Beryl Markham and The Right Stuff

"Six feet of amiable Swede and, to my knowledge, the toughest, most durable White Hunter ever to snicker at the fanfare of safari or to shoot a charging buffalo between the eyes while debating whether his sundown drink will be gin or whiskey."

--West With The Night

Reading Ms. Markham, it is easy to forget she was more than a writer. She became famous, not for her writing, but for her flying. She was the first woman to fly against the wind, across the Northern Atlantic from Europe to America, more difficult trip than Lindberg's. And she didn't quite make it as planned, winding up, nose down, in a Newfoundland bog. but she got a ticker tape parade in New York City anyway.

Little did those throngs realize her most exceptional talent was not flying.

She was perhaps the best writer of her generation, and that generation included Hemingway, who had to write an entire short story--"The Short Happy Life of Francis Macomber" to say what Markham conveyed in this single phrase--not even a sentence about the Swede.

I don't think Hemingway would have argued about who should win that particular gold medal.

But writing and art in general are not about competition, so the point is absurd--it's just meant to convey the eternal truth that quality is not about fame. Beryl Markham is little known. Hemingway the most famous person writing in English of his time, and they were both covering the same story.

Markham can also master the simple declarative sentence. Hemingway tended to convey his message by showing you rather than telling you, which can be an art in itself, but Markham can simply tell you and make it stick. She compares in this respect, to Thoreau. But what she has over Thoreau is her own boldness in life; her lessons were not learned sitting along in a hut by a quiet pond, but flying above a vast wilderness, her life suspended by two wings and a single engine, with the natural landscape not a homey pond but a vast savanna, so endless that to fall into it was to be lost forever. 

"To see ten thousand animals untamed and not branded with the symbols of human commerce is like scaling an unconquered mountain for the first time, or like finding a forest without roads or footpaths, or the blemish of an axe. You know then what you had always been told--that the world once  lived and grew without adding machines and newsprint and brick walled streets and the tyranny of clocks."

So Thoreau could thrill to the sighting of a single warbler outside his hut on the pond, but Markham can give you untrammeled nature in thrilling panorama--she can show you the majesty.

Which is not to say she missed the detail on which Thoreau made his name: 

"It is amazing what a lot of insect life goes on under your nose when you have got it an inch from the earth. I suppose it goes on in any case, but if you are proceeding on your stomach, dragging your body along by your fingernails, entomology presents itself very forcibly as a thoroughly justified science."

Now, this is a woman you could get to like.

Beryl Markham, My Good Friend

"Passed years seem safe ones, vanquished ones, while the future lives in a cloud, formidable from a distance. The cloud clears as you enter it. I have learned this, but like everyone, I learned it late.”              --Beryl Markham, West With The Night

When the world becomes frustrating or boring or petty, I go back to an old friend who I  know will not disappoint me. Over the years, some friends have grown old, and tiresome, but some continue to rescue me. 

Beryl Markham is one who has not grown old for me.  Her most wonderful memoir is West With the Night and like so many wonderful books, it begins with a wonderful opening:

"How is it possible to bring order out of memory? I should like to begin at the beginning , patiently, like a weaver at his loom. I should like to say, 'This is the place to start; there can be no other.' 

But there are a hundred places to start for there are a hundred names...Names are keys that open corridors no longer fresh in the mind, but nonetheless familiar in the heart."

And with that, she sucks me into Africa, where she grew up, and she tells her stories so effortlessly, so elegantly I am amazed every time I read them, no matter how many times I read them. 

I am not alone in this. 

I was lucky enough to have stumbled on her book when my sons were about seven and five and I read the whole thing to them, every page, a chapter at a time as their night time reading, one kid in the upper bunk the other in the bedside chair with me, and they loved it as much as I did.  We did a lot of books: Narnia, with its Christian stuff, Myths and Monsters, Where the Wild Things are, Shel Silverstein, but nothing quite sunk into us and bound us quite like Beryl Markham.

And now she's back, or I'm back, wrapped up in the magic of a book--touching and touched by an intelligence greater than my own, a friend I can call up any time, just by opening the covers. She never tires of me, never interrupts, and she is always available.

I don't read as much as I ought to. Never have.

But this is one of those pleasures which enriches life and gives it wonder, rapture even.

If you have kids--of any age, five to fifty, try reading this book to them, in bits, chapter by chapter. 

You'll have a new best friend for life.

Dead Seals, Seacoast New Hampshire

Last fall, I wrote about dead seals and birds washing up along the beaches of Hampton, New Hampshire. 

It was a disturbing event, and it felt as if nature were out of whack. The experience conveyed how early man, pre science, must have felt when life in the natural world took a strange, astonishing turn. I could well understand how people without knowledge of organisms smaller than the eye could see, would conjure up other explanations for things--we have offended God, or the gods; we have seen the coming of the end of the world.

But now a report, "Emergence of Fatal Avian Influenza in New England Harbor Seals,"  arrives, a work of a joint effort of the United States Geological Survey, the New England Aquarium, the Columbia University School of Public Health and others, appears.  

Here is the link:

mbio.asm.org/content/3/4/e00166-12

The seals died of a new strain of avian influenza A virus, H3N8. This virus has been seen in birds since 2002 but recently mutated (a D701N mutation--they could  even tell you where in the genetic code the change occurred) and this made the virus able to attach to mammalian respiratory tract cells. The authors remark this mutation has been known to facilitate the leap from bird to mammal, and, of course, human beings are mammals.

So, once again, thanks to the coordinated efforts of local authorities in the towns of Hampton, Rye and Seabrook, who alerted the folks down at Wood's Hole and the federal people, who collected the bodies, sent them down to Massachusetts and samples of lung on to New York.  This is not something we could have done here in New Hampshire.

The Phantom has another blog for political expostulation, but he cannot help but observe this is another example of the value of cooperation, or if you are Rush Limbaugh or a Tea Party true believer (like our current Congressman, Frank Guinta), you would say, "Big Government."  

Oh, the horror. Big Government.

Well, bigness helped here. It was Big Government, but it was Good Government, and if the Tea Party had its way, we would all be back in the 18th century, wearing three cornered hats, keeping our gun at the ready and preaching from the pulpit this calamity occurred because we had offended God by paying taxes to the British.



mbio.asm.org/content/3/4/e00166-12

Salomon Brothers and the Meaning of Manhood

                                                                                       

ABOVE: U.S. GRANT, COMMANDER OF THE ARMY OF THE POTOMAC; HARVEY CUSHING, NEUROSURGICAL PIONEER; JOHN GUTFREUND, CEO SALOMAN BROTHERS

Reading Liar's Poker,  the memoir by Michael Lewis about his coming of age at the Wall Street firm, Salomon Brothers, is oddly familiar for anybody who has ever been sucked up into the maw of a large, "prestigious" university hospital training program.  Easily recognizable is the talk of how very lucky you are, and how often you are told this.  Oh, you are so fortunate to have been selected for the great, glittering prize of Salomon Brothers, or for Columbia P&S or for Mass General or Johns Hopkins--when so many others were just bleeding for the chance.  
You are  poised on the precipice of great good fortune, and  lucky  to have this chance to succeed, to go on to dazzling fortune and professional success, but also conveyed is the risk  you will fail, that you will be spit out and wind up "on the street" as a homeless person, or, almost as bad, you may wind up a failed professional. 

That's how they do at these august institutions, (as they would say in Baltimore).

They make you think you are special and they get you to try as hard as you can to "succeed," and they are reasonably clear about how success will be judged.

At Salomon brothers, success is measured in dollars; at the university hospital, it is based on less numerical criteria, but at either place there is a familiar aspect of your success being judged by older, established, powerful people who have demonstrated why they have reached the pinnacle and their success justifies their power over you.

Of course, whether it's the army or the hospital or a Wall Street bank, the people who succeed are often sleaze balls of the lowest order.

But that's not really what struck me. What struck me was the imagery at Salomon:  The successful, older, established high priests were all described in terms of the "jungle," and they were, admiringly described as "ruthless," remorseless, powerful predators.  

Now, think about that. What were these men doing?  Were they cutting into a belly?  Were they trying to save a life?  Were they faced with a decision to send a thousand men charging across a field into an uncertain fate?  Did they have astronauts aloft who they had to bring back safely to earth?  

No.  The worse thing that faced these masters of the universe was the prospect of losing money.  They might lose money  for the firm, money which could be made back the next hour or the next day. 

John Gutfreund, after all, was nothing more than a salesman, or a gambler.  Those who dreamed of being like him, dreamed not of the glory of saving a life, while the family in the waiting room down the hall prayed. The 20 somethings who wanted to be the next Gutfreund did not imagine themselves faced with the wrenching decisions facing the general of the Army of the Potomac, as he considered his next move against Lee and thousands of lives and the fate of a nation hung in the balance.

The young brokers told each other how cool they were because they were risk takers, daring young turks about to do figurative battle on the trading floor, wielding not swords or scalpels but telephone head sets and slick talk. 
But what, really, did these young hot shots risk?
Did these young brokers risk throwing away their youth?  No. Their training program was roughly five months.  It takes more time to train an apprentice tool and dye maker, a welder or an auto worker. Unlike the poor pre medical student, who risks wasting four years, these brokers were risking five months. 

The Salomon neophytes emulate a man who is  simply betting and selling and putting neither life nor limb nor really even his own fortune at risk. All he risks is making less money today than he has on other days.

And what of the other Salomon"predators?"  Are they in any way really brave or fearsome or lethal or wondrous or admirable? What have they done to be so adulated by these best and brightest graduates of Princeton and MIT and Harvard and Yale and Penn? They have placed bets, won some of them and made money.

Mothers, don't let your sons grow up to be brokers. Oh, sure, they will make money, and never have to worry about starving. And they will do it without risking their lives. Unlike the men who go down to the sea, fishing on the dangerous oceans (as real predators) Unlike men (and women who serve in the military) their is no risk of bodily harm.  

But when they look back to write their memoirs, at the end of their 5th or 6th decade, what sort of life will they have to look back upon?  Who will they think about, when they think about who they affected as they did their jobs?

The fact is all the talk of ferocity is a cover to hide the lack of that very quality.  It is true people often criticize others for traits and failings of which they secretly know they are most guilty--in fact, these "men" speak of ferocity and importance to mask their own sense of timidity and unimportance. They are weak and by  choice, worthless.   On some level, in the dark of night, they must realize what they are. 
They are politically correct, socially acceptable gamblers--an inclination which can be exciting when there is something really important at risk.

I heard Martin Luther King once, in college. He gave a talk which I'm sure he had given a hundred times. I stood on the lawn outside Sayles Hall with a lot of my classmates and listened as his speech was broadcast out to the College Green from within the hall.  He said, quite simply, that sometimes you can gain the world and lose your soul in the process.  Pretty standard stuff, I imagine, from a Southern Baptist. 

But I was a freshman in college and it seemed like a pretty powerful idea to me.

About Face: In Praise of Older Women

"The heads she once turned, 
Long gone.
She finds no takers, for yesterday's papers.
She leaves and takes the back door out."
--Dave Loggins, "Sunset Woman" 

Some time ago I wrote about a long ago encounter with the young Cheryl Tiegs;I had seen a photo of the more recent version of Ms. Tiegs, and it got me ruminating about what it must mean to women like her to become older and no longer capable of turning heads.

When I was about 17, I worked as a lifeguard at a swimming pool in Bethesda, and a woman who must have been in her late thirties, came down most mornings and she would sit in the sit near the Lifeguard stand and we would talk about life. This was the 1960’s and before women’s lib and before the sexual revolution of the 1970’s, and our town hewed to the conventional ideas about marital fidelity, pre marital sex, female desire, what a respectable and desirable life for a woman ought to be.  This lady was reading Simone DeBeuavoir’s The Second Sex.  She seemed endlessly amused by me, mostly by my very conventional views, and by how completely I had bought into the ideas a good suburban boy should buy into, if he wanted to get the stamp of approval from the local gentry so he could get into an Ivy League school and get the hell out of town.

She never told me what she thought directly. She just asked questions and laughed at my answers.  Do you think married women do not lust after younger men?  Do you think married men are always faithful to their wives?  Do you think the best thing that can happen to a woman is a good man?

I don’t know why she bothered talking to me. I could not have said anything of interest to her.

I made some progress in my opinions about life and women, so by the time I was in my mid twenties and living in New York City, I probably would not have disappointed her quite as much. And still, while there was no shortage of willing young ladies my own age, I found myself involved, more often than not,  with older women.

I did this for no conscious reason, but in retrospect, they shared certain characteristics. For one thing, they were more confident, and they were not nervous. They did not seem to think they had much to lose, where I was concerned. They were not expecting or even looking for any future with me. They were just enjoying the moment.  Often, they were forbidden fruit, or they simply had more money and social status than I was ever likely to have. And they could do one thing which women my age only rarely could do: They could make me laugh.

That’s why I loved that line in Roger Rabbitt , when Eddie asks Jessica Rabbitt, the knockout vamp who  married  Roger Rabbitt,  what she sees in Roger and she replies, in that wonderful, unhurried Kathleen Turner voice, “He makes me laugh.

So when I saw Downton Abbey and watched all those drawing room parties, I knew I would have been drawn not to any of the younger women in the room, but to Maggie Smith’s dowager, who always had the most interesting, subversive, penetrating and funny things to say.

So, yes, I see the problem for post menopausal women, whose bones are getting thin, whose cheekbones are resorbing, whose breasts are sagging, whose muscles are shrinking, whose vaginas may be drying out. 

On the other hand, there are likely some twenty something men out there who would be very grateful to learn at the knee of an amused, detached, knowing older woman..

Women in their 4^th, 5^th and 6^th decades could perform a vital societal function. No, they may not turn heads, but they need not take the back door out.

Stick around and ask those confused boys some pointed questions.  It might be, as they say, a win-win.

Who Is Qualified and How: What Andrew Hacker Means

                                         Rugby Team
                                 Columbia College of Physicians and Surgeons

Would you be disturbed to learn the person taking care of your daughter, when you leave her in the hospital overnight with her fever and throat pain, the person writing the orders for intravenous fluids and medications is not a physician, but a “physician’s assistant,” who has never gone to medical school, or passed the licensing exams a resident with an MD degree has passed?   Would you be disquieted to learn the man holding the scalpel in the operating room, the man who has his hands, elbow deep in your chest, is a physician’s assistant or an operating room tech?

As MBA’s looking for cost savings have  driven hospitals to save money by hiring less expensive help, many jobs which once were thought to require the highest level of qualification are now done by less costly, less extensively trained people.

But is this a bad thing?

First, let’s consider what those more costly people were like.  They certainly made an investment in time and money and effort in their own training. They spent two years in anatomy labs dissecting cadavers, in biochemistry labs, in classrooms, not to mention the four years before that in organic chemistry labs, calculus classes, physics labs, biology labs and classes. They competed intensely for the few spots in medical school classes and they spent nights in the library and laboratory while their classmates partied and pursued the pleasures of the flesh adolescents and twenty somethings will do.

But did any of that make them more likely to be able to save your daughter or to be better in your chest when you needed it?

At  The New York Presbyterian Hospital/Cornell Medical Center, you can now be admitted, cared for and discharged by a nurse practitioner, without ever having seen, talked to or come into physical contact with a recipient of an MD degree.

And yet, when you have a colonoscopy, a procedure which requires no knowledge of biochemistry, physics, calculus, or even much anatomy, only a physician can do this procedure, which takes about three to six months to learn, and maybe a year to really master.

Before I became an intern, I had done six weeks on a ward as a third year medical student, and another 6 weeks as a “subintern.” I had done some elective courses in cardiology, endocrinology and I had a six week rotation in neurology and another in radiology.  All that was useful, but none of it prepared me for treating acute pulmonary edema.

When a patient bubbled over in pulmonary edema at 1 AM, what saved him (and me) was a single hour of training I had undergone in the first weeks of internship. The training session had been effective: I remembered what to do and did it, step by step, just as they had instructed and it worked and the patient was saved. I felt like a very sophisticated, competent young doctor. And I had learned it in an hour.  Would a physician’s assistant, who never did organic chemistry, passed a calculus exam or dissected a cadaver have been trained as well in an hour and been as successful? I have no doubt the answer is yes.

I learned to treat gram negative sepsis in patients with acute myelocytic leukemia, and that took about an hour. I could have told you the mechanism of action of the antibiotics involved, and I could have explained the physiology of how the glucocorticoids and fluids used in this rescue worked, and I’m not sure the nurses who worked on those wards could have delivered those explanations, but they knew what to do even if they could not have explained to the satisfaction of the professors the why of how it all worked. In practical terms, they were as good as I was, if not better, because they had been doing it for more years.

What has happened over the years, is each task I learned as an intern—lumbar punctures, phlebotomy, starting IVs, arterial sticks, placing CVP lines, placing Swan Ganz catheters, adjusting respirator settings, each of those procedures can be taught to specialized non physicians who can learn to do them quickly, and perform them just as well or better than any doctor. In fact, physician’s assistants can be taught when doing these procedures is warranted, which is actually a more difficult process. And, over time, nurses and PA’s can learn how to interpret the results of blood gases, lumbar punctures, CVP readings, Swan readings. CCU nurses learn to interpret heart rhythm disturbances just as reliably as physicians and they know which drugs are used to treat them.

Scrub nurses in the operating room hand the surgeon the exactly correct instrument before he even asks for it because they have watched him do a particular surgery so often, they have learned all the lines, just as stage hands often know the lines of dialogue the actors speak because they have hung around the stage during repetitive rehearsals.

Could we get away without doctors altogether?  Could we break down every problem into its parts and have people who have a year or two of training in the practical world do what we have always required people with 4 years of college and 4 years of medical school and 4 years of residency after medical school?

In fact, the English have been doing this for decades. They limit the numbers of MB’s (bachelor of medicine) and they severely limit the number of specialists. They had figured out the hospitalist system in the 1960’s—the same system we have only discovered over the last decade here in the USA. In England, a student goes from high school to medical school, and gets a bachelor's of medicine and being a GP (general practitioner) is not much more exalted than being a nurse practitioner here, with about the same social status and economic benefits. The number of cardiologists, endocrinologists, hematologists is severely limited--proportionately a much smaller percentage than we have in the USA. But they make the system work, and some would say better than what we have.

My son, who is doing a residency in surgery astonished me the other day, when he told me he was on call on Saturday, but he was home by 10 PM. He had begun his day at 6 AM and worked until 8 PM, when he was relieved by a “night float” to whom he signed out his patients. He spent two hours entering notes and data into the hospital computer and went home.  But he did not sleep overnight in the hospital, in some on call room where he would be awakened every 30 minutes or so by nurses on the phone wanting orders.

Who was the night float person who did this work? A physician’s assistant.

I was floored.

But as I thought about it, what sorts of problems were keeping me awake all night, when I was an intern?  Phone calls from nurses asking me to come down and do a blood culture on a patient, or to approve a sleeping pill for a patient or to draw a blood for some test which had been ordered to check at patient at 1 AM.  None of these things required much thought, training or education. That is why we didn’t kill many patients when we did those marathon 36 to 96 hour on call stints as interns. The tasks we were doing were mostly mindless.

Of course, interspersed among all those calls about trivial things or calls from nurses who could barely speak English or who did not understand that giving an order for  a pain medication over the phone required a physician to give that order some thought—what medications were being given to that patient? Was the pain med likely to cause respiratory arrest in this particular patient?  So among all the blizzard of calls were a few which required real thought, which might require a doctor, or at least a person who had spent a couple of years on the ward and could recognize the dangers of each order.

Among all those calls one night was a call about a patient who was found sitting in a bed full of her own stools. The nurse called, annoyed, not really with a question but more a complaint about having to clean it all up. But this particular patient had breast cancer metastatic to her spine and she had a metastasis compressing her spinal cord--a medical emergency requiring urgent radiation therapy and possibly neurosurgery. Putting all this together took neuroanatomy, neurology and some prior experience with cord compression. Could a physician's assistant have done that? I do not know. I'm not even sure what physicians' assistants learn or are required to know? Should a nurse or a nurse practitioner have recognized acute cord compression? I do not know.  

I’m not sure whether or not we have gone in the right direction when it comes to organizing the delivery of medical care: I think we likely have. But I am sure of one thing—the way we decide what education, what training we require for specific sorts of medical workers, particularly for MD’s has been rank stupidity.

We have allowed professor of math and chemistry and physics who depend on groveling pre medical students to keep their own graduate students and professors employed to bamboozle the medical powers that be into delivering pre medical students to their hands. We have done the same in the medical schools themselves, where professors of pharmacology and microbiology and biochemistry have taught the wrong courses to aspiring doctors and we have been smug and self satisfied while we did this, and we have failed in our responsibility—our obligation to our own country—as we have mindlessly done the easy thing of accepting without a murmur of complaint the nasty system we have allowed to fester all these years.