Book Review: Final Exam - A surgeon's Reflections on Mortality by Pauline Chen

Not long ago, I was at a Pittsburgh Symphony Concert which had pieces that reflected on death and mortality Pittsburgh Symphony: reflections on death. This is another view of the topic, in this case the final exam is for doctor's, who have to face the fact that their patient is facing death and how dealing with this should be part of the doctor's profession. Pauline Chen, a transplant surgeon, makes the case that (1) providing care in death is not part of a regular doctor's training, (2) it really should be (3) there are experiences that can be used to provide this type of training (in the same manner that other parts of the doctor's training are provided through experiences)

When I was an EMT I was told a joke by a nurse. Q: What does 'MD' stand for? A: Made Divine. It was a reference to the fact that doctors had a tendency to believe they were as gods, with the power over life and death. But the problem is that this was not true. At some point, death wins. The reality is that most people are not able to face this honestly. In the case of doctors, because (for many specialties) they see death frequently in their training, one could expect they learn how to work with death. Pauline Chen's point is what they learn is coping mechanisms that allow them to avoid dealing with death. What they do not learn is how to continue care as the patient is known to be approaching death, which is something very different.

In the U.S., this is a controversial subject. There is a large portion of the U.S. population that believes doctors should have no part in discussion with clients how they want to die. (most obviously expressed during this past summer's controversy over what anti-doctor people called "death panels") And on the doctor's side, many of my friends have commented on how the care they were providing to patients who were beyond any reasonable expectation of recovery seemed to be tantamount to torture and mutilation. Forced by families that refused to let their loved ones die with dignity and wanted to fight, despite the costs in pain and suffering of the dying.

What Pauline does is to go through the stages of training of a surgeon, from medical school to residency to fellowship and show how doctors are trained, and then how their training involves the use of experience to teach them how what they learned in school relates to the realities of patients with actual conditions and histories. As she does this, she also talks about how death is dealt with as part of the training. How death is addresses, how the subject of death is ignored through denial or withdrawal, and how the practice of teaching and thinking about death is changing within the medical profession.

Pauline's book is not just the usual 'what is wrong about . . .' As she goes through the training program, she describes experiences that occurred that could have been used as teachable moments, along the same lines that medicine is taught in the modern day. In some cases they came and went without notice. In other cases, she observed mentors dealing with death in what she viewed as highly insightful and humane ways, but without an explicit teaching moment, leading her (as a trainee) to observe (or not) the example without comment. And she discusses some of her own cases. Some cases that she reflects on that she could have handled differently. And some cases where she did not know what to do, but from feedback later (after the patient is deceased) from the family she learns that there was genuine healing for both the patient and family from how she handled the case.

There are a number of lessons here, not just how the medical profession handles death (or avoids it) and how the medical profession could handle/train for dealing with death, but on how one trains others in a profession. I am teaching, not only in the classroom but also with students working on projects. And as part of these projects, we are aware that we are teaching values and an art form to the students working with us, not just the technical skills of our profession. It shows in the how we address the project, how we talk to those outside of our profession, the questions we ask, the questions we choose not to ask, and the directions we choose not to go in. And this book questions those values.

Movie Review: Ride with the Devil by Ang Lee (1999)

Ride with the Devil is set in Missouri and Kansas during the Civil War, when pro-Southern elements waged guerrilla warfare against the Union occupation of Missouri. It is from the point of view of the Southern "bushwackers" as they raid and harass Union forces and sympathizers.

This has an incredible depiction of guerrilla or irregular warfare, known nowadays as insurgency. You see both sides attack civilians who sympathize or support the other side, or even are suspected of supporting the other side. It is shown in raids against isolated settlements, and massacres of entire villages. The use of language in shaping perceptions of one's own actions as well as the opposition. The fighters going to ground blending into the population and depending on the support of civilian supporters. All of these very familiar to anyone with familiarity of Iraq or Afghanistan in recent history, or Algeria, Vietnam or many such places.

The other theme here is the motivations of the Southern sympathizers. The focus on wanting to live their own way without interference, contrasts to the Union, who would impose their rejection of slavery on the Southerners. The portrait of the Southerners is sympathetic. And the view it shows of insurgency and its brutality, especially on civilians who are caught attacked by both sides with no security, is especially hard hitting. Well done movie by Ang Lee.

Lessons Learned: Notes on teaching Fall 2009

The past semester was spent teaching two classes,the introduction to operations research that is typically taught to juniors as their introduction to the more mathematical side of industrial engineering/operations research. It is a required class, so it gets the entire year at once. The other course was a new course in Homeland Security modeling which was a concept course for graduate students. We are working on a emergency response certificate program, and one of the requirements will be a quantitative modeling course.

I had the advantage of the syllabi from the last two people who have taught the course. The main issue is retention of material over time after the course. With that in mind, the course coordinator (a faculty who was given 'ownership' of the class over the long term) and I made the choice to focus on modeling as opposed to algorithms, with the goal of the students learning modeling which can be applied, even if the actual methods are forgotten.

As a preface, I think the reality is that the top students would do well pretty much regardless of how (in)competent the professor is. For them the best I can do is make the claim that something is worth spending time on. But as much as we may be proud of our top students, and we probably can't do much about the bottom, the middle is where we as professors show our worth. And I try to resist the temptation of only thinking about the top of the class in these notes.

1. Focus on modeling and sensitivity. The overt choice was made to focus the course on modeling and sensitivity as opposed to methods. Given that these are engineering students, it is accepted truth that methods are easier to teach then modeling. The issue is that these students have been taking courses that teach them how to follow procedures for 12+ years in their math and science classes, so modeling is something different. And there are lots of people who work in the field who never really learned how to do this.

One result is that the class was more fun to teach. Because the focus was on the modeling, the concepts could be introduced with examples and the models can be built up from understanding the physical example. For some of the models, after going through the example I could discuss the historical situation that led to the model. For one quiz, I used a paragraph from a New York Times article to provide the problem the students had to model.

Response seemed reasonably positive. In particular, there was gradual recognition of what they were learning as various students started clicking as the semester went on ("I've started to think in sets!"). Others were somewhat resistant, as they were much more comfortable following algorithms. (e.g. simplex, Dijkstra's, MST) There was a general resistance to visualizing the problem through the use of diagrams. In the end, the real test is if they have developed modeling skills by next year when they do senior projects. (while they have LP, queuing, simulation, etc. senior projects tend to be process improvement projects.)


2. Software. In my preclass survey of goals, more then half of the students mentioned something about using software. The textbook uses LINDO (matrix generator) and Excel Solver. I had them learn Excel solver and GLPK. I don't think GLPK was any harder the LINDO. In particular, I think software was less important then I expected. Other then the middle portion of the course that focused on sensitivity and duality, there was not much use of the software to actually solve LPs. There was considerably more time spent on interpretation of output. I don't know if the students actually got skilled at using the software. We went through a few rounds of giving instruction, in class examples, live demonstrations of translating a formulation into a model, a YouTube video (by a business school professor demonstrating the Excel Solver) and a grad student presentation on GLPK.

We also found two bugs. Excel had a tendency of giving solutions that violated a constraint. The issue is that there was a default setting for the tolerance that was positive (>0) and was less then the rounding in the standard display. So the Excel solver violated constraints, even on small problems (where finding a feasible solution should not have been too much work). GLPK had a problem with bounds analysis in the Windows version of the software. It turned out that a fix to this problem was recently found and the patch developed by a senior in the Pittsburgh IE department (i.e. someone who took this class a year ago).

3. Class management. It was a 58 person class, so very large. A large portion of the course was taught semi-socratic, mostly the overview of different types of models. While this was fun as an instructor, the issue with socratic method is you go at the speed of the fastest students. Which I soon realized meant that I was loosing a big chunk of the class, even though there is a lot of repetition involved.

4. Team teaching. For the Homeland security course, this was team taught by myself and the head of a Center that was developing the certificate. There was a problem with communication. While the topics were agreed upon, we seem to have somewhat different ideas on what the use and purpose of models are. This was made worse by a lack of a communication plan between us, so when questions came up, they were not resolved. In addition, he had his students in the class do their project that was of very different character then the rest of the class (or the stated purpose of the course), which made grading and advising problematic. Before doing something like this again, I would have to have a more formal discussion on goals and purpose, as well as plan for ongoing adjustments.

Modern Love: A Joint Account that Underwrites our Marriage (New York Times)

Modern Love: A Joint Account that Underwrites our Marriage

By David Sarasohn, New York Times, December 11, 2009

Back when we became engaged, our news was also greeted with baffled curiosity. It was the ’70s, after all, when the freedom to be able to hop from one relationship to the next was as essential as anything in the Bill of Rights. Our friends were profoundly perplexed; nobody, they thought, could want a fondue set that badly. We had already been together three years at that point, pretty much ever since I turned around at the orientation meeting for new history graduate students and saw her in her granny dress. (As I say, it was a long time ago.) Our feelings about marriage may have been shaped by our pursuit of such a traditional area of study. Perhaps our attitudes would have been different had either of us been in gender studies.

Of course, back then no one had heard of gender studies.

The surprise that now greets us at the fact that we’ve managed to stay married so long — as opposed to having shaken hands at some point and decided who kept the ice cream maker — is even more extreme. Friends you haven’t seen for a long time often inquire delicately about the spouse you had when they last saw you.

In this piece, David Sarasohn discusses his experience of marriage, through the years that have seen many of his friends divorce or separated, through the loss of friends as a side effect, through the struggle with infertility (and listening to may supposedly pro-marriage people proclaim that the primary purpose of marriage is to bear children).

When I was 19 I was first told I was entering into an activity that was associated with a high risk for divorce. And of course, of this group of 19-20 year olds, not one blinked at the thought. Now, while this was being said by some kind nurses who were warning us of what we were getting ourselves into, so maybe we could do something about it. And some of us filed that away for when that became an issue. And I've been told many other reasons why relationships would be problematic since them by people without the same level of caring, including my choices of friends, acquaintances, and relations.

There have also been others like that nurse who were more interested in my well being, and if I do get married, that it be done well. First, that this is done with eyes open. We know who we are and how we got this way. And not everyone is ready for a life with such as us. We all knew of stories of people who got into relationships where their partners first priority was to try to get them to stop going on the calls (i.e. the very things that developed the character that made them so appealing, at least to us)

David talks about his marriage and the hard times. What he says:

Being single is all about the future, about the person you’re going to meet at Starbucks or after answering the next scientific compatibility questionnaire. Being married, after a certain point, is about the past, about a steadily growing history of moments that provide a confidence of comfort, an asset that compounds over time. What you share is what you’ve shared, and measuring your communal property in decades puts you in a freakishly high bracket.

So this is what we are looking forward to. Our albums include pictures and letters from war zones, disaster areas, question and thoughts on dealing with risk. Questions about our careers. Engaged and sharing in the toil of our chosen paths. Learning to endure/appreciate/experience each others patterns, reactions and language (spoken and not).

And somehow we take each other. With both of us having edges adapted for environments with little tolerances, somehow we manage.

I am somewhat better with words than my wife is; she is infinitely better with people. In different ways, we translate each other to the rest of the world, and admire each other’s contrasting language skills. Being married to someone you respect for being somehow better than you keeps affection alive. That this impressive person chooses you year after year makes you more pleased with yourself, fueling the kind of mutual self-esteem that can get you through decades.

The other part, about how those decades change over time from obstacles into assets, is something my wife’s student will have to figure out for herself. It could take awhile.

Like, forever.

Book Review: The Fourth Star: Four Generals and the Epic Struggle for the Future of the United States Army by David Cloud and Greg Jaffe

The Fourth Star: Four Generals and the Epic Struggle for the Future of the United States Army by Greg Jaffe

My rating: 4 of 5 stars
This book follows four Generals who have had various levels of command responsibility during the U.S. war and occupation of Iraq from 2003 and on. John Abizaid, Commander CENTCOM from 2003 - 2007. George Casey, Commander MNF-Iraq in 2004-2007 and current Chief of Staff of the Army, Peter Chiarelli, Commander MNC-Iraq (under Casey), and David Patraeus, Commander MNF-Iraq 2007-2009 and current Commander CENTCOM. These were the commanders who took over the occupation of Iraq after Tommy Franks and Ricardo Sanchez. Of importance for this book, these were also officers that recognized that Iraq was not a conventional war and what the U.S. faced in Iraq was an insurgency, one that the military and its political leaders were ill-equipped to fight from an attitude, doctrinal and training standpoint.

The first part of the book was about their training. Abizaid, Chiarelli and Patraeus were all given assignments and training experiences that encouraged them to be thinkers as well as soldiers. Abizaid having spent a few years on a college fellowship in Jordan, Chiarelli and Patraeus both spent time on academic assignments, with graduate school followed by teaching stints at West Point in the Department of Social Sciences, which the book depicts as a wellspring of unconventional ideas, which trained those who spent a tour as instructors in the willingness to question what who the Army prepared for and fought its wars. The book returns to this theme of Sosh as the place where officers were taught to think, which served them well in learning a new kind of war.

The book makes it clear that those that came before them, Franks and Sanchez were completely out of their element. And while Abizaid, Casey and Chiarelli began to understand that things were wrong and had ideas of what needed to be done, they were hampered by and Army that did not want to change, and a political leadership that was more interested in managing U.S. involvement then they were interested in winning in Iraq. And this interest in merely managing gave a growing insurgency (which was being willfully ignored by the U.S. political leadership) room to blossom, and cause the large scale casualties over 2004-2006.

The star of the book is David Petraeus (with Odierno as his understudy). With the exception of his assignment into the hinterland of the Combined Arms Center, which would have been better then the career ending assignment that was another option. But still a disappointment after the lauded 101st Airborne which was one of the brightest spots in the immediate post-invasion occupation of Iraq. The book paints Petraeus as a hard driving genius who was a stickler for detail and drove his people hard. It was evident in his field level commands detailed in the book, and his first combat command as Commander 101st Airborne in the invasion of Iraq and the occupation of Mosul. And his return to the combat zone as Commander MNF-Iraq after rewriting the new Army Counterinsurgency doctrine had the feel of the rescuing hero, taking over from the exhausted Casey and Chiarelli who had to fight off their political supervisors in Washington as much as the insurgency.

How does it fare? Many of the current conventional wisdom does not credit Abizaid, Casey and Chiarelli since they presided over the worst period of the Iraq occupation, even if the seeds were planted before their arrival and they were hamstrung by a civilian leadership that was in denial of the reality of the situation and was more interested in perception then fact. The book notes what they recognized and tried to create, an Army that recognized that it's goal was to win the population, not necessarily just build up a body count. But they were not able, and that failure hung over them. And the lauding of Petraeus may not be misplaced. I remember a Command Sergeant Major preparing me and some other civilian analysts for deployment to Iraq and Afghanistan describing Petraeus as a 'warrior-poet', and this was before Petraeus took his position as Commander MNF-I.

The driving point of the book is the requirement for a military to be flexible in thought and adaptable in the face of an enemy. It is a lesson that is learned with every new war. A peacetime military rewards conformity to standard. An actual war against an adaptable enemy requires leaders who can themselves adapt. The book identifies Charielli and Petraeus as officers of this type. And it also identifies them as generals who are actively raising and promoting the careers of other officers of this mode, in many cases against the desires of some of the institutional army. It means creating room for inventiveness and dissent, which is not always the easiest thing in an institution that is necessarily conservative like the Army. But, even if the heady responsibilty of the life of its soldiers requires some level of conservativism, it also requires innovation in the face of an innovative opponent. The book makes the argument that the Army needs these officers and leaders. And more importantly, it needs institutions that will provide these officers and leaders room to grow, and the ability to question and provide dissent in safety, so that the Army can benefit from them.

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PSO: Relections on Death

[This post is originally published at Pittsburgh Symphony Orchestra: Outside Perspectives]

At the beginning of Mozart's Requiem the Pittsburgh Symphony put a commentary noting that while Death was no stranger to Mozart's life, in modern U.S. society we have tried our hardest to make it a stranger to ours.  And I am not an exception.  While I have deployed to war, have been an volunteer EMT, regularly respond to fires and other disasters and take part in activities that entail some degree of risk, like the veteran cop who has never fired his service weapon in anger, I have not had anyone die on me (not for lack of some people trying).  So in a sense, I do not know how I will respond (but a line of counsellors are ready to talk to me when it does.)  And in my professional life, I regularly am faced with the fact that while society may cry out that it values life above all else, and that it refuses to put a price or limit on how much it would pay to keep life, that society indeed does put a price on life, and reacts badly when this is pointed out.

There is a community that does face its own mortality.  And is willing to write about it.  I follow the writing of blogs of soldiers and others involved in our wars in Afghanistan and Iraq on The Sandbox, a project of Gary Trudeau (Doonesbury).  Along with commentary about the absurd in daily life that is common to every first person account of war there are essays on fears, humor, relief, anguish, and sometimes the understanding that this is a serious business that can result in death.

And occasionally there is an essay by someone who has, like Mozart, prepared for his own mortality.  The willingness to acknowledge who you were.  Realising that you had long passed the point where dreams were there for you to reach, but what you have accomplished something in life, and it was worthy of having lived (for most of these writers).  A thankfulness for those who you were privileged to live your life alongside.  And a recognition that you probably did not deserve to have it so good.

My wife and I long since have recognized that some of the things I do are risky.  But it has been a choice that is a part of a rich life, full of joy, laughter, truth, and companionship that I would not trade for the safety and comfort of a life spent in fear and worry.  Already, I have had opportunity to pass on lessons to others who do the same.  And while there are no guarantees in this sort of thing, we treasure the memories and stories that we have been able to add to our families histories.