Poker

Though the cards you’re dealt are a matter of luck, poker is a game of skill.  You must play whatever cards you’re dealt.  But good cards or bad, over time the skilled player will usually come out ahead.

Poker lends itself to many life lessons.  For example, we don’t control the cards we’re dealt, nor do we control the cards dealt to others. Lucky amulets and other superstitious rituals don’t change the random distribution of the cards. We don’t control the cards any more than we controlled who were our parents or the circumstances into which we were born.

Bad cards happen to good people. Good cards happen to bad people. The virtuous player and the sinner are equally likely to get good or bad cards.  The cards are indifferent. Nothing is more frustrating than watching someone you dislike get good cards time after time, while sitting for hours getting zilch.  But you shake your head, learn to live with it, then go home and read Job.

Sometimes you get unlucky and a good play has a bad outcome.  Sometimes you get lucky and a bad play turns out okay.  Good play means making good decisions, irrespective of the outcome. Make good plays.  It’s good to be lucky.  But luck is fleeting and over time luck evens out.  It’s good to be lucky, but it’s better to be good.  Luck never lasts but skill endures.

Poker, like life, is a rollercoaster.  There are always hot and cold cards, good and bad streaks.  At those times I recall the words attributed to the wisdom of Solomon, “This too shall pass.”

One of the most important lessons for successful poker is, “know thyself.”  Stay humble, knowing that there is always someone certain to be better. A sure path to losing poker is to overestimate your skill and underestimate the skill of your opponent.

When poker, or life, is not going well, there is a tendency to blame the cards.  “It wasn’t fair.”  “It wasn’t my fault.”  “I had no choice.”  These are familiar cries.  However, if as I believe life is a lot like poker, you may not control the cards, but you are responsible to make the most from what you’re dealt.  Knowledge of the game matters.  Experience matters.  Practice doesn’t make perfect, but it does make you a whole lot better. You may not control the cards, but you can control a lot.  

Before I go all-in on my poker-as-life comparison, I will point out a few significant differences.  In poker there are no win-wins.  For every hand that is dealt there is only one winner and up to nine losers.  Poker is not a team sport. Collaboration is not allowed, it's cheating. Cheating's not allowed, but lying and deceiving are.  If you’re caught lying, oh well, you made a bad bluff. If you lie well, you’re a good poker player (or politician). 

Happily, I get more out of poker than just lessons in life. I read in a monthly AARP magazine that playing poker helps prevent cognitive decline in seniors.  I was especially pleased that the article was supported by the authoritative testimonials of several neurophysiologists.  They consider poker to be mental exercise.  Poker’s not my vice.  It’s my workout.

Powers of Ten

1980 was a time of revolutionary change in psychiatry. It was the year the DSM-III was published (Diagnostic and Statistical Manual of Mental Disorders, 3^rd ed.).  It happened to be the year I began my residency training.

In the 1960’s and 70’s psychiatry was under attack.  At that time, academic psychiatry was predominantly psychoanalytical, based upon Freud and his successors.  Psychiatry was criticized for its abstract and unproven theories.  It was criticized for lengthy and expensive therapies of unproven efficacy, that ministered primarily to the worried-well.  At the same time, there was little research and little enlightened treatment for the severely and chronically mentally ill. Psychiatry was harshly criticized for being out of step with the other medical specialties.

The diagnoses in DSM- I (1952) and DSM-II (1968) reflected the dominance of psychoanalytic psychiatry.  DSM-III, however, was a paradigm shift, written by psychiatrists who believed that psychiatry was and should be focused on the biology of mental disorders. DSM-III brought psychiatry back into the mainstream of medicine and DSM-III subsequently became psychiatry's 'bible' for diagnoses.

For me, 1980 was a time when clashing academic perspectives competed for the hearts and minds of we who were in training.  I was taught and supervised by a new generation of biological psychiatrists.  I was also taught and supervised by an old guard of psychoanalytical psychiatrists.  I felt adrift in the middle of a war of ideas. As if I wasn’t already confused, among my teachers there were also a smattering of family system’s therapists, behaviorists and developmental theorists.

It was the illustrations in a book that showed me how to reconcile the seemingly contradictory perspectives of my teachers. During my residency, I found Powers of Ten, by Charles and Ray Eames (1982). It became for me the most influential book I never read.  (I only looked at the pictures.)  It’s based on 42 illustrations.  In the middle of the book the picture is of a man peacefully sleeping on a picnic blanket. If you move back one page you see only his hand.  Move back another page and you see the fine detail of his skin.  Each picture turning backward is magnified from the preceding picture by a power of ten.  Now, if you go back to the middle and turn the pages forward you see that the man on a blanket is in a park. Next, that the park is on the Lake Shore of Chicago, and so on., Each page forward distances by a power of ten. The 42 pictures range from the smallest known subatomic particles up to the furthest known reaches of the cosmos.  My ‘aha’ moment was when I realized that no one picture was more real, or more ‘true’, than another.  Each was only a different lens, a different power of ten.

I understood then that my teachers each viewed psychiatry through a different lens. Each perspective was true in its own way.  People can be seen and understood through a variety of lenses.  They can be understood through the biological lenses of anatomy, physiology and genetics.  They can be understood through psychological lenses or interpersonal lenses, lenses focused on family or lenses focused on society and culture.  Some lenses offer more clarity.  Some lenses offer greater clinical utility.  But what was most important to me at the time was my realization that different perspectives did not have to be mutually exclusive.  Each perspective was just a different lens, a different power of ten.

During the subsequent thirty-eight years of my career, I taught and I practiced knowing that many lenses are needed in order to begin to fathom the complexity of human beings. Though each lens is in some manner true, no one lens encompasses Truth, with a capital “T”.  However, when we can look through a variety of lenses, we learn many small truths, truths that I believe lead us to see ourselves, others and our world with greater clarity and wisdom.

Making America

Reading about the Revolutionary War and the years immediately thereafter, I’ve become fascinated by Thomas Jefferson, Alexander Hamilton and how they came to be archenemies.  At a time when the survival of our young nation was at stake, the Republicans led by Jefferson and the Federalists led by Hamilton hated and feared one another. Each party believed that if the other came to power, the country, along with its hopes and promises, would be destroyed. If the Federalists came to power, the country would revert to monarchy, as in England.  If the Republicans ruled, there would be chaos and a reign of terror as in post-revolutionary France.

The newspapers were driven by partisanship, some supported by the Republicans, others supported by the Federalists. News was filled with innuendo, venomous personal attacks and outright fabrications, ‘fake news’. Many of the most qualified citizens refused to serve in public office, not wishing to live with the inevitable scrutiny and character assassination. Party leaders were accused of colluding with foreign powers, Hamilton with the British and Jefferson with the French.  The welfare of some foreign economies was tied to the American economy. Foreign agents, especially foreign journalists, were suspected of meddling in American politics in order to influence government policy and election outcome. It all sounds eerily familiar.

Jefferson had his admirers and detractors.  To his admirers, he was a great scholar and philosopher, author of the Declaration of Independence, spokesperson for religious tolerance and advocate for the rights of all men.  To his detractors, he was a Revolutionary War coward, an inflexible ideologue, a slave owner and hypocrite.

Hamilton, too, had his admirers and detractors. To his admirers, he was a Revolutionary War hero, constitutional theorist, advisor and confidant to George Washington, and visionary first Secretary of the Treasury. To his detractors he was brash, egotistical, ill-tempered, power hungry, and indiscrete in his personal affairs.

Historians continue to weigh the merits and faults of these two antagonists, these two founding fathers.  Jefferson and Hamilton continue to have their admirers and detractors. Based on what I’ve read, here’s what I think. Each of them had significant flaws, significant shortcomings. Yet each was an original, a brilliant and visionary thinker.  Each was a towering leader during a perilous time in American history, a time when the new country needed brilliant and visionary leadership. The challenge they faced was not how to ‘make America great again’.  Their challenge, more difficult yet simply put, was how to make America.

Currently, Hamilton’s star is rising, his reputation resurrected in Ron Chernow’s biography Alexander Hamilton and the Broadway show it has inspired.  Now, having read the book, I look forward to someday seeing the stage interpretation of Hamilton, the musical. That’s a rap.

After Life?

“There are more things in heaven and earth, Horatio, than are dreamt of in your philosophy.”  (from Shakespeare’s Hamlet)

Both of my grandfathers died when I was sixteen.  A few months after each had died, I dreamt that they had returned to say goodbye.  These dreams were different from other dreams.  They were vivid, lifelike, as if I was really in the presence of my grandfathers.  Each dream was accompanied by my tears and by a deep sense of loss and love.  Each grandfather came to say goodbye only once and never again returned.

My mother died on February 16^th, 2010.  Her final days began with agitation and ended with the calming numbness of morphine.  I wished from her a last moment of awareness, a lucid and quotable last thought, perhaps to tell me that she had glimpsed the other side of life and that there was no need to fear.  But she did not do so.

I have few warm memories of my mother.  She was an often depressed and always anxious person.  She kept an immaculately clean home.  She was not demonstrative with affection.  I don’t remember hugs or kisses.  In my household, food, order and cleanliness were the substitutes for love.  My mother died of complications from dementia.  In her last months, she would stand at the window of her apartment, count the cars in the parking lot and repeatedly wonder out loud where so many cars came from.

A brief digression while I set the stage.  Approximately 8 months after my mother’s death, while driving at night with my wife, I had an odd and momentary vision of a deer’s face in the leaves of a passing tree.  I thought to myself that this might be what a hallucination is like, or maybe it was a sign of my old age, with declining mentation and advancing imagination.  It lasted for only a second and I really didn’t make too much of it.  If anything, I was a bit amused by the spectral vision.  A few moments later my wife grabs my arm yelling, “There’s a deer!”  I got a momentary glimpse of a large buck looking in my direction, standing broadside across my lane of the road.  This was no hallucination.  I hit the brakes and swerved, missing the buck by a few feet and a few fractions of a second.  Had my wife not been looking forward at the road, I doubt I would have seen the buck in time to avoid a serious collision.  My wife and I arrived home safely, both of us a bit shaken by a disaster barely averted.

That night I went to bed and had a dream.  My mother came to see me.  We were sitting side by side riding in a car.  No one else in the car knew she was there.  But she was visible to me.  She was beautiful and serene in appearance, not withered, gray and demented as my mother came to be in her last years.  I asked her to tell me what it was like on the other side, the side beyond life.  She did not speak to me, but she held me, comforted me, and softly kissed me as I never remember her having done in life.  And in my sleep, I wept as I had not done for many years.  I awoke that morning remaining sad, grieving for my mother believing, as was true for my grandfathers, that this too was to be a onetime dream, one time to say goodbye.

I am a psychiatrist, trained in science, trained to interpret dreams rationally.  Freud’s great discovery was that dreams are a glimpse into our unconscious, an expression of our unfulfilled wishes.  The rational part of me tells me to accept this as the explanation and interpretation of my dreams.  But there is a part of my soul that wonders, “what if?” These dreams of my grandfathers and of my mother were so real, so vivid, and so different from all my other dreams.  What if these ‘dreams’ were not just the yearnings of my psyche, but visits from those who loved me, trying to offer their comfort and their goodbyes?  What if my mother was trying to answer my questions about the other side, telling me she had found a peace and love in death that she had not known in life?

My rational self says that this is not so.

But how do I know for sure?

Maybe, just maybe . . .

Reason tells me “not so.”

My soul cries, “what if?”

The Electronic Medical Record

“The development of the child’s soul is connected indissolubly with his craving for the Thou . . .”  (Martin Buber, 1878--1965)

As a Child and Adolescent Psychiatrist, I witnessed the corrosive power of electronic media on children’s behavior, education and socialization.  Of all I witnessed, perhaps the most disturbing was the negative impact on the interactions between children and parents. Children and parents spoke less to each other, played less with each other, and looked less at each other.

Every day, I reminded parents of the importance of being parents; unplugging, monitoring the electronics, setting limits and having rules.  I encouraged children and parents to read together, play games together, have conversations together, be present, engaged and undistracted together.

Yet, at a time when I was informing families about the importance of turning off screens and making eye-contact, I was under pressure to turn away from my patients and towards a computer screen.  I was expected to embrace technology that promised to enhance and revolutionize medical care. Medicine had entered into the age of the electronic medical record, the extraordinarily labor-intensive and time-consuming electronic medical record.

An article in the Journal of the American Medical Association had this to say about the skills required of the future physician.  “In addition and most importantly, the physician will have virtuoso data entry and retrieval skills, with an ability to talk, think, listen, and type at the same time rivaling that of court reporters, simultaneous interpreters, and journalists on deadline.”  (JAMA, June 12, 2014 – Vol 309, No. 22, pg 2385)

I, a physician of the past and present, who happens to be significantly challenged in data entry and retrieval skill, was at first offended, next bewildered and then outraged.  Is this true?   Will this be the next generation of doctors? What about ‘bedside manner’, compassion, integrity, and problem solving, virtues I always thought defined the desired skillset of the physician?

I know when I was a medical student, my teachers worried about my generation of doctors. My teachers lamented that my generation was becoming enamored with laboratory tests and radiologic studies.  They feared we were losing the skills of taking a good history and a doing a thorough physical exam.  My teachers feared that laboratory tests would replace the physician’s skilled and observant eyes, ears and hands.  To a large extent, they were right.

Now, having been teacher to a new generation of doctors, I fear that as technology is embraced and becomes the norm, the young physicians will sacrifice yet another powerful tool for diagnosis and healing . . . the power of relationship.

Societally, relationship seems to matter less.  Where once I-Thou mattered, it is an increasingly I-it world.  I-Thou and I-it are concepts of dialogue and relationship from theologian and philosopher Martin Buber.  I-it is the nature of most interactions.  I-it interactions can be pleasant and friendly, but I-it interactions are impersonal, the exchange with one another often being a means to an end.  I-Thou occurs only when one is fully present in the company of the other, listening, engaged, undistracted.  It involves not only eye contact, but I-contact, full presence.

I have recently retired.  A new generation of doctors will determine how medicine will be practiced.  Will they practice I-it or I-Thou? Will they integrate virtuoso data entry and retrieval skills and still remain present, able to respond with compassion and humanity?  What’s at stake is not only how they will practice, but the example they will set, how they will model for the patients, parents and children who will seek their guidance.

A Point of Light

“Twinkle, twinkle little star, how I wonder what you are.”

When I was a child, I had a telescope.  I learned the names of the stars and the constellations.  I tried to fathom the vast distances that separated one star from another and them from me.  I looked up in wonder.

My favorite constellation was Orion, visible in the winter sky with its two bright stars Betelgeuse and Rigel, and its belt made of three aligned stars.  The brightest, yet most distant of these three stars is the middle star Alnilam, Alnilam meaning ‘string of pearls’ in Arabic.  Scientists have studied Alnilam and estimate that it is four-million years old.  It is a ‘bright supergiant’.  Its distance from earth is approximately 1350 light-years.  When I look at Alnilam, I look at history.  The point of light I see and call Alnilam started on its journey at a time when the world’s total population was just over 200-million people, when Constantinople was the world’s largest city, when Mohammad had just died and when Islam was in its early ascendancy.

I ponder the mystery of light.  How does a point of light, a photon starting from a distant star, penetrate the emptiness of space and reach my eye?  How does that point of light trigger the chain of reactions that occur within my retina and my brain that causes me to perceive that light?  How does my perception become conscious awareness of that light that began its journey over a thousand years ago?

Scientists ponder the mystery of light.  I learned in Physics about the paradox of light.  It is both a wave and a particle.  It is both, and it is neither.  In other words, our language and our knowledge are not enough to penetrate the mystery and complexity of light.  Einstein’s great insight was that light always travels at a constant speed, and that there is no such thing as real time and real space.  Light is absolute in an otherwise relative universe.

I am no Einstein.  For me, these are difficult and mystifying concepts.  I understand that there is a complex and mysterious “out there” that I perceive with limited understanding.  I really know very little about this complex universe.  But I look at the sky, at a billion points of light, and find solace in the mystery.  The stars remain beyond human explanation, beyond human reach, and beyond human folly.

Mystics ponder the mystery of light.  I am no mystic, but I’ve read the Kabbalistic story of creation, about the Light of creation and the primordial Vessel that was created to contain the Light, and how, when the Vessel could no longer contain the Light, the Vessel shattered.  I am unable to understand the mystery of a single point of light.  Yet I, like the primordial Vessel, must receive the constant influx of almost infinite points of light.  The light is contained in the images and memories of my mind.  And, miraculously, I don’t shatter.

If I taught Science or if I taught Sunday School, I would want my students to ponder the mystery of light, to reflect on the journey of a point of light from its moment of creation to the moment of awareness.  I would want them to look up at the stars in wonder.  I still do. 

 

Addendum:  Years ago, I told my wife that should I die first, and should there be an afterlife, I will signal her by becoming a star in the sky.  I told her to be on the lookout for a fourth star in Orion’s belt.  Since the universe is expanding and Orion is getting older, he could probably use the extra size.