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Being human Medicine Reflections on Life, Being Human, and Medicine Reflections on the Christian Life

A Desk and a Chair, a Feeling, and the Future

I drove by Blodgett Hospital yesterday. I was shocked to see that they tore down the parking structure that was attached to the professional building. The garage was old and failing but to see the hole in the ground was a shock. It brought back memories. Oddly, the memories felt good. They brought a light of sunshine and warmth inside of me. 

Let me explain.

The year was 1998. I was walking through that parking garage. From the garage I could see the windows for the physicians’ offices for Grand Valley Internal Medicine. I was finishing my internal medicine residency. I had accepted a job as a new primary care physician. I could see my desk and my chair. It was an exciting feeling to have that be my desk and my chair. It was exciting to tangibly see a future. 

I remember coming into my office for the first time. I had the keys to the back door for the office.[1] My office was empty except for the desk and chair. It felt really good. It was a place for me. It was more than that. This was where I was going to settle. This was where I was going to be able to see patients and work. It was where I was going to have a future.

I worked in that office for about 4 ½ years. They were good years. The practice itself was something that I will forever be proud to have been a part of. The doctors were truly excellent clinicians. I could tell anyone where I worked  and then just mention the names of a few of the doctors and immediately I would gain their respect. “That is a great office!” they would say. From the start there was a steady stream of patients. The patients and their problems were wide and varied. They challenged my internal medicine skills. They grew me and completed me as a physician.  

When I left it was not because I didn’t love the office, my colleagues, the staff or my patients. It was a hard thing to leave the office. But then there was something else. There was a drive inside me that made me leave. It was an intense sense of purpose. It was a need to be focused – to be a specialist.  I needed to be someone who could contribute in his own way – in his own niche – to the community. I have never regretted leaving. But I still love that practice. And I loved that office and that desk and chair.

As I continued to drive home yesterday I tried to understand why I felt the warm and nice feeling inside. A few minutes before that I was feeling frustrated and stressed. I had COVID 19 stress pulling at me. But a glimpse – and then a thought – could in an instant – cheer me up. 


Why?

I think it was the memory of being young and enthused and with a future. 

It was just an empty desk with a chair. But it was a nice desk and a nice chair in a carpeted office with a window (even though it viewed the parking garage.) It was just a desk and chair but so much more than that. It was my desk and chair. It was a place for me. It was opportunity for me. It was a future.

I think now that the warm feeling is about “hope.” It is about looking forward. It is about not staring at and indulging in the pain of now. It is about not obsessing over the problems or failures or anxieties of the past. It is about looking forward to what is next. It is creating a plan and marching forward. 

It is getting the new school clothes with the tags still on them and with the new smell to them to be ready for another year of elementary school. It is the new lunch box complete with a plastic Snoopy thermos. It is going to the college bookstore the month before classes start to buy your books. It is moving into the apartment in a new city and making your bed for the first time and learning your way around. It is the scary first or second or third dates – scary but filled with excitement and dreams of what the future could be with that person. It is getting out of the moving truck and walking around your new empty house with your spouse looking for where each piece of furniture will go.

Dear Lord, please help me if I stop having a future. There must always be a future. 

I am not saying that it won’t be without some anxiety. 

Starting as a brand-new primary care physician meant that I had a lot to learn and do. I did not have years and years of practice patterns to guide my decisions and work. I had to figure out how I as a physician was going to handle each diagnosis and medical problem. Every day brought new challenges and new things to do. It was heavy lifting. I worked hard. It wasn’t easy. 

Our futures now are not easy. 

We are looking at how to navigate another year or two of COVID 19. We are looking at how to live in a world with social distancing and face masks and obsessively using hand cleaner and anxiety and worry about who might get seriously ill. We have all the arguments and all the uncertainty about how we move forward. We have so many questions and unknowns.

Many have lost their jobs and are not sure where to look next to find another. 

Many of us are working in distressed health systems. We are looking at working with a lot fewer support staff and pushing ourselves to work harder. We are figuring out how to go back to work and to see more and more patients. We feel a drive to deliver more care so that not only can we help our patients who need it but also so that our health system can dig out of the revenue hole that COVID 19 has created. 

There is a lot of uncertainty and a lot of work ahead. 

But this morning the trees in our back yard have budded out with new leaves. They are rapidly closing in our back yard again with their lush green just like they do every spring. They have not frozen in place in anguish. Summer is coming. There is a future.

We are not the first to live through a lot of changes. 

I think of the ancient Israelites who were carted into captivity in Babylon. Imagine being conquered by an enormous army and being dragged away from your homes. What should they do? How were they going to survive? 

In that setting the prophet Jeremiah spoke these words from the Lord God Almighty, “Build houses and settle down; plant gardens and eat what they produce. Marry and have sons and daughters; find wives for sons and give your daughters in marriage, so that they too may have sons and daughters…”[2]

I think you get the idea?

He continues later in the passage, “For I know the plans I have for you,” declares the Lord, “plans to prosper you and not to harm you, plans to give you hope and a future.”[3]

One of my teachers gave me a gift with that verse on it when I graduated from high school.  I didn’t really understand what it meant. I do now.

The desk and the chair are all about having a future.  We may not know what the future will be. It likely won’t be easy. It can and will create anxiety inside of us. It will mean changes and new things. It will push us to learn and grow. But now is not the time to stop. Now is the time to get up and live.

But what does that mean? 

To paraphrase the prophet Jeremiah: “Figure out what you are going to have for dinner. Later get a good night’s sleep. Get up the next day and think about what work you can or want to do. Look for opportunity. Look for what is next. Love your family. Live your life. Raise your kids. Be excited as they too live their lives. Look to the future.”

Last night I went from feeling frustrated and anxious to feeling warm inside. Then and in this moment I remember the feelings I had when I first looked at that desk and chair. They are good feelings. They are exciting. In that memory, I am okay. I can feel warm and good. 

I can and will look to the future – whatever it may bring.


[1] https://manmedicineandmike.com/he-has-the-keys-to-the-back-door/

[2] Jeremiah 29:5-6, New International Version

[3][3] Jeremiah 29:11, New International Version

Categories
Being human Medicine Reflections on Life, Being Human, and Medicine

The Story of the Miser and the Blacksmith and COVID 19

When I was in 7th grade one day, Mr. Houseman, our science teacher, gave us a math problem. 

He told us the story of the miser and the blacksmith.

A blacksmith is putting shoes on a miser’s horse. The blacksmith charges $10 for the job. The miser refuses to pay. “Ok,” the blacksmith says, “I will make a deal with you. There are 8 nails in each horseshoe.  The horse has four shoes. That would be 32 nails in all. I will ask you to pay one penny for the first nail, two pennies for the next nail, four pennies for the next nail, eight pennies for the next nail, etc… until the 32nd nail.”

Our teacher asked us if we would take the deal if we were the miser. Most of us said, “yes.”  I mean – it is just pennies. It won’t add up to very much.

He then had us start doing the math and told us to bring our answers to class the next day.  We were told that we had to do the math by hand (no calculator) and that we had to show our work.

If any of you have ever done this problem, you know the secret. 

Later that night at home I had a huge piece of paper filled with numbers. With each additional nail the numbers got bigger and bigger. It was hard to keep it straight and to do the math by hand.

The total cost was $42,949,672.95 (almost 43 million dollars).[1]

What is the trick? It has to do with exponential growth. If you want to see more interesting illustrations, search for exponential growth on YouTube.[2][3] What you will see will be a variety of similar illustrations. They are really quite wild. 

It doesn’t make sense. It defies common sense.

But it is real.

Why does this matter and what does it have to do with COVID 19?

COVID 19 in a society without suppression has an Ro or rate of spread of 2. This means that it follows the same math as the miser and the blacksmith problem.  That means that how it spreads will not make sense from a gut level or common-sense approach. That math however can be alarming.  If it were to spread unchecked, it can seem like nothing is happening and then seemingly out of nowhere – a simple $10 job becomes $43 million. Or a few cases become tens of thousands and hospitals and health systems become overwhelmed.

But if suppression measures are done and are effective, the Ro can go down and the exponential growth goes away or is reduced.

In early to mid-March, our health system and the experts they relied on started using epidemiologic mathematical methods to predict what might happen.  The graphs and predictions were terrifying. We were looking at needing thousands and thousands of hospital beds, intensive care rooms and ventilators. The potential was far greater than any health system could ever handle. 

The next models looked at what would happen if we implemented social distancing. They started out estimating based on a 30% social distancing model. This assumes that we can never completely 100% isolate everyone from everyone else. If you have to pick a number what number is realistic? Experts suggested that the reasonable degree of social distancing that we could expect in our population would be around 30%. 

The models started giving us data that we could potentially work with. The demand still looked enormous, but it was at least in the ballpark.  The predictions included a peak of 2500+ patients in the hospital with 1000 patients in the ICU and around 700 on ventilators at a time.  It meant that we would exceed all possible capacity of the hospital system. Teams went to work implementing plans to build out more and more capacity depending on what happened. 

Something different happened in West Michigan, however. Cell phone data has suggested that the degree of social distancing has in reality been around 58%. This has had a dramatic difference on what has happened. Instead of the huge surge in numbers of patients with COVID 19, it has been a steady stream of patients with numbers in the range of 50-80 patients per day in the hospital.

Does this mean that the models were wrong?

The answer lies with the miser and the blacksmith. 

It has to do with exponential growth. If we achieve a high degree of social distancing the exponent drops. Depending on the exponent, wide variations in the numbers of cases at a time can occur. The math shows that what happens can go beyond what common sense will tell us. 

The projections depend very much on the percent of social distancing that is achieved. If it loosens up a small amount (which seems likely based on the trends in society) then the numbers look like there will be a higher peak (perhaps around 500 patients per day in the hospital).  

Is this all theoretical? Nope.

It suddenly makes sense of why we can have had such dramatically different outcomes in places like New York City or Detroit compared to Grand Rapids. Those places that had time to implement social distancing before the exponential growth took off have a lot lower numbers of cases.  The experiences in the US (and the world) match the math.

So – we might only see about 50-100 patients in our hospital system at a time (the current state), or we might peak at 500 (if social distancing loosens a little bit), or we might have 2000 (if restrictions are loosened a lot.)  

But then where do we go from here?

As I stated in a prior blog[4], the problem is not with the math or the effectiveness of social distancing. It has all worked. 

The problem now has to do with sustainability.  The tail end of the curves are now extending far into 2021. We are all going to be forced to figure out different solutions on how we can live through this. We need to somehow maintain some degree of safe social distancing – but we have to be able to do it for a lot longer than any of us would like.

In some ways it is like trying to open the valve on a fire hose just a tiny amount so that you can get a drink. We are very thirsty. Not opening the valve is not really an option. Maybe we will be good enough to open it up a little bit. Maybe we won’t and we will get blasted in the face. Maybe the number of cases will go up a modest and manageable amount. Maybe the number of cases will surge and we will see repeats of New York City and Detroit.

A Wall Street Journal headline yesterday described May 2020 as being one of the greatest social experiments in history.[5] The huge experiments are going on in states that have loosened up social distancing (like Georgia and Texas.) I am really hoping and praying that these go well. If they do perhaps they can provide lessons and a guide for all of the rest of us. 

I don’t have the answers. 

But I did find it very interesting to look at YouTube posts from 2019, 2016, and 2013 that described potential pandemics and the exponential math that has happened in our world.

The miser and the blacksmith and what I thought was an odd assignment from Mr. Houseman comes back to me so many years later.  It makes so much sense to me for what is happening in our world now. Who would have thought it?


[1] https://www.pedagonet.com/brain/brain43.htm

[2] https://www.youtube.com/watch?v=Tm38xA3KcQY

[3] https://www.youtube.com/watch?v=0BSaMH4hINY

[4] https://manmedicineandmike.com/the-path-forward/

[5] https://www.wsj.com/articles/america-wants-to-reopen-from-coronavirus-but-disagrees-about-how-11588350721