Dr. Mike Merrill

Anxiety is like a virtual reality headset, showing another dimension.

Leadership Maxim 10: Anxiety and Fear are Part of Being Human. 

Most of us would rather not have anxiety. We turn away from it, or ignore it, or try to medicate it away with things like alcohol, distractions or exercise. And, of course, ignoring an emotion creates bias and makes it harder to think clearly.

But anxiety contains information that we can use. It is is like a web reaching through life and work to a thousand places where there is uncertainty or looming danger. So if we sit with anxiety, and look at it, and study it, we can gain great information that can help us personally and professionally. It contains another dimension of information. It's a path into our intuitive understanding of our environment. It tells us what to pay attention to, and what to start working on.

We're not talking about severe anxiety here; this is not agoraphobia, or paralyzing social anxiety. We're talking about a lesser form, a more common form, that can be your friend and ally.

"We are wired for anxiety, because of the fight or flight instinct," says Gary Dinezza, Ph.D., a neuropsychologist in Buffalo. "It's a response to perceived threats in the environment." It can be what gets us out of bed in the morning, and it can focus our minds, so it can be positive, he says. 

Think about having to make a presentation next week. If you know your material well, and you know your audience well, it might not cause any anxiety. But what if you don't know them? The answer is to listen to your anxiety and start to prepare, and then over-prepare, learning your material, refining your talking points, and learning everything you can about your audience. The best speeches I have ever made were when I knew the material absolutely cold. 

Of course, as for any emotion, you can't just listen to and follow anxiety blindly. Emotions, after all, are not always the ultimate window to the highest truth. We still have to think, and carefully assess what we see and what we do.

And keep in mind that anxiety can manifest as a lot of different things, such as grouchiness, social withdrawal, or feeling unhappy with one's choices. 

You can't escape anxiety unless you're medicated or dead. You might as well use it. 

 

www.overcomingthenatural.com

 

 

Doing the dishes, repeat.

I'm returning to the kitchen sink. Every night I return to the kitchen sink. There are similar pans present, with similarly encrusted food. There is usually a napkin in one of the bowls. There are bits of food on the countertop. The lighting is so-so. The coffee pot needs cleaning. 

A friend of mine said that during COVID, "Every day is the same - so we can make the perfect day."

Again and again, I return to the sink. I try to make the sink-work more meaningful by focusing and practicing working meditation. I focus on my movements and try to find a half-second here and there by being efficient. I try using music. But it is still the sink. 

Sometimes it is uplifting, and sometimes it depresses me. 

But all this is the best it can be. It is a repetition. I don't look back, I don't look forward. I am familiar with what I am doing. Repeat. 

"... repetition is a beloved wife of whom one never wearies, for one becomes weary only of what is new." (Kierkegaard)

 

 

Save Black Lives from COVID in your community. Do what Buffalo did.

In March, black deaths from COVID in Buffalo were on track to being as bad as the rest of the USA. The black community is 15% of the population of the county, but was 36% of the deaths. 

Then Rev. Kinzer Pointer and his team started their public health program. Now the deaths are 16%. This isn't happening in the rest of the USA. 

This saved many lives. 

This is what they did: 

• Find trusted community leaders from the black community. This is key. 
• Add public health professionals and doctors to the work group. 
• Set up testing sites in the black community - as many sites as possible.
• Provide transportation and connections to primary care practitioners. 
• Provide extensive educational efforts, including on masks, hand-washing, avoiding crowds, and other established public health measures. 
• Establish a call center.  
• Help with food security by delivering fruits, vegetables, beans and rice.

These simple measures save lives. It will take some organization (and some money), but it looks doable anywhere. 

Rev. Kinzer Pointer is available to talk about the details. Email me and I'll get you in touch: [email protected].

 

 

 

 

I was right about deaths due to refusing Medicaid expansion, pretty much

In 2013, I quickly estimated that in Texas, not adopting the Medicaid expansion under Obamacare would mean 3,200 deaths per year. 

A more recent estimate puts that number at 750 deaths per year.

So I was off by a factor of 4. 

 

 

A letter to my grandchildren about climate change

I know climate change is terrifying to the youngest generations. Their eyes are not blinded by decades of experience and the expectation that old patterns will repeat. So the raw reality of a rapidly changing world, and the risk of the end of civilization, are evident and emotionally overwhelming. 

I'm writing this to tell you we have a pathway out of this mess, and to a better future. 

As things get worse in coming years, there will be water shortages, and wars and refugees. All sorts of unimaginable bad things will happen. You and I may die before our time. But whatever happens, here is always here, and now is always now. There is work to be done today, and the correct path to be followed, and people around us that need care. Even in the worst situations, social networks remain. People keep caring about each other. 

Eventually, when the coastal property of the rich is threatened, the world will take action. And around that point, the risks of climate engineering will be lower than what is actually happening. Scientists knew it would come to this. They have been working on solutions for decades. They know what to do already. We just have to persist through whatever day-to-day disasters befall us, until the world is stabilized.

Humans have become so powerful we have dominated the earth. Now that we have done so, we must take responsibility for it. We must preserve it through whatever means are at our disposal. We are like fish in a dirty fish tank. Eventually we will turn on the filter. 

Reportedly, someone once asked the Dalai Lama how he could remain positive in the world we live in. He said, "What else would you suggest?" and laughed. This is the correct perspective. 

 

Why are hospital prices so confusing?

A new law requires hospitals to post their prices online. The prices vary quite a bit. Why is this? 

The main reason, I think, is that in a hospital it is difficult to do cost accounting. "Cost accounting" is figuring out what it costs to do something inside an organization. 

Let's make my argument concrete. Let's say you're admitted with pneumonia. The hospital obviously has to charge for the nursing care. To simplify, let's say there's one nurse taking care of you for each 12-hour shift. How do we figure out how much of their time is spent on you? Minute to minute, this nurse could be walking from room to room, sitting down at a computer working on several different charts at once, talking to her supervisor about a problem, and pulling meds out of the medication room. Essentially they are taking care of multiple people during the same hour. It's hard to parse out that time. 

And then it's hard to predict how much of the hospital's resources will be used by any individual. Let's say you are in with the pneumonia, but you have chest pain, and a "rapid response" is called. About six people show up in your room within three minutes. One starts doing an EKG, another one checks your vital signs, another puts some different leads on your chest to watch your rhythm on the defibrillator, and another one starts recording the events as they unfold. The doctor arrives and orders a chest x-ray and some lab tests. The x-ray tech comes up from the basement and shoots the film. A nurse from another floor comes over to draw the blood. About 8 minutes have elapsed. This unforeseeable series of events goes on for maybe 25 minutes until the situation is figured out. How does the hospital account for all these resources in your bill? 

What about the cost of ensuring that the second-level backup generator works? Of ensuring that if the power goes out in the operating room, the first-level generator kicks in within three seconds? Of quality control on instrument sterilization? Of medications in the pharmacy that reach their expiration date and have to be discarded? 

I defy anyone to identify a business environment so complex and so regulated, and that provides so customized a service. 

 

Metrics are based on humanness

In healthcare, we understand that metrics have limits. So when we measure diabetes control, we know we're not seeing all of healthcare quality. It's only part of the picture. And we know that each number has a story behind it. For example, diabetes control in a disadvantaged population means something different than in a wealthy population. There are multiple factors underlying the number, and to understand it, we need to ask questions and have conversations. 

I like to say that "metrics are good, but thinking is indispensable."

Following are some interesting thoughts on metrics from Dr. David Shaywitz's December blog post at Forbes, and other stuff he points to. 

In Nobember 1984, when spreadsheets were permeating the business world, Steven Levy wrote a thoughtful essay in Harper's on how spreadsheets were transforming business thought. (The article's title was "A Spreadsheet Way of Knowledge," apparently an allusion to Carlos Castenada's book, The Teachings of Don Juan, a Yaqui Way of Knowledge, which is a highly mystical story of a Native American shaman):

• Measuring something makes it easy to ignore what is not measured. "The aspects that get emphasized are the ones easily embodied by numbers. ... Even a hostile takeover seems cut and dried, perfectly logical, in the world of spreadsheets. The spreadsheet user has no way of quantifying a corporate tradition or the misery of stockholders or whether the headaches of a drawn out takeover bid will ultimately harm the corporate climates of the firms involved."
• Spreadsheets and mathematical models are based on assumptions with highly variable reasonableness. "The accuracy of a spreadsheet model is dependent on the accuracy of the formulas that govern the relationships between various figures. These formulas are based on assumptions made by the model maker. An assumption might be an educated guess about a complicated cause-and-effect relationship. It might also be a wild guess, or a dishonestly optimistic view. ... People tend to forget that even the most elegantly crafted spreadsheet is a house of cards, ready to collapse at the first erroneous assumption "
• Spreadsheets are "a metaphor," and there are other kinds of metaphors apart from math.  

From Frank Pasquale of Yale Law School: 

• Don't let metrics be the only thing that tells you what is good: "There is an almost evangelical quality to [metric-driven] work, a passionate belief that older, intuition-driven decisions are a sinful relic of a fallen world…. [Metrics] colonize our own understandings of merit.”

From The Black Swan author Nassim Taleb: 

• Measurement "increases overconfidence": "Risk measurement and prediction —any prediction — has side effects of increasing risk-taking, even by those who know that they are not reliable. We have ample evidence of so called ‘anchoring’ in the calibration of decisions."

Please let me know what you think!

"Social determinants of health" are macroeconomic, not micro

There's a lot of work on "social determinants of health" that involves helping individual patients get the things they need: secure housing, food security, transportation. 

But the real message of the literature on social determinants is that factors larger than the individual - factors on a society level - affect individuals' health. And a corollary is that addressing these large-scale factors is likely to improve health for individuals. 

A blog post by Health Affairs points out this distinction nicely. 

Things that truly affect social-level function: building a grocery store in a "food desert," improving the safety a neighborhood, providing a low-cost gym, creating affordable housing, and creating a new employer that offers good jobs.  

Unfortunately, truly addressing social determinants requires large-scale intervention. The market by itself cannot be counted on solve the problem because, after all, poor people don't have money.  That leaves government, and in today's political climate, government action on almost anything is problematic. 

Eventually, we will collectively discover that having disadvantaged environments in our midst is bad for everyone, and that individual responsibility cannot solve all problems in an interconnected world. 

 

Three cuban professors define socialism (short videos), and other notes from a visit to Havana

My wife Melanie and I enjoy learning things while traveling. For example we had some great private tours from Ph.D.'s through Context Travel in Rome last year. I can't express how much the non-stop lecturing and question-answering added to our visit. 

This year, on a lark, we booked a cruise (our first - it was actually OK), and decided on one that goes to Havana for two days. In the spirit of learning, we bought a few "experiences" through Airbnb, rather than just doing the cruise ship tours. 

Our first tour was with Leo, an economist, and Cesar, a historian. We went through the history of Cuba, the revolutions, the complicated and difficult relationship with the USA, the partnership with the USSR, and the difficult times when the USSR fell apart (the "Special Period" of austerity). Again, I can't express how enriching these hours were. For something to share with you, I made two brief videos, asking our hosts to define "socialism":

 

At the end of the tour, I told Leo I wanted to learn about central planning, and he said, "I can get you a visit with the University's chief of central planning tonight." 

Wow. 

Another few hours of fascinating conversation. I asked him the same question about socialism: 

What really struck me, talking to these guys, is how much what they said aligns with what I have heard/read economists say in the USA. For example, they understand that a planned economy cannot satisfy everyone's needs, and that a separate economy, using market forces, will occur - whether explicitly or hidden (i.e.,black market). They acknowledge that the tradeoff of a rigidly planned economy is lack of efficiency. For example, for an entire month last year, there was no toilet paper in Cuba. (Of course, part of the difficulty is the trade embargoes, which make it difficult to find trading partners.)

The one difference in their thought was the primacy of the goal of making sure everyone is OK, that everyone benefits in some way from changes. Especially, as they integrate into the world economy, they are intent on ensuring that no one gets hurt. They seek to protect the poorest. "In Cuba, it is difficult to die" - you will not starve, you will have a place to live, you will have health care. I swear you could feel it on the street, even in the poorest neighborhoods - I never felt that desperate anger you can feel sometimes in the USA. There was resentment of inequality, to be sure, but never that sense of "it's me against you." 

We also spent some time in the Museum of the Revolution, documenting the events of the late 1950s and early 1960s. It's fascinating that the revolution was not intended to create a socialist state, but to push away USA-domination. The revolution was "as green as a palm leaf," Castro said - i.e., not "red". The embrace of socialism and the alliance with the USSR came a few years later, after the Bay of Pigs cemented Cuba's opinion that the USA was not to be trusted. They had to turn to someone else for help, and there weren't too many options then. 

 

At the art museum (Museo de Bellas Artes Cubano) you could see politics everywhere - anti-capitalist most notably. Some of it was a bit heavy-handed, as in "Heaven and Earth" by Marcelo Pogolotti, 1934: 

 

Havana itself was tremendously safe, but it looked like a war zone. Buildings falling apart, streets with huge holes, broken down cars. No capital. Here's a banyan tree growing on top of a building: 

 

But there are construction cranes elsewhere. It will be truly interesting to see how the country changes over the next few decades, and especially interesting to see how the government tries to protect the poorest during the process. After all - consider the huge death rates during the "shock therapy" doctrine in Russia during the 1990s. Cuba's ideology would not tolerate such a thing. 

 

 

This is $1 million of the drug Eyelea

Eyelea is used to treat macular degeneration, a disease of the eye. This is about 500 vials of it, so about $2,000 a dose. There is a generic available, Avastin, that costs about $80 a dose. 

This is a stack that a Buffalo ophthalmologist made using the empty vials he accumulated over about two years. 

Here's what you can do with $1 million: 

• You could hire 20 substance abuse counselors for a year. 
• You could completely immunize 1,000 children. 
• You could feed 300,000 meals to homeless people.
• You could house 200 homeless people for a year. 
• It's 50,000 bags of groceries. 
• It's Head Start for 200 kids for a year. 
• It would cure 50 people of Hepatitis C.
• It's prenatal care for 1,000 babies. 

 

Merry Christmas.