernment are half-asleep--I am happy to announce a small victory against this dastardly tide of gadgets. With a little ingenuity, and paradoxically the Internet, I managed to turn back the clock in our kitchen to cooking 1.0. And I saved us about $200 in the process. Johnny, I know you'll dig this part the most, but for the rest of you read on for a fabulous tip on how to clean your own super-mega magic thing...

Allow me to introduce, the blender. Yes, that modern yet retro, that sleek yet 70's item that you probably have stashed in a closet since your wedding or since you replaced it with some newer and much more expensive culinary gadget that promised it would do away with all the other gadgets that came before it and that was touted as what the French call "le must de la cuisine".

Well I'm happy to report that I just talked Debbie down from her Magic Bullet, Health Master, Vita-Mix infomercial buying mania with a simple, yet elegant steel and glass blender by Oster (imaged here) and the power of a little thing we call the scientific process. Here's how I did it:

1) Leave the product's flashy website and flash video demonstrations (though this is where I did get that cleaning tip I'll tell you about in a second) and go to a reputable resource like or Read a few reviews about the different products. Concentrate on the negatives.

2) Drop a carrot, an onion, a few stalks of broccoli and some water in the blender you have and see how good of a purée it makes. Add salt and pepper to taste and heat.*

3) Drop a banana, a couple clementines, a dollop of yogurt, a few ice cubes and some water in the blender and see how good of a smoothie it makes.

4) Review your recent bank statements and see whether spending $300-400 on a super blender makes sense.

5) Buy a $5 Good Housekeeping blender recipe book used from Amazon promising over 150 sensational recipes on soups, appetizers, smoothies, baby food and more.

6) Do a little victory dance as the ineluctable power of your demonstration sets in.**

* If you try this, you'll understand the need for #5.
** You may want to skip this for the sake of better relations.

I have to admit that I got a bit lucky because it just so happens that way back in the early 21st century when I bought my blender at Target I grabbed the stainless steal and glass pitcher one by Oster, more because I thought it looked good than, as it turns out, because it was recommended as one of the best. The point is, these blenders go for about $60. With depreciation, the recipe book and avoiding buying one of those other gizmos, I reckon we saved well over $200 with our little admittedly pseudo-scientific experiment.

So what's in it for you? Those of you who have already shilled out for some other gizmo? Those for whom it is too late to benefit from our experience and sage advice? Well, here is a great little tip to make cleaning your own personal blenderizer thingy "simple comme bonjour": after you blend, do a quick rinse then add warm water and dish soap and blend that for a few seconds. Can't you just see and feel the potentially lost years of your life just anti-oxidizing away?

By the way, no need to send me a thank you card as there is no address down here in Margaritaville where we will soon be wasting away... from all the calories and money we save of course!


Thursday, March 25, 2010

What I did for my Birthday...


Wednesday, March 24, 2010

Time 2 Rn

10pm and I'm still @ the hospital. This is s/p day 2 working w/ a nurse. Also approx. day 5 of juice fast b/c of prolonged ↑ dietary intake. Calculation approx. r/t friend in NYC last pm → a macrobiotic meal. Thankfully, all Pts remain stable through hand-off to night shift. Log entry: "Subject woke at 5:45am today. Reports feeling like he has been sprinting since."

In keeping with the MD lexicon, I will say that my preceptor is +++, though she is d/c'ing me for a week to go to Haiti. As if they need her help more than I do (kidding!). She started me right away caring for 3.0 patients, top to bottom and side-to-side. I feel a little scared/nervous and overwhelmed just about every second from when we take report at 8am to when we give report to the night shift at 8pm. Lunch lasted about 20', during which time I was not scared.

Something about the patients, the pace of work and frenetic action makes it almost impossible to feel hungry or tired, or sorry for yourself. In fact, working in health care generally makes you content with simple things like your health, a good meal, a good shower, a good hug, a bit of sunshine, and being able to pass a good BM in the peace and quiet of your own home (ideally with a book or magazine if you are a true Lapin).

Time management is key. Knowledge is helpful, particularly where it involves not making a mistake (or not catching someone else's) that will cause Pt. sequella. Unfortunately, the demands of documentation and Rx mean that there is almost 0 time for much of what traditionally might be considered nursing. The whole caring, advocating and helping people thing. The chronophagistic (chronophagal?) aspect also makes it hard sometimes to do things like go to the bathroom, look up new information, call your sweetheart etc. You know, that type of thing. Or to paraphrase Woody Allen's "Irish Genius" remember to rejoice, rejoice and call your mother once in a while.

My dad actually warned me about not letting medicine suck me in so far that I lose sight of the rest of life. Case in point, I'm here at 10:16pm, doing a Hx and Pe on a Pt and collecting info on him for a case presentation at school. As for real life, tomorrow is my birthday and I have big plans with Debbie. I am also desperately trying to fit a new play, PT, friends, NCLEX, a job hunt and maybe a trip to South Korea in as well. Oh my, time 2 Rn...!


Thursday, February 11, 2010

Once more unto the breach, dear friends, once more...

The game is truly afoot, dear friends, and with just a couple weeks until the "Health Care Summit" on February 25, I urge you dishonour not your mothers, follow your spirit and upon this charge cry 'Give us substantive health care reform!'

The breach that needs filling today is not the gap in the wall of Hafleur but the gap in health care access, cost and quality. What I'm asking you is über-simple: contact your state representatives and the media and show them your mettle. One website allows you to do both with a couple clicks and you can use the following letter as you see fit, or compose your own, to tell them just what you want them to do.


I am writing to you as a member of [INSERT YOUR COMPANY or ORGANIZATION NAME] because today offers a special opportunity to make history through the passage of substantive and intelligent health care reform. We believe that today we have come too far to turn back and that many lives, not just elections, will be lost if we do not make changes to the way health care is accessed, paid for, regulated and researched in our country. The stakes may never have been higher.

We believe in giving the best evidenced-based medical care that money can buy, and giving it so that it helps the greatest number of people. We believe in a fair and compassionately regulated system that guarantees every member of our society a minimum level of care and services while still encouraging the best that innovation and research has to offer.

In short, we believe in the following fundamental areas of reform and we believe that a majority of rational and compassionate Americans like us would agree to their necessity:

Prevention… we believe that an ounce of prevention is worth a pound of cure, and costs less too. We need to support and expand primary care, preventative care as well as community-based and home-based care.

Research… providers need to be free to do what is best for the patients that they know best, but they deserve to have the best guidelines, protocols and clinical research possible to help guide them in their decisions. We support Evidenced Based Medicine which means more high quality and unbiased comparative trials and research. More longitudinal meta-anayses. More safety studies. This is a job for someone like the NIH, not drug companies or groups that have vested interests.

Choice… people should be able to choose their doctor and should have at least several insurance plans available to them. This is not the case in many areas of the country or with many employers, which is why we advocate for public options and national exchanges where individuals and groups can shop for insurance plans in a regulated and fair market.

Cost… there will always be a finite amount of resources. The question is how they are allocated. These decisions should not be driven by profit, but from a public health perspective of what will do the most good for the most number of people. Currently there are insurance companies telling providers what they can and cannot do, we believe these decisions would be better made by public health officials. We also need out of pocket caps for policyholders because there is no point in having insurance if you can go bankrupt when something goes wrong. Finally, we need to lift the yearly caps for insurance companies because there is also no point in getting chemotherapy for cancer only to die of a cold because you passed your yearly limit.

Accountability… taking care of people is a serious responsibility and all aspects of the system need to be held accountable. Nevertheless, punitive malpractice suits may not be the best way to do this. We need to put an end to defensive medicine by reforming malpractice law. National oversight and regulation of hospitals, payers and providers is a better way to enforce policy, set best practices and create accountability.

Access… the best health care in the world is all for naught if there is not adequate access to it. This means starting with giving access to the millions of uninsured, but it also means guaranteeing proper access to the basics of a healthy lifestyle: fresh fruits and vegetables, clean air and water, reproductive services, and education about age appropriate diet and exercise.

Because we hold these ideas to be vital to the very survival of our health care system, economy and moral fiber as a nation, we urge you to take action now!

We urge you to pass a substantive, intelligent and compassionate health care reform package that includes the fundamental issues described above.

Respectfully yours,
A concerned and voting citizen


Tuesday, February 2, 2010

Ethiopia 2009--super Gobez!

Debbie and I are going to spend the holidays warming up under the African sun, or at least that's the plan. This is also my "meet the parents" trip. No pressure, but Debbie's high-school friends used to call her dad "the General". I've already met several of Debbie's aunts and cousins here in the city and I'm hoping that their preliminary reports will have helped laid the ground work for the coming encounter. Debbie has not been helping things by telling me about all the things I should watch out for in terms of etiquette, like standing up when her parents enter the room, not talking with my hands in my pockets, not licking my fingers, and how elders from the village might spit on us as a sign of respect--and this is exactly what happens to Debbie when she is getting her personal blessing after St. Gabriel's, though the man spits towards her hands that he is holding rather than on her head or face...

But let's start at the beginning, our trip really begins in the Dulles airport where we are stuck for over three 3 hours. We’ve already avoided a blizzard in New York and this delay makes a long trip seem even more punitive. It’s funny because as we were walking through the terminal we overheard a boarding announcement explaining that the airport is really busy so the flight to Cancun would be using a temporary boarding gate. We find, however, our Ethiopian Airlines flight at the far end of the terminal all alone with several empty gates around it. It’s almost as if it has been quarantined here so other flights or airlines can go about their on-time business without being affected. As these things go, there is no clear reason why we are not boarding the plane that is sitting right there. At one point they announce we are waiting for “the boarding agent to bring a document” which could mean anything or nothing, then later they claim we are delayed due to the weather. The runways are clear, however, and the flight to Cancun is long gone, so go figure. The pilots and crew do not seem phased and sit in a cluster chatting or napping in the corner. We are still in DC, but somehow we are already on African time.

Speaking of African time, Debbie has always had her own sense of tardiness. She is never late for court, but misses our fourth or fifth date because she was taking a three-hour shower. It's what I call DST (Debbie Standard Time) or what Polly Platt might call quark-chronics. Here in Ethiopia, things definitely move at their own pace. When we wake up at 3:30 pm (yeah that's right, I said it) it is actually 9:30 pm Habesha or Ethiopian time. So if you ask someone when they are coming over to fix the plumbing, for example, you may need to clarify whether you are talking about Habesha or Ferengi time--not that it means they will arrive à l'heure, of course.

One explanation for why Ethiopia has it's own clock is that because it is so close to the equator, days are generally 12 hours all year round (and nights as well), so Ethiopians got into the habit of counting the hours from sun up to sun down, which is about 6 hours different from what the folks in Greenwich would have you believe (sometimes six hours less, sometimes more). There are also 13 months in the Ethiopian calendar year and a difference of about 7 or 8 years in the date, depending on whether you arrive before or after the Ethiopian New Year in September. This embassy webpage provides a good explanation of it all and how it came about.

When you talk about Ethiopia, Western people often think of two things: famine and coffee. True besides coffee exports, the Ethiopian economy is based heavily on subsistence agriculture which makes it vulnerable to crop failure and famine, but in spite of this, or perhaps because of this, Ethiopian culture practically revolves around eating. It is considered almost insulting, for example, to go to someone’s house and not eat seconds or even thirds. I’ve learned this the hard way as Debbie’s aunt locks eyes with me and then slowly extends a finger back towards the buffet table. Blurp. The trick is to start low and go slow. Don’t put too much on your plate, eat slowly and always have something on there. Because an empty plate is apparently a sign for give me another large helping in the Horn of Africa.

The story I love the best about Debbie’s mom, who is definitely one of the kindest, sweetest women on earth, involves her passing me the bread basket one night. This was about day 8 or 10 of the trip and I have just gotten over being sick. I’m almost grateful for my flu, however, because I haven’t eaten anything for like 24-hours and my stomach is no longer feeling like a packed canon. I’m trying to reach for a small piece of bread but somehow the basket keeps moving and my hands find themselves over the biggest piece in the basket. When I finally realize what is going on, I look up to see Debbie’s mom with a huge smile on her face. So sweet.

Ethiopian food is definitely delicious, and fun to eat too! Ethiopians love meat, but they also have a lot of vegetarian options. The Ethiopian Orthodox Church prescribes fasting, eating vegetarian, twice a week as well as for extended periods around Christmas and Easter. What makes Ethiopian dining really fun is that you get to eat with your hands. The idea is to use the flat crêpe-like bread called injera to gather up a mixture of stuff without getting any on your fingers (thus the proscription against licking one's fingers).

The meat in Ethiopia is also worth mentioning. I think it has something to do with its local and non-industrialized raising and processing. Whatever it is, it’s really flavorful and delicious. This wonderful meat experience is called tibs (pronounced with a sort of retroflex ‘t’). Basically, it’s a large side of raw beef (it’s really cow or carcass still at this point) hanging behind a counter that you have the guy slice for you. They take away the kilograms that you order and return with a plate full of steaming fajita-like tibs that you can dip in spicy mustard or berberé sauce. It melts in your mouth. In fact it was so good, we went back again the next night (see the video for more tibs action).

Another unique thing about Ethiopian cuisine is the butter. When I first visited Ethiopia, my friend’s host family showed me these huge blocks of butter and explained how they got them from their hometown outside the capital and how they would store in the cupboard for months or years. That doesn’t sound good, I thought, but I was wrong, because the butter is clarified, like ghee from India, so it really doesn’t spoil because the organic fats have been removed during the clarification process.

One of my favorite Ethiopian traditions around eating is what’s called a gursha. A gursha is when you grab a bunch of tibs or wet-ever (wet or sometimes wot is another yummy dish so that’s a transliteration pun) and then feed it to your guest or loved one. It’s very sensual and very fun. Kind of like when the bride and groom feed each other the cake at the wedding, except Ethiopians do it all the time.

The final thing that has to be discussed is Ethiopian coffee. Ethiopian coffee beans are excellent (much like their Kenyan neighbors) and can be found all over the world, thanks for better or for worse to places like Starbucks. In Ethiopia, coffee is call buna and is often served as part of a ceremony that involves roasting, grinding and infusing the beans right there in front of you. As you drink it, frankincense is usually burnt giving the whole experience a magical air.

As I said before, we are a bit surprised with the weather during the trip, with bouts of rain and average temperatures below the usual 70s. Addis is at 7-8 thousand feet of altitude so one expects it to be cold at night. On several occasions, we light a fire in the living room and practice some traditional dancing--which involves a lot of shoulder action. I realize I look like a chicken on the video, but you’ll get the idea from watching the others.

Christmas is approaching and we are having some trouble finding an appropriate tree because 1) pine is not part of Ethiopia's native flora and 2) it is currently illegal to cut any trees down. This means we have to choose between a potted tree from the plant nursery--which contrary to what you might think has an incredible selection of flowers and plants, just not pine trees--or a fake one. We end up getting both, but the branches of the tree won’t hold the decorations so it will have to wait until next year. What a great idea, making it illegal to cut down trees like this. Why shouldn't everyone have a live tree for Christmas? It would be less of a fire hazard and much better for the ozone. After Christmas it could be a tradition to go out into the woods (or your backyard) and replant the tree, or you could just keep watering it until next year. Okay, I realize that the whole root thing would make it well nigh impossible to have a large tree, but maybe a few could still be cut down for municipal displays or the Rockefeller center type thing. I’m just thinking out loud here…

We are having our big Turkey and stuffing meal today, the day after Christmas. Mostly because yesterday was Friday, a fasting day. So we will be opening our gifts and celebrating today. Much like other Orthodox churches, the ceremonies here are quite long and elaborate. For the most part they are conducted in a language called Ge’ez which is an even more ancient language than Amharic and more directly related to the country’s coptic origins. Women, I am told, are not supposed to attend services if they are menstruating, and apparently when she was young ,Debbie was able to use this excuse at any old time of the month to get out of going to church and the men were none the wiser. These things do remain a mystery to most of us men, don’t they?

After Christmas we spend several days in Woliso, where Debbie's father was born. It’s about 60 km west of Addis. A small town with a church her father built in honor of his father who was a famous General under Haile Sellasie. In fact, when the Emperor was overthrown, Debbie’s family, like many in Ethiopia, had to flee the country for fear of retributions. This is why Debbie was born and raised in Rome. Her family still owns property in Woliso. The land and farmhouse go back several generations. Debbie’s uncle lives there and is turning the land into a proper farm with honey, apples, teff (the grain that is used to make injera), and of course tej which is a meady, honey-beer like drink that many households brew out back as it were. The stuff will put you down if you can keep it down, is all I’m going to say on that topic.

The 27th is Saint Gabriel’s, a big holiday in the Ethiopian Orthodox Church, and people come from kilometers around to chant and pray all night long and most of the day. The prayers are broadcast over speakers so the huge crowd that gathers around the church and that can't fit inside can participate too. It's a really beautiful moment and we don't want to leave. Several priests and the bishop, head of the local diocese, come over to the farmhouse after the ceremonies to break their fast with us. It’s a huge feast and celebration--you really have to watch the video to see what I mean. It is very interesting being in such a big crowd and being the only white person. Especially in a small town/village like Woliso, it makes you something of a spectacle--kind of like being Brad Pitt or Angelina Jolie for the day. You either get used to the staring (and sometimes pointing and touching), or you don’t. Every aspiring actor should give it a try.

There is also a village elder, who is something like 98 or 100 years old, who gives Debbie and her brother Gulu a personal blessing (this is when the spitting happens). The elder and priests mostly speak in Orominia (the local language of the Oromo region), and the translation of the blessing seems a little short compared to the length of the speech but apparently breaks down to telling Debbie and her brother that they should get married and have kids, by next year if possible!

It’s New Years now and we spend the countdown flipping between the French and Italian TV stations, both of which are airing their traditional réveillon galas. One features three 8 year-old kids covering bad Euro-pop songs and soccer highlights from several seasons back, the other decides to cut to a sponsor's logo with 30 seconds left in the countdown and spends half the time promoting the guest commentators' latest albums and tours. Thank god for the Champagne and Pandoro or I would be worried about Europe. 2010, woohoo...!