Causality and Consequences - Why I'm Biking

 

In my post from 3/12/2011, I alluded to the “Why?” behind this trip. Without the why, there would be no bike trip, no planned 90-day journey by bicycle with my daughter from Florida, to California, to Washington State and a journey towards Maine until time runs out.  Without the why, I would remain ensconced in my comfort zone at home, immersed in my daily routine and the things I enjoy.  So, here is the why and a discussion of causality.  This will take a minute, but it’s important to me if only for the fact that if life had properly unfolded, there would be neither bike trip nor blog.  But…they did not.

Things happen for reasons, not all of which are obvious or of our own doing.  While we would like to think that we are the makers of our own destiny, the actions and deeds of others, covert and overt, shape our lives.  Even my interest in causality, which dates to age 11, was not of my own doing.

Prior to 6^th grade, I was an aggressive reader of non-fiction, covering as much of the math and science textbooks from our school and public library as I could.  (Those of you who know me are probably thinking, “That explains a lot.”)   That worked just fine until I met Charles Danner, my 6^th grade teacher, who was intent on having me expand my horizons, demanding that I read a novel.  To make it easy, he handed me a paperback, The Light in the Forest.  I can still visualize the book and its cover.  Had the word gay been part of my lexicon back then, I would probably have judged the book that way by its cover.  My displeasure was obvious and Mr. Danner offered me a choice: read his paperback or find a novel from the school library.

So, entering the library, I did not make the familiar right turn to the non-fiction section, but made the unfamiliar left, towards the fiction section.   I stared at the alien shelves of books, wondering how to judge a book by its binding.  And then, my first bibliographic epiphany: two books, out of the hundreds and hundreds of others, had simple line drawing of a rocket ship at the bottom.  A rocket ship!  That had to be good! Having thus judged each book, I picked them up and was introduced to the world of Doubleday Science Fiction.

I still remember the first book: it was about a space-based weapons system orbiting Earth, a wildly fantastic idea that turned out to be prescient during my lifetime.  Immediately, I was a devotee of sci-fi.  

Satisfied of my literary touchstone, I then approached the fiction section of our public library and was overwhelmed by the number of bookbindings with the Doubleday logo.   “Might as well start with the A’s”, I thought.  All the way on the left side of the stacks – and this image is also clear – where the works of Poul Anderson and Isaac Asimov.   I skipped Paul and turned to Isaac, intrigued by two anthologies of robot stories: I, Robot and The Rest of the Robots.  I loved them and, before long, I was reflecting on The Three Laws of Robotics.  The Foundation Trilogy followed and, at some point the book that introduced me to the notion of causality, The End of Eternity.

Eternity was a futuristic agency whose technicians traveled through time tweaking things to better improve the lot of Man.  The technicians were trained to identify the minimum necessary change to achieve the desired outcome.    The future became a collection of “what ifs”, affected by subtle changes in the past.  In the years that followed, I would often look back at the turning points, invariably involving an event I could never had recognized at the time, an event that had changed my life path.  Similarly, I came to appreciate how my actions affected the lives of others.  One such instance, as an example, involved a young physician named Martha.

From 1986-1995, I ran the Internal Medicine Residency program at the West Los Angeles VA Medical Center.  When I first spoke with Martha, she was a few months from finishing her internship at another UCLA affiliate, the excellent Harbor-UCLA program.   She was in the 1-year program, but had decided to continue in Internal Medicine for a full three years.  Harbor had no openings and she contacted me, looking for a vacancy.  I did have an opening for the next academic year and, after confirming her credentials, offered her a position.  Contracts were signed and all was good until…

Two weeks before the next academic year was to start, Martha called me; Harbor suddenly had an opening and had offered it to her.  She wanted me to release her from her contract.   The simple answer to her request was “No.”  We had a schedule ready to go in just two weeks based on her presence.   The prospects for replacing her this late in the academic year were nil and I simply could not afford to be a physician short.

Martha was prepared for my reply and indicated that she would not be showing up in two weeks in favor of taking the position at Harbor.  Unable to convince her otherwise, I called her program director.  Dr. Tanaka, also the Chief of Medicine at Harbor, was a sagely, Yoda-like physician and an international expert in Hematology, the sort of person who had authored more articles than I had read.   

“I understand you offered Martha a position for the next academic year.  Were you aware that she had signed a contract with me?” I inquired of Dr. Tanaka.  In a simple display of honor and integrity, one I shall never forget, he replied simply: “I was not aware and, now that I am, I will withdraw the offer I made.  And, even if you release Martha, I will not offer her the position.”

While I was overwhelmed by Dr. Tanaka’s principles, Martha, on the other hand, was not and showed up as one very unhappy camper.

But, life unfolds in strange ways.  Within a year of joining my program, Martha met someone at the hospital who became her husband, an event that would not have happened without a simple telephone call to Dr. Tanaka.  When I reflect on the branch points of my own life, I wonder if Martha has ever thought of the turning points in her own.  

The event that would re-direct my life and, ultimately lead to this bike trip occurred late in my senior year of college as I went to my interview at New Jersey Medical School.  My previous interviews, I later found out, had gone poorly.  It seemed that when it came to the distinction between poise, confidence and arrogance, I was screamingly unaware of any meaningful distinction.  In retrospect, I probably came across as a bit of a dick.  (I know some of you are thinking “little has changed.”  All I can say is that 35 years ago, I was a lot worse.)

In any case, on my interview day at New Jersey Med, positioned on the bridge of my nose was the world’s largest and most repellant acne mass.  (It was beyond pimple stage.)  Ducking into the nearest bathroom before the interview to adjust my tie, all I could see was how it pulsated.  I felt horrible.  But, I interviewed like a decent, normal person…and that’s where I was first accepted.

So, it was the pimple that lead me to medical school in Newark, New Jersey and, a year later, the waiter/bartender job that would introduce me to a woman who would steer me to California for my residency (1981), the residency where I would meet my future wife (1983), pursue pulmonary/critical care (1984) and become an Internal Medicine Program director, ICU attending and educator (1986).  This set the stage for my eventual departure from Los Angeles to become the Critical Care Program Director and Chief, of the Pulmonary/Critical Care section (seriously, do not be impressed by this; it was a dismal environment) at the newly opened West Palm Beach VA (1995), leading me to Florida where I would hire a young physician out of his pulmonary/critical care training, a physician who would later steer me to a position at the Gainesville VA (2003) where I would obtain great professional satisfaction as a clinical educator.  It was in Gainesville that I would eventually see a primary care physician (2006) who would refer me to a urologist when my initial PSA (prostate specific antigen, used to screen for prostate cancer) was 5, a Urologist who would biopsy my prostate and then declare “It’s All Good”, only to see my PSA rise to 95 in 2008, leading to another biopsy and another proclamation by the Urologist “It’s All Good…and don’t check your PSA again…it will be high”, only to develop a vague lower abdominal discomfort in 2009 at which point I found out that my PSA was now 245 and had metastatic prostate cancer.

Just like that.  

I remind myself, things could be worse.  I could have been hit by a truck…or stepped on an I.E.D…or have been living by a nuclear reactor when the mother of all tsunamis followed the mother of all earthquakes.  The initial treatment for metastatic prostate cancer, androgen deprivation therapy, is usually successful for quite awhile, though there is a lot of variability.

Still, among the ugliest words in the English language are “metastatic cancer” and “palliative therapy.”  Nothing quite looks the same and the existential threat is a relentless nag on your conscience.  Planning for the future becomes even less certain.  Should I continue working, doing something I love?  Should I retire and do other things I had planned for later in life?  Is there anything meaningful I want to do or accomplish?  

I had thought about retirement for some time already and had found inspiration in philanthropy.  Walking around the University of Florida campus, the names of benefactors on buildings were obvious signs of charity.  But, what had really inspired me for years were the Ted Turners (who donated a billion dollars to the United Nations in 1997) and organizations like the Bill and Melinda Gates Foundation.  Of course, anything I did would be several exponents smaller, but I filed paperwork to start my own charitable foundation (www.apointoflight.us; site under development pending IRS approval.)

Then, I thought of things I wanted to do…I guess this is why some people have a “bucket list.”  While I never had such a list (it sounds just a bit too macabre), I’m always looking for a new experience.  My sister had ascended Kilimanjaro in 2009 and had invited me to go, but the timing was bad.  Now, newly motivated, my family and I went to Tanzania in 2010 to summit Mt. Kilimanjaro.  The 9-day trip is still vibrant in my memory.

Russell, my son, a short distance beyond the Kilimanjaro summit at 19340'.

So, back to the issue of causality: why am I here, biking and blogging?  It’s the pimple, of course.

Absent the pimple, I would have attended Georgetown University medical school (the only other school to accept me) and likely have met at the appropriate time a competent urologist who would have looked at the PSA of 90 with the negative biopsy, appreciating that even with a negative biopsy such a PSA still screams prostate cancer, recognizing that absence of proof is not proof of absence, thereby repeating the biopsy and not told me “It’s All Good” rather than waiting until I discovered - on my own - that it was pretty effing bad. 

Done in…by an acne pimple.

It was my daughter, Lani, who later suggested the cross-country bike trip.  I figured I’d never have the time for it.  But, at the end of 1/2011, following two months of radiation therapy (a wholly unpleasant experience, both the process and the way it left me feeling), the people I work with allowed me to take some extended sick leave, providing me the time for a long bike trip.  I was torn between simply recuperating, snowboarding (Mammoth Lakes was having an epic season) and doing something unequivocal.

Unequivocal?

In the minor movie with Anthony Hopkins and Alec Baldwin, The Edge (1997), Charles (played by Anthony Hopkins) and Robert (Alec Baldwin) are fighting to stay alive in the Alaskan wilderness after a small plane crash.  Stalked by a grizzly bear, Charles, who possesses a tremendous amount of knowledge and knows how an Eskimo could singlehandedly kill a grizzly, proceeds to do so.  In the dialog that follows:

Charles Morse: For all my life, I've have wanted to do something that was, um, that was unequivocal.
Robert Green : Well, Charlie, I certainly think this qualifies.

Taking an extended bicycle trip, aiming for the four corners of the country, seemed pretty unequivocal (as well as unrealistic, but…hey…a 3-month trip could cover a lot of ground).  On the other hand, with my general state of crapiness following two months of pelvic and abdominal radiation, there were other things I would have preferred to do.  So, why the bike trip? 

Easy…because my daughter expected me to.  Besides, becoming neither healthier nor younger, this would be my only opportunity.  So…here we are...biking

Those of you remaining alert to this point might be thinking “Geez, it seems like someone messed up.”

And I thought the same.  A few months into my chemical spaying, I called up the university’s legal office and inquired “I wanted to see if the university wanted to make me an offer for failing to diagnose my prostate cancer as an alternative to me bringing a suit.”  The woman on the other hand paused, then took my name/number.

A physician liaison called me back and discussed historic details.   He was serious, earnest and assured me that my case would be reviewed.  As the weeks ticked by, I thought about what the remainder of my life was worth.  I was 54 and had stayed in as best shape as I could.  Cycling 7 miles to work each day and then running 5 miles daily followed by the cycle ride home each day, I was within a few pounds of my high school wrestling weight.  My resting heart rate was about 50/minute.  I had planned on at least 50 years of marriage and reaching the late-80s.  I had looked forward to being half of an aging couple with a long and busy retirement, punctuated by grandchildren.  What was that worth?

A few weeks later, I was contacted for a meeting with the physician liasion and two other members of the university’s legal team.  I biked to the meeting after work and sat down with the three.  The physician apologized for what had happened, indicated that mistakes were made and that the people involved felt terrible.  

It was then I was made aware of the sovereign immunity law that limited damages against the state.  Actually, I should say I was reminded of the limits.  Whenever someone seeks treatment at the university, there is a disclosure form you sign covering things like release of information to insurance companies.  You have to sign the page or you will not be treated...it is a lot of small print containing a critical paragraph about Florida state sovereign immunity.  

They offered me the limit according to law.  You can Google it, but it was a sad amount.  All things considered, it was meaningless.  “That’s it?” I asked.  “I don’t have a polite response to that.”  I walked out, got on my bike, headed home and tried to not think about it.

Things could always be worse.

Thanks for reading and following.