Category: Medicine

Posts that are specifically tailored around the practice of medicine.

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Medicine Reflections on Life, Being Human, and Medicine

Debates, Uncertainty, Frustration, and the COVID 19 Pandemic

I struggle a little bit with the idea of debates.  

I understand the idea. Each side can argue the opposing points with conviction and strength. It is like making a “pros” and “cons” table to consider a hard decision. It is a way to get a really good understanding of the details on each side of a controversy.

I have participated in debates at medical meetings. It is a straightforward thing to do. I just need to come up with the strongest arguments possible for my assigned viewpoint. I don’t even really need to decide what I consider the best or correct viewpoint. That is not my job as a debater. My job is to argue my perspective. It is not my job to tease through or guide everyone through the conflicting arguments to come up with a final answer. Hopefully I will have been asked to argue the perspective that I really believe in, but my job as a debater is to argue whatever viewpoint I have been assigned.

I am told that a “good” debate has balance or equipoise between the two debaters.  When the debate is finished you should be able to really understand the points on each side. 

The problem is that often when leaving a debate, as a listener you don’t know what the best or “correct” viewpoint really is. At medical meetings I have commonly found myself going to watch a debate and leaving the session as confused as I was (sometimes more) than before the debate.  Often, I leave feeling just sort of frustrated.

Lots of information. Strong arguments. Not really sure what to think. Frustration. Sound familiar?

The past year has brought up a lot of debate.  With it I have heard from many people that they feel frustrated. They are feeling like me after the debates at the medical meetings. And it seems like the more they read or talk to people, the worse it seems to get. They don’t really know what is true, real or correct. What are they supposed to do? 

With the vaccination debate, the easiest thing to do when you don’t know what to do is to do nothing. Generally in life, if there is a question about doing something, the safest thing is to not do it. Is that the best approach with COVID? Or is there risk if you don’t act?

More recently as the pandemic has heated up again, the pressure has intensified. One podium yells at the other for inflicting harm by the large surge in numbers of cases predominantly among unvaccinated persons. The other podium yells that they are not evil people and how dare you judge them when they are acting out of their best conscience.

To be honest, it all grieves me.  I joke with people at work, “I just want to be clear about my stance on COVID. I am against it. I think we should not have it be a thing anymore. Can we just have it go away?” People will graciously laugh at my stupid joke, but I think we all get it. We are tired of the conflict, and we just wish we could all come together to fight this awful enemy that we share.

I have hesitated to write anything on this for some time. There is a LOT of information being posted in social media. I wasn’t convinced I would have much to add to the huge amount of information (and noise) that is “out there.” But this past week our health system set a new record with 406 patients in the hospital with COVID 19.  On my hospital rounds I saw so much death and grief from COVID this past week. It feels like it is time to say something. 

A few ground rules:

  1. I am a cardiologist. I am not a virologist or a public health expert. I am sharing my opinions based on my scientific training and on my 30+ year experience as a physician rather than as an expert on COVID.
  2. I am not sharing to enter into a debate. I know that you may disagree with some or all of what I say. You are welcome to your opinion. I am not stepping up to the podium to enter the debate. This blog post is instead an attempt to step away from the two debate podiums and sit down on the edge of the stage in the middle to share from the heart. It is funny but this is usually what has happened after I have been a part of debates at the scientific meetings. Once the crowd clears and the microphones are off, the two of us can sit and chat about what we really think. I am going for the “after the debate” thoughts with this blog.
  3. I am not going to comment on mandates. We can have a very valid and vigorous debate about what governments or employers can and should do, the ability to choose vs. public health concerns, etc. That debate is beyond the scope of my comments.
  4. I am hoping to share concepts that make sense to me. I do not have a specific agenda. My goal is not to convince you of anything. It is to share what and how I think.

COVID 19 is Real. I don’t know that anyone debates this at all anymore. While some people get only mild symptoms, it is not the same as a simple cold or flu. We have never dealt with anything like this. Over 1/4 of our hospital beds are filled with patients who are very ill (scary ill) with COVID. This is NOT business as usual. We really don’t have anything to compare it to within our professional careers. If it seems like we are making up rules and then changing them as we go, it is because all of this is new. The medical profession is doing the best it can to adapt and change as new information becomes available.

Hypothesis generating vs. proven treatments. We are all eager to have wonderful and highly effective treatments. This takes a lot of time and study to figure out. Science generally looks to see if there is a “signal” that something might be effective. This could be in-vitro (test tube) or in-animal model data. It can also be observational data (not structured or randomized but noticing that people who do x,y or z do better than those who don’t.) Science has taught us that this early data is only “hypothesis generating.” This means that it gives you an idea of what to study, but it does not prove that it works. It is disappointing but very common that what looked promising in the test tube or in observational studies turns out not to work. For new drugs, it is estimated that only 1 in 5000 end up making it to market.[1] Looking for common treatments or available drugs that might help treat COVID is an important and valuable thing to do. The early reports however are only hypothesis generating and not proof that they work. It should not be a surprise that most of these agents didn’t end up showing benefit in properly conducted, randomized controlled trials. The problem often is that the beneficial effect is too small to be relevant, or the effect occurs only at doses that prove toxic. This has become complicated by a few key reports that have subsequently been found to be fraudulent (included made up patients.) [2]We were all eager to have hydroxychloroquine, ivermectin, diphenhydramine or whatever treatment work. There is just no convincing evidence that they do.

Vaccine Risks. Are the vaccines perfectly safe? I think it depends on how you ask the question. The short answer is that by and large the vaccines are quite safe.  The rates of serious adverse events have been exceedingly low despite very intensive tracking to monitor for such events.  To date over 425 million doses have been administered. Out of the population who have been vaccinated, the number of deaths that have been reported has been 0.002% or 0.02 persons/thousand.[3]  To compare this to the general population, the rate of death in the US is 8.7 persons / thousand per year.[4]

The longer answer is that nothing in life is perfectly safe. Everything is a balance of risk and benefit.

Many don’t like the idea of introducing a foreign substance (antigen) into their body intentionally. Just to be clear, the mRNA part is not really the concern. The mRNA just causes your body to manufacture the spike protein. The concern is always with what could happen as a result of your body’s immune response to the spike protein. The immune system is very complicated. It is involved in fighting off infections (bacterial, viral, fungal) and even in fighting off cancer. On the one hand, if the immune system is too weak, you can get infections or even be more prone to cancer. We deal with this risk all the time with our immune suppressing medicines we must use for transplant. On the other hand, if the immune system is overactivated, it can cause the body to attack itself.  

So far, the risk of the vaccines appears to be low (not zero, but low). Many are concerned that we just don’t know what can or will happen in the next 20-30 years. The honest answer is that they are right. We don’t know nor do we have a way to know. In a perfect world you wouldn’t have to have any foreign substances enter your body. We are nowhere close to living in a perfect world at the moment. The odds are very high based on community prevalence and the persistence of the pandemic that if you are not vaccinated you will eventually get COVID. And if you get COVID 19 your body is going to be exposed to an enormous and very high level of not just the spike protein but all sorts of antigens that are part of the SARS-CoV-2 virus. That exposure in my opinion is far more concerning than the exposure that comes from the vaccine. We are already seeing a lot of concerning conditions that seem to be a result of having had COVID 19 including the poorly understood “long-haul COVID” syndrome. We will have a lot to learn in the next 20 years.

Let me share an example related to the heart: Myocarditis. Myocarditis is a condition where the heart becomes inflamed or injured as a result of the immune response. The SARS-CoV-2 virus enters the cells by the ACE2 receptor which is highly expressed in the heart and blood vessels. It is therefore important to look to see if the immune response to the vaccine can cause heart inflammation. There were a couple of reports earlier this year that noted myocarditis after mRNA COVID vaccines.[5] This has fortunately been reported to be very infrequent (occurs in only about 2 out of every 100,000 persons or 0.002%.) In adolescent males, for uncertain reasons, the figure is higher at about 6 per 100,000 persons. Fortunately, the vast majority of these cases have been brief, mild, and with rapid recovery. 

If we compare that, however, to the risk of myocarditis from getting COVID, while the risk is also rare it is much higher at about 150 out of 100,000.[6]  This means that the risk of myocarditis from the vaccine is about 75x lower than the risk of myocarditis from getting COVID. Ideally, we would be able to not have either. If we could be confident that every person would not get COVID, we would not want to take the risk of the vaccine. Unfortunately, however, there is a real, large and tangible risk that the unvaccinated are going to get COVID. This means that the decision is straightforward. The risk of the vaccine in regard to myocarditis is tiny compared to the risk of getting COVID, even in the higher risk group of adolescent males. 

This does not even take into consideration the other tangible risks from getting COVID. From the data that we have to present, the risk of a serious complication from a COVID vaccine is much less than the odds of getting COVID and having a complication or dying. When it comes to a risk vs. benefit calculation the odds are strongly in favor of vaccination.

Why are people who have been vaccinated still getting ill from COVID? Does this mean that the vaccine is not working?  The vaccines have shown significant benefit. The answer, however, is more complicated than a simple answer.  Last week our health system reported the vaccination statistics. Unvaccinated patients account for 86% of the patients with COVID requiring hospitalization, 90% of the COVID patients in the ICU, and 97% of the COVID patients requiring a ventilator. On average, patients who are vaccinated who get hospitalized with COVID are older with 2 more comorbid medical conditions than those who are not vaccinated. 

This means that the current surge is mostly a surge of the unvaccinated. It is a moral challenge and a source of frustration with our ICU teams. The vast (97%) majority of patients dying in the ICU are unvaccinated. Many of these persons were alive and well and healthy as soon as 1 week prior. There are a few breakthrough cases of vaccinated patients getting very ill. These patients however are generally persons with a lot of other health conditions. 

We are used to sick people getting sicker. We see patients get pneumonia or influenza and die when they have other conditions. It is really hard to see someone who was healthy get suddenly ill. Often I find myself thinking about how a week before they were out working in their yards or going to their jobs and now they are dead. It makes it even harder to think that this might have been prevented if they had been vaccinated.

Vaccines are not perfect. They provide an advantage to your immune system so that when you are exposed to the virus you are less likely to become infected. If the virus is able to get around your immune response and you do get infected, your immune system is able to fight it off sooner so that you should have a milder illness. We wish the vaccines were perfect and you could be impervious and never get infected. That is just not possible and is just not reality. It doesn’t mean that they don’t work. It just means that they may not work as well as you or I would wish they did.

If your favorite football team is going to be competing against a hard team, you would hope that they would prepare for the fight. Going into the Michigan / Ohio State game, I am assuming (and hoping) that the Michigan coaching staff and team members have been looking in depth at the Ohio State games. I want them to be know the usual plays and ways that they have been successful. I want them to be preparing a defense against what Ohio State has done to other teams with their offense. I want them also to have an offense that can get around the ways that Ohio State has shut down other teams.

They could just walk into the game blind. They could decide to not look at film clips or study or prepare. Even if they prepare there is no guarantee that they will win. But they have a much better chance if they do. They can look at a set up and it will trigger a memory, “I know that play. We have seen this before. We can defend against that.”

In the gamble of life that is COVID 19, the vaccine gives you a much better chance.

Do the vaccines really prevent infections, or do they just keep you from getting as sick when you get it?  This is hard to answer in the current state with a delta variant predominance for COVID. Early studies after the mRNA vaccines became available had health care workers who volunteered for weekly testing in order to be able to assess reduction in symptomatic and asymptomatic infections. The rates of both symptomatic and asymptomatic infections dropped significantly shortly after vaccination. Prior to the vaccination the rates of COVID 19 in the health care workers participating in the trial matched the community rates. After vaccination the rates of detected virus on weekly tests showed a sustained and progressive reduction in infection rates in those who were vaccinated. The peak effect occurred 3 weeks after the 2nd vaccination dose and showed a 94% reduction in both symptomatic and asymptomatic infection compared to the rates of symptomatic infections in the community.[7]  

As time has gone by and the delta variant has become predominant, the degree of protection has become less from the vaccines. There has however been no signal to suggest the vaccines only protect against symptoms. The data that is available suggest that the vaccines reduce infections, symptoms, and serious illness.  

Booster Data: Going back to my football analogy, it is not enough to have studied the Ohio State plays 6 months ago. You must continually be looking and studying and preparing. Your immune response weakens the further out you get from the vaccine (or from having had COVID). Fortunately, the Pfizer booster study data looks very good. The Pfizer trial studied > 10000 patients randomized to a booster dose or placebo who were 6 months or greater after their first series of shots.[8] The booster shots were well tolerated with a small percent having minor symptoms (transient fatigue or achiness). Serious adverse events (SAEs) were very rare and were actually more common in the placebo group than the treatment group (0.48% vs 0.32%).[9] COVID was detected in 6 patients who received the booster and 123 who received the placebo. This is a significant 95.3% reduction in odds of getting COVID in persons who got the booster shot compared to those who got the placebo. The benefit happened quickly with the incidence curves separating 7 days after the vaccination.

Why are we having such a big surge now?  The answers are not completely clear but likely reflect two factors: (1) Relaxed social distancing and (2) the predominance of the more highly infectious delta variant.  We easily forget but November 2020 was a different world than what we are living in now. Remember the Michigan restaurant restrictions were not lifted until June 2021. Many schools and jobs were virtual. Social events and concerts were unheard of. If you scroll through your Facebook or Instagram feed, look at the difference between November 2020 and November 2021 in regard to masks and social distancing. The contrast is real and significant. In my opinion this is the driver of the surge. We are all tired and fed up with COVID and because of it we have let down our guard. We are paying for it with a much higher number of cases.

Will this ever end? The honest answer is that no one knows. There is a snowball effect. If community prevalence goes up, more people get COVID and community prevalence goes even higher. The opposite can become true, however. If the cases begin to drop then your odds of being exposed go down and the community prevalence goes down further. Cases can go down through any of the following: (1) Enough people get COVID to have a degree of immunity, (2) Enough people get vaccinated to not get infected or if they do become infected, they tend to shed virus for a shorter period of time, or (3) Social distancing goes up.  Christmas vacation may help (school age children not being exposed at school). Warm weather also helps (people tend to be outside which reduces the risk of transmission.)  I am dreaming of a day where these forces have become enough that community prevalence drops so low that COVID is only a small or infrequent thing.

Conclusions:

  • COVID is bad. I don’t like it.
  • The vaccines work. The booster data looks really good.
  • Vaccine risks are much smaller than the risks to you and your body from getting COVID 19.
  • I wish we didn’t have to deal with any of it. We are all doing our best to navigate our way through it to the best of our ability and our conscience. I am not claiming to be an expert on all things COVID. This is my personal effort to navigate my own way through it.
  • There is still a lot we don’t know. We have good things coming including promising new vaccines and new medications. I hope and pray that they prove to be effective. We have reports of new variants coming. We have no idea if they will amount to a problem or not. None of us know everything. I hope that we can extend a little bit of grace to each other as we try to find our way through this.

[1] https://www.medicinenet.com/script/main/art.asp?articlekey=9877

[2] https://www.medpagetoday.com/special-reports/exclusives/93658

[3] https://www.cdc.gov/coronavirus/2019-ncov/vaccines/safety/adverse-events.html

[4] https://data.worldbank.org/indicator/SP.DYN.CDRT.IN?locations=US

[5] https://www.nature.com/articles/d41586-021-02740-y

[6] https://www.cdc.gov/mmwr/volumes/70/wr/mm7035e5.htm

[7] https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2781727

[8] https://www.cdc.gov/vaccines/acip/meetings/downloads/slides-2021-11-19/02-COVID-Perez-508.pdf

[9] The SAEs with the vaccine each had explanations by other conditions the patients had and each resolved quickly without long term sequelae, similar to the placebo group. It is important to always have a placebo group because in any large group of persons, illnesses or events are going to happen that are completely unrelated to the study.

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

The Hype Video: Purpose and Meaning that Drives What You Do

The big screens lit up and the speakers boomed. The crowd cheered as the video played. By the end we were all excited. The freshmen were lined up with some upperclassmen holding them back. Then the upperclassmen released the freshmen and they stormed across the football field as they ran the “Baylor line.” 

It was a five years ago and I was in McLane Stadium at Baylor University. I had flown down to visit my daughter JJ. We had walked around the tailgating areas and had bought green (it was a green day) Baylor logo hats and shirts to wear. We were in the huge stadium and the “hype video” was a key part of the experience. We spent the rest of the day with our arms in the air doing the Baylor Sic ‘em. The weather wasn’t the greatest. It rained. Baylor didn’t win. But it didn’t seem to matter all that much. It was fun to be there and experience it and especially to do it with JJ.

So much fun watching the freshman class run the Baylor line!

The hype video was well done. It really got me excited about the game. I felt happy to be in the stadium and be a part of all of it.

It reminded me of a story that I had been told many years before. 

One of my teachers had worked for a large appliance store before he became a teacher. He told how each morning before the store opened they would get all the salespeople together. They would go through a “pep” talk – sort of the equivalent of a hype video. They would tell them how it was their duty to (a) sell, (b) sell and (c) sell some more. The more they sold the stronger the economy. That would then mean jobs and prosperity for our community and our country. He told me they would get them so hyped up that by the time of the doors would be opened he said he was ready to go. Every day he would be enthused and ready to convince anyone who came in to buy the latest and greatest electronics equipment. It was his noble and patriotic duty to do so.

When he told me the story, it made me understand that store better. Every time I had been to that store the salespersons had always been very eager to sell. I bought a big powerful stereo from that store. I loved it. It was strong enough that you could feel it as well as hear it.

It does, however, raise the question that confronts a lot of us: Do we have purpose in our lives?

A part of being human is a need to have a sense of purpose. We need to believe that what we are doing has meaning and value. To do less than that can lead to drudgery and eventually to burn out. “It’s time to make the donuts…” was the old commercial[1]. At times any job can seem like that: a never-ending cycle of delivering a product or service. But we all want to go beyond that. We all have a need to find purpose and meaning in what we do. 

You can argue for or against the hype that the electronics store used. Honestly, it sounds ridiculous to me. But if that is your business, you likely will need to work through what you are doing. If it is just about doing something over and over again for no reason, you will not last. You will not be effective. If it is just about making money you may find a deepening hole in your soul that will eat at you. To last and be happy you will need to think through it to find a purpose or meaning.

I was unsettled. It is a long story but ultimately I had decided to leave my primary care internal medicine practice and go back to training and into a cardiology fellowship. My purpose had shifted. I couldn’t stay. In spite of the risk and loss of income I had to make a change. It was the right move for me.

In the time of that transition, I was at a dinner meeting and I ran into Mark. He was another internist that I had known for several years. “I thought about doing what you are doing,” he said to me as we put our coats on and walked toward our cars. “I admire you for it. I was really close to going back to fellowship myself at one point.” 

“Why didn’t you?” I asked him. 

“Growing up when I thought about wanting to be a doctor it was because I had a vision – a desire – to be “someone’s” doctor. In my mind it was the long standing and lifelong relationship that defined what it meant to me to be a doctor. I thought about specializing but realized that to do so would betray what my purpose in being a doctor was about.” 

It made sense to me. I was happy that he had figured it out. He was in primary care because that was where he found purpose and meaning. The reason he didn’t do a fellowship wasn’t because of a lack of ability or courage or drive. It was because it would have been wrong for him to betray his purpose. I was happy he saw his purpose.

It challenged me to think about my purpose. It was clear to me that there was something – or some things – that were driving me to do the fellowship and pushing me forward. The unsettled feeling was all about purpose. For me it may have gone further to even be a calling or a vocation.

How do we each find purpose and meaning in our lives? I have learned that it is a very individual thing. It also can shift and change throughout your life. 

It might not be at work. Some never find their purpose or meaning in their jobs. That is okay. Obviously throughout human existence there are times when just surviving is enough. Trying to find some deeper purpose or meaning in your work can often be a luxury. There are millions of people in the world who work to just survive. They still have purpose in their lives, but the content of their work may not be where it is. 

We all know people who do work to have the resources and time to find their purpose elsewhere.  For them their purpose is found in many different places. Family is a common driving purpose. Sometimes it is friends and the time invested in them as they pursue their favorite hobbies. Clearly faith and serving God is a big and driving purpose for many. Some do amazing things in their churches or other areas.  To them a demanding job might just distract or pull them away from their purpose. 

Some find meaning in the how rather than the what of what they do. For them their drive comes from doing whatever they do with quality and excellence. This is a common source of purpose early in a career. There is a real challenge and satisfaction in mastering an art, skill or field of specialty. In that phase of life, purpose and meaning is found in the effort of acquiring competence and eventually expertise.

There is something admirable about being an expert – or a craftsman – in whatever you do. I am convinced that a clerk at the gas station can have true purpose and meaning in their work if they are determined to do it well. The book, “The Fred Factor”[2] is an excellent discussion about this type of thinking.  The subtitle explains the concept, “How passion in your work and life can turn the ordinary into the extraordinary.”

The point is I am convinced that the secret to sustainability in whatever you are doing is to find your purpose and drive in your life.

And now I pause.

Because it sometimes is easier said than done. Sometimes your purpose is crystal clear. Other times it shifts and changes. 

Sometimes you get cancer and it stops you in your tracks and confuses everything. Sometimes even though you recover from cancer surgery and treatment, you are left easily tired and not the same person as you were before. Sometimes you can no longer drive hard anymore. You find that you can no longer stay up late, working into the night, and then pop up in the early morning to continue to work for an hour or two before the clinical day starts. Sometimes you have a gym membership that you used to go to at 5:30 each morning that you still pay for but leave unused for months on end. Sometimes you get home at night and do not have the energy or desire or drive to answer the emails that accumulated during the day. Sometimes you have to figure out again what drives you – or what motivates you – or what is worthy of the energy that you do have.

I am not complaining. As I went through the cancer diagnosis and treatment, it occurred to me that I had no desire to continue with business as usual. I was eager to rethink what was important. It meant digging down into my person and my soul and my world to see what I wanted – or what I needed – to do. And even now, I continue to dig down and evaluate where I am and what I am doing. I would be disappointed if nothing changed. I would feel like I had wasted the trauma of having cancer (can’t I get something good out of this?)

What drives my hype video now?

Over these past three years since my diagnosis, I have been slowly figuring out some things. 

It is not about selling stereos. I don’t care about selling a product or making anyone profitable.

Some of it may have elements of what my friend Mark said. It has been a real honor to play the role as a heart failure cardiologist for the good of my patients and their families. In the past I would think in broad sweeps about systems of practice. Looking back now I realize that systems rise and fall and come and go. It is the patients, families, friends – the people – who have been helped that makes me really happy and satisfied. 

It doesn’t mean that improving systems and pushing to improve things doesn’t matter. I can remember the many times when I had a vision of ways that things could be so much better. In those settings, I was driven not to just endure the status quo but to work to make substantive changes. There is real value and honor in improving the systems. You can make things better not just for yourself but for everyone else as well. But the purpose is not just to have a shiny system to show off. No matter how wonderful and shiny the system is, it always tends to get rusty. The purpose is to have systems that work so that people get taken care of.  It still comes back to the people.

And so, the focus begins to return for me. I want to do whatever is necessary so that people are helped. Sometimes the best way for me to do that is to be a worker in the process. Maybe it is a time in life for me when the best thing for me to do is to “make the donuts.” But is there more?

I have found a desire to expand the reach of our specialty of advanced heart failure. It is for this reason that I have been pushing to have an increased role in developing outreach clinics. I want to see and help the patients that might not have been referred to us or might not have been willing to drive to Grand Rapids to see us.

What about beyond medicine?

It is odd to me the passion I have found for writing. I was never the student that was drawn to writing in college. I gravitated toward math and the sciences. But now it is a joy for me to pour out myself into these blogs. I hope that somehow maybe this writing could influence people in positive ways. 

I don’t know that I have it all figured out. I do know that there are things that I want to do. If one of them is to in some way help you – or push you – in a positive way then I am sincerely and deeply happy.

Please do not just exist. 

Don’t settle for just “making the donuts” for the sake of making donuts.

What motivates you? What is important to you? What do you care about? What do you wish you could change? Is there something that gets you excited or that can drive you? Even within what you currently do, is there purpose or meaning that you can find?

I can hear the hype video starting. The screen is large as the images start to appear. The speakers are powerful with deep base tones. The booming music is starting up. What is it saying for you?

For me it is:

  • There are patients who need help and hope in the midst of their advanced heart disease.
  • There are people who are suffering who need a kind and understanding physician to maybe make it just a little bit easier.
  • There is a large community of healthcare workers who are getting lost and forgetting their purpose. They are burning out not because they can’t do the work. They are burning out because they are losing their purpose and meaning in the midst of the pressure of their work. They need to resist the forces and the stresses that threaten to make them just workers selling or delivering a product. They need to find again their purpose and meaning in what they do. There is so much good that the do. Can they see it or hear it again?

Can you hear the hype video now? It is playing loudly. I can – I will – get up in the morning and ignore how tired I feel and how my achy muscles are – and go to work. I can do it. I want to do it. It is worth it.

[1] A reference to a classic Dunkin Donuts commercial that depicts the owner getting up early every day to make the donuts fresh. https://www.youtube.com/watch?v=1AA1XDqK8tY

[2] The Fred Factor, by Mark Sanborn, Penguin Random House LLC, 2004