Boston Indicators: "Exclusionary By Design"

The Boston Indicators team at the Boston Foundation has done a lot of fantastic statistical work on Boston housing and other equity issues. This report is a more historical examination, quite detailed and also expansive in its scope, of exclusionary zoning in the Boston metro area. One of the strengths of the paper is that it doesn’t overstate the case: rather, it explains how zoning processes, particularly in the 1970s, never had to say a word about race while remaining very obviously and profoundly about race.

If you’re interested in housing in Boston, I think this is a must-read.

EXCLUSIONARY BY DESIGN: AN INVESTIGATION OF ZONING’S USE AS A TOOL OF RACE, CLASS, AND FAMILY EXCLUSION IN BOSTON’S SUBURBS, 1920-TODAY.

What do I do? Well, I'm a part of the Chic Organization.

Any pop music nerd will know the name of Nile Rodgers. Some of us even read his autobiography. I recommend it.

I’m always dazzled by how many different parts of pop music he touched. You could have a wedding DJ that played only Nile Rodgers-associated songs and you would have an amazing wedding. It is possible that the wedding DJ industry may owe its very existence to Nile Rodgers.

So. Here’s him and his band gamely making the best out of the NPR Tiny Desk format.

If Goldman Sachs was having a party and paid them an appropriately hefty amount of money, Nile Rodgers and Chic would show up, they would look like they were having a great time, and in fact, they would imply that this was the best corporate gig they’d been at for a long time, everyone there was a special kind of fun, and maybe even give an enthusiastic, “C’mon Goldman Sachs! Put your hands in the air!” Maybe even a little, “When I say Goldman, you say Sachs!—Goldman!” “SACHS” kinda thing.

Nile Rodgers is all about doing the job, knowing it’s a job, and doing that job right.

With the exception of Nile Rodgers (who looks either like he runs a non-profit that teaches yoga and meditation to incarcerated men, or maybe like one of the greatest pop music geniuses of all time) most of the band looks like any other folks who might be standing on the side of their kids’ sporting events.

I’d like to imagine someone saying something like, “Oh yeah, Oliver’s dad is a keyboard player” and someone says oh cool, what kind of music, and gets back, “I think he does some studio work, and then he tours with Nile Rodgers and Chic.”

And I hope that the guy lives in LA. Because if he lived in LA there would surely be a good number of people there who would know their pop music insider history. And they’d know, Nile Rodgers chose that guy to be in his band. And they’d know right away: Oliver’s dad must be something… really really special.

Trauma therapist, 1946-2023.

This site seems to lately be an obituary site. For my stepfather, then my father, and now my mother. In fact, I see now that I haven’t written anything here except two music posts (and another music post I deleted), since my father’s death. In retrospect, not coincidentally, this year has been a kind of stuck year, with lots in my head, but not as much coming out.

My mother and my father have not been together since I was four years old. So somehow it was completely unpredictable and shocking to me that their deaths would come so close together, less than a year apart, both unexpected.

My father’s death was different; as soon as the oncologist showed me the MRI I understood what was almost certainly going to happen; and then when the biopsy results came, what was certain to happen. It was terrible but it was understandable. There was a brief rally for a treatment that might buy him some more time; but the pace and slope of his decline was almost exactly what the oncologist had predicted would occur without treatment. It was horrible; and I’m revisiting its horror now, almost exactly a year later. But it was horrible in a particular way, and a knowable way.

My mother’s death came after a long struggle in the hospital, first on the regular floor and then in an ICU, a terrible irony in several respects. My mom at some point had said, “The problem with our healthcare system is we’ve got all of these old people in ICUs instead of spending that money on children!” She was prone to absolutist statements of this kind, though to her credit she would usually engage the nuance of my objections. I remember convincing her of what I’d learned as a medicine resident, and observed and talked about with my wife who is a critical care doctor: that you don’t know who’s going to survive when they enter, and yes, it doesn’t make sense to continue if you know someone’s certainly not going to survive, but, you rarely know for sure. So when do you stop? When do you decide that the time for death has arrived? Do you just devalue the lives of old people because of their proximity to life expectancy?

And that’s how it was with my mom. A certainty, then a hope, then a desperate yearning, that surely this would get better. I kept telling the doctors, who saw an ill and frail older woman, that until recently she’d been walking by the river for miles daily by the river, driving, paying all her bills. I hoped somehow that this meant she would therefore have the well-being to survive the blows of her mysterious but progressive lung inflammation. I hoped it would mean they wouldn’t give up on her.

This was countered by an inexorable march towards irreversible damage and then death. If I drew a line in my head—I was never able to bring myself to do it on paper—her oxygen requirement had a steady slope of increase that never was too dramatically different day by day, but was more or less relentless, more or less linear, and shockingly rapid by the scale of a lifetime. Even by the middle of the hospital admission, I could see where that line was headed. It was not a complex curve.

I’m not a denialist. With a doctor I trusted, I sort of ran my own family meetings, the one thing in the ICU I was good at as a resident. Before he could walk me through that family meeting pathway, I reviewed the data as I understood it, confirmed that my understanding was correct, related that to her values and who she was as a person, and made clear that I understood there was a time that we would declare it done. With people I didn’t have to keep searching for, my family meetings were conducted very efficiently, by me. I knew for a while that after the last thing was tried—something with a low chance of success—I was going to have to choose the moment to withdraw ventilator support and thereby choose her time of death. And I knew, when I finally made that decision, that it was the right one. But it was as horrible as you can imagine it would be.

I find it still too painful to rehash the hospital course; I have so much sadness and frustration, and anger which I don’t know how to properly target, about different parts of it. When I wrote her obituary, I suggested people should donate to any of three causes in her memory; one of them, without any ambivalence on my part, was the UC Davis Medical Center Nursing Recognition Fund. So, I can at least say my anger isn’t targeted at the nurses.

And at least one thing I know for sure is that I was so disappointed and angry about the doctors who I had to prod into rethinking the differential, and the plan, all through deferential language and indirect questions, all this “I wonder if…” “I am so appreciative of… but I mean, it’s probably just my worrying, but I just can’t help worrying about…”—that kind of managing other people’s pride and self-doubt that women do to try to influence prideful men all the time. It was absolutely exhausting and demoralizing, just like that version is for women. It infuriated my mother when people expected that of her. She performed that masquerade much less often than some people do, and was sometimes taken as startlingly blunt or confrontational as a result.

I was disappointed and angry most of all about some of the doctors who kept me at arm’s length, avoided talking to me, didn’t include me on rounds; even in some cases, seemed scared of talking to me. Obviously her care was not going well; judgment calls could have gone differently; I’m sure they doubted themselves or felt defensive about how they anticipated me judging them. Still, I have frank contempt for doctors who are unwilling to face their own self-doubt or share it with another physician. That all too familiar sad and infuriating charade. I was so grateful for the doctors who did that differently. Who simply talked to me and to my wife like doctors talking to each other, which is what my mother wanted and needed them to do.

My mother was proud of me, and in fact she was especially proud of me going to medical school and becoming a doctor, and marrying a doctor, and the way we made our lives as students and then doctors together. “I admire you,” she said, with emphasis, as I left to go back to Boston for the first time, before I returned, on the plane while she was being intubated.

But that thing? The doctors acting like Doctors instead of humans, talking down as a power strategy, talking confidently through the cracks and tears in their reasoning, blowing past personal particulars with generalized assumptions and fallacies? She hated that about doctors. She had always hated that so much.

* * *

I think, well surely there must have been some other month of my life that was worse than August to early September of 2023. There must have been, right? But right now, at least, I can’t think of one.

* * *

My baby passport, picture from 1970 I think.

Her passport, 1971; she was a young mother, 22 when I was born.

I probably need to write much more about her. To tell her story. But as I try, I find that I’m still too raw, too sad, too confused by my intense mix of emotions about this moment, to write more than a typical obituary, that hides much more than it reveals. But it at least states the basics:

Sacramento, California - Emily Mason Wright. A retired therapist, she died last month of an unexpected and rapidly progressive autoimmune condition. She was 76 years old.

She grew up in Salina, Kansas, spending much of her childhood and teenage years playing violin and finding comfort in the small but devoted bohemian and arts worlds of central Kansas. She attended the University of Kansas, worked as an air photo interpreter and cartographer, traveled and lived in Latin America, and became a mother.

After the end of her first marriage, she studied geography and history at California State University, Sacramento; and then later returned to CSUS for a master's degree in social work. She worked for many years as a therapist for child survivors of abuse, primarily at the Child and Family Institute; and provided clinical supervision for staff at Sacramento Self-Help Housing.

She was a poet, a devoted keeper of journals, a voracious reader, and as she put it recently, an "ardent feminist." She was a founding member of the La Semilla Cultural Center, and of the Sacramento Labor Chorus; and a volunteer docent for the California State Indian Museum. She walked many miles every week along the American River Parkway, and had a deep love and knowledge of the plants and animals of Northern California.

She is preceded in death by her husband, and life partner of more than four decades, Ernie Isaacs; as well as by her brother Peter. She is survived by her son Joe Wright and his wife Jen Stevens, and their daughter Lucy; as well as by her sister Molly Cooley, her brother John Mason; her nieces and nephews; and Ernie's children, grandchildren, and nephews. In lieu of flowers, consider donations to the California Indian Basketweavers' Association, the National Network of Abortion Funds, and/or the Nursing Recognition Fund of the UC Davis Medical Center.

I will say this. Once when I was a medical student, I went to a big multi-hospital palliative care case conference, and they presented the case of a “difficult” family. And they were really having a hard time in figuring out how to connect to and help this family. I don’t recall all the details and couldn’t say them even if I did; but the general summary was that they were intellectuals, clearly comprehending the medical details, and yet confronting the medical team all the time, battling them, distrusting them. More details. And they were absolutely baffled. Good case, they seemed to think; tough problem; hard to solve. Meanwhile, this was sounding more and more familiar.

Finally, I raised my hand. “I just have to say, this sounds exactly like my family.” I remember that the people in the big lecture hall all turned to me, like, truly startled. My mother, is what I really meant. “The reason they are behaving that way is that they see medicine as a system of power, and of patriarchy, and they do not trust that the system has their best interests at heart. They disagree with the whole political basis of the authority that the team is trying to exert. They’re part of a feminist tradition that explicitly rejects that. You’re asking them to trust you implicitly and that’s not on offer.” They seemed to find this revelatory, though I’m still not sure they were going to treat the patient differently.

Anyway, I will always remember that moment. Some angry Cambridge feminist with a dire medical problem, being presented to the hospital like a problem, by mostly women clinicians incidentally, as if they had never heard of the women’s health movement, as if they had never questioned the moral and political legitimacy of academic hospitals and their ilk, as if they just saw those politics as some kind of oddball smart-person psychological problem. As if they assumed that they were the Good People, and anyone who resisted was somehow missing that point.

Which is just one of the reasons, among many, that I am heartbroken not only about her death but about the fact that it happened in a hospital. Not that she was like that family in the case conference; for one thing, she was too quickly sick, and everyone was struggling to understand what was next. It was not the time she would have been outright battling her medical team. For another thing, she was relying on us. She traded that mode of feminist confrontation for trusting that at least these doctors—her family—would be sticking up for her, would see her as a whole person. I’m not sure it did any good. That trust is painful now.

I’m grateful, though, that the nurses acted through conscientiousness and kindness, generally not trying to impose power, seeing my mom for who she was. Especially in the ICU, they were calm and kind companions to my grief and worry. After all, as you realize when you sit with someone in the hospital day after day, even in the ICU, you barely see any doctors. Your relationships with doctors, in the long days of nothing happening for hours and hours, are mostly defined by the relationship of the suffering person’s body to decisions entered electronically in other rooms. Their orders.

UC Davis Medical Center, Sacramento, California. The hallway to the medical ICU.

Music: "To Never Forget The Source", Sons of Kemet

sent to me by my sister

Music: "Survival Mode", Maya Jane Coles

The music, and the title, have meant different things to me through this year. But I keep playing it again and again.

Historian, 1945 - 2022.

My father, Angus Wright, died last week, of a fast-moving glioblastoma. He was a scholar of Latin American agriculture and an early member of the discipline of Environmental Studies. He was the kind of environmentalist who thought more about farmworkers than birds, but he loved birds too.

A friend: "I don't trust a man our age who doesn't have a complicated relationship with his father." I pass that test. A fellow CSU Sacramento faculty kid told me in 8th grade, clearly we would be professors. He was half right: he's tenured at Yale now! But I was intent on something – anything – different.

But. I am my father's son, there can be no doubt. I remember a trip he and I took with two former students of his to Baja California, camping on the beach and canoeing. I was 15. A great trip. As he and I drove back to Sacramento, we had a big canoe tied to the top of his car.

We were driving by some tomato fields, and he saw a group of migrant workers applying pesticides to the field. "I'm gonna go talk to these folks. But stay in the car and keep the windows up," he said, and parked the car, with the canoe on top, at the side of the field.

He later described the scene (he left out the canoe!), which I still remember vividly, in his book The Death of Ramón González, the paragraph starting “On a day in June 1985…”

He got back in the car, stinking of chemicals; he had a headache all day. I've never looked at a tomato the same way again. A tomato, a pepper, an ear of corn: I know from my father a long history of indigenous agriculture, colonialism, neo-colonialism.

While that time was for research, still, in many ways, and at many different kinds of times, he loved going and "talking to folks" (always "folks"). All kinds of folks. When he stopped canoeing and swimming as much, he sat by the side of the American River. Watching the mergansers and the herons. Talking to folks.

One called him "King of the River". He was bemused, but I noted that he did not decline the crown. He was that guy, sitting there all the time in his lawn chair by the banks of the river, talking to folks about the river. He loved the natural world, including in the middle of a city, with high-power transmission lines crossing the river, and under them: a great blue heron flying, merganzers. Trees. My sister and I both remember the sun-ripened blackberries you could only pick from the canoe, their bushes pushing out onto quiet parts of the river.

After his death, I found myself at a Sacramento farmers' market. A DJ was playing; sponsored by SMUD, our local energy utility, and powered by solar panels. A pretty pure Sacramento vibe. (If I was as eager to get out of there as Lady Bird, I'm just as loving about it as Greta Gerwig. IYKYK.)

Yes, solar panels, sustainable farmers, and corn tortillas brought echoes of my dad. But another thing came later. I went up to the Food Not Bombs table, picked up a sticker and a pamphlet, saw that they had harm reduction supplies, started talking to them.

"I'm in the homeless union," one guy says. I start asking him about health outreach. He doesn't know of much. I explain funding: "There's grantees in most metro areas, and you can hold them accountable." "HRSA. H,R,S,A." I express concern that there isn't more syringe exchange.

I tell him some more, ask him some, express appreciation for their work. I give him my contact information. I don't know that he'll get in touch. It doesn't matter.

I know what I was doing. I was out there talking to folks. As I do.

* * * * *

Being a doctor helped me find ways to be there for my dad in his last two months. At one point, I drove him to the same Kaiser Permanente ED where he had taken me for ear infections when I was 4. We drove there listening to music I'd grown up with, like the album Kind of Blue, and songs by a mutual favorite, Abdullah Ibrahim:

"My son's too modest to say it," he told a nurse, as we waited for a result. "But he's a doctor." A week or two earlier, a Kaiser neuro-oncologist had shown me MRI images on a Zoom call, and talked to me a long time.

At the end, I asked, “Are there questions I should've asked, that I haven't?”

"No," he said. "You've asked all the questions you should ask."

"And anyway," he said – it would only be kind if said to another doctor, but in that context it was so kind – "you already knew all the answers." He fell silent. “Yeah”, I said. “Yeah, I did.” Then I cried for the first time.

Anyway. There are people without homes everywhere in Sacramento. And various housed people I encounter there say the usual stuff, like, how are we going to get them off drugs, etcetera, etcetera. And, then I of course start in with something like: "Well, if people want help with addiction, of course, that’s important, and I spend a lot of time doing that, but homelessness is about housing supply",... and off I go:

It's structural! It has a history! The history goes way back! It’s like a favela! A dome tent favela! You can't understand an encampment without knowing about racism! about capitalism! About how making land into property changes everything!

Yes.

I am my father's son.

Limantour Beach, Point Reyes. A beloved spot for me and my dad throughout my life.

An encampment that will soon be cleared...

originally posted as a twitter thread

In a site slated for "redevelopment", an encampment of five or six people is barely noticeable to passers-by. The development itself, a large multi-use building that includes new housing, is fine. But it also highlights a built-in problem with "urbanism" – a problem of success.

An urbanist focused on housing supply will see this project and appreciate that, yes, it contains new housing. But it’s aimed at housing categories of people more palatable than the people in the encampment. (I'm being vague b/c this isn't about the project, which itself is... OK.)

These people need housing too, but they are mostly just housed in less ideal conditions currently. And while in the bigger picture, adding housing overall is important for unhoused people, it can also make their conditions worse.

Adding housing in a thoughtfully-designed way can simply bring more people into a city – increasing demand as much as it increases supply. This is lovely for housed city-dwellers as cities become more and more pleasant to live in. But it may not improve urban homelessness.

These outer suburbs are not eagerly building low-income housing, putting out welcome mats for disenfranchised and impoverished refugees from the center city's design victories. Nor are they good places for really poor people to live. My patients who do get shipped out there end up deeply isolated, cut off from any but the most basic public transportation, and therefore from much of their prior supports. And as the city core gets more and more lovely and Jane Jacobs-y, and prices continue to rise in response, another thing happens.

The supply of sub-standard housing – a run-down single-room occupancy hotel, for instance – also starts to decrease. This kind of housing is just harder to find in vibrant city cores. So even if you get some money some kind of way, it's still hard to get a room without a lot of money.

So what will happen to the people in the encampment? The new development – mixed-use, incl. housing, inclusive of cultural context of the neighborhood, etc – will be one more part of reducing interstitial in-between space – the places they can tuck themselves away.

That will mean that wherever they land will likely be somewhere more visible. Somewhere more likely to inspire San Francisco-style rich liberal anger – the impervious-to-logic zone that combines "how could we allow people to be unhoused" with "get these people the f**k out of here.”

I give credit to Boston's mayor. She's done a lot to quickly house unhoused people. In fact, the fast moves she's made just show how much unused possibility there was. But the pressures are structural. Their effects are indirect but powerful and relentless.

Without even more effort, what will happen more and more, is what's happened in San Francisco. The people who've been in tucked-away spaces, in SROs, or other marginal or interstitial spaces, get those spaces taken away. In the "successful" city every square foot is claimed.

That means the people tucked away will more often "appear" on the street, in public space. Other ppl will blame substance use or mental illness – problems that have afflicted these folks most of their lives – as if these things were new. There will be calls for a crackdown against these very people who right now, are staying in an encampment no one is noticing. (Well... no one but them and a few of the rest of us.)

So: while no one is mad about the unused space they're taking... is their homelessness a policy problem? Or, is homelessness not such a big problem as long as it takes place in an unclaimed interstitial space? If you care about the problems of the people themselves, it's the same problems of poverty and despair whether housed people see them or not. The only solution is housing.

If you want a vital living city where every bit of space is used and alive, we have to find spaces for all the people. Not just "affordable" housing pegged to some amount less than average median income. But truly, housing for people with no money at all. This encampment can only last so long.

healthcare as an "anti-state state"

[A prose version of a twitter thread:]

Understand medicine as a system of social control. It helps explain why healthcare has been a more politically acceptable form of attention to social welfare. Unquestionably medicalization is gentler than criminalization as the focus of the state. But progressive reformers within medicine risk being trapped inside an enclosed system where attention to people’s safety, happiness, and well-being is only politically acceptable if these things are “determinants of health”.

From a governance point of view the ever-growing share of health spending as a share of GDP, reinforces the idea that all other things must then serve the needs of that budget, i.e., we should pay for supportive housing if it leads to savings on health spending, or that in this logic supportive housing “doesn’t work” if it doesn’t efficiently reduce expenditures on health. If homelessness itself was the outcome of interest, supportive housing would “work” or “not work” to the extent it kept people housed and content with their housing.

The underlying logic: people who don’t earn money, in a system where the only way to earn money is to work, must then be sick to merit concern or inclusion. Disability becomes the only basis for guaranteed income and health outcomes the only reason to care about inequity.

This is of special importance for addiction medicine where we are classifying addiction as a disease in part as a way to remove it from the world of moral judgment and criminalization, but then in essence “owning it” from a social policy point of view.

We should be very cautious about people describing any form of homelessness as a “public health problem” or a problem of “not enough treatment” because these discourses lead ultimately to putting doctors in charge of social policy that is not medical.

A frame of well-being that extends past health would ask why people are homeless and why people use drugs to the point that it creates big problems in their lives and why those two things are related but not at all the same.

Medical people are important but not central if we properly understand overmedicalized forms of mass despair and social abandonment and trauma.

Areas of high degrees of street homelessness, drug use, and impoverishment, are the refugee camps of the adult survivors of a war on children; maintained and amplified by housing as investment instead of social welfare. You can’t medicalize that and do it justice.

On a policy level, the more we medicalize suffering and inequality and responses to trauma, the more we grow the healthcare budget to the point where it becomes what Ruth Wilson Gilmore describes as “the anti-state state”, i.e., an arena of spending and social ideas in which “good deeds” are really a constraint on our imaginations.

For instance: if we cannot pay for practical caring about children, making them feel safe and valued, because a healthcare system spends more and more to attend to the wounds of adult survivors of wounding childhoods.

Healthcare is a necessary component of any society just as some form of social order and protection against violence is also necessary. But when we reflexively view social questions as either medical or criminal, as with addiction, we are really asking, what form of anti-state state will we choose? Rather than asking, what do we all need to make a better world?

Love and clinical practice, part 3: the rule of tears

* * *

For a long time, I’ve followed this idea of a career shaped by what I call “The Rule of Tears”. And the idea is that the things in your work that bring you tears, not like frustrated or grieving tears but more like just-saw-an-overwhelming-movie tears, just-heard-a-beautiful-piece-of-music tears—these are the things you should move towards.

I still believe in that idea, at least partly. It’s what led me to HIV work and away from trying to make movies; towards medical school and away from applying to Ph.D. programs; and then what led me to leaving academic primary care to do addiction work among people without homes. It is an expression of a secular spiritual impulse; those tears come from a feeling of love, of connection, of beauty. Of fiercely shared common purpose. I found that feeling in the community of people fighting HIV; in needle exchange; in certain parts of medicine.

The Rule of Tears has taken me to good places, and then has led me to walk away from some of those places. When I’d started drifting away from the core thing that had brought me there. When it was time to find that somewhere else.

* * *

But as I get older, I also have added a kind of caution to the Rule of Tears. Sometimes a closely-related variety of tears come because my own feelings are obscure to me. In other words, when we’re overwhelmed with emotion, it might not be because the emotion is inherently more important than not-overwhelming emotions, but because we don’t have language to figure out what we’re feeling, the words and explanations we need to contain it.

It’s a feeling that is strong, remains undescribed, only poorly grasped if sometimes deeply felt, coming from underneath the surface and out into torrents from time to time. And that strong eruption of feeling is what makes you cry with it.

I’ve felt the tears of beauty and spiritual connection at all kinds of times, from listening to a house music record, to being part of a political demonstration. But the things I keep going towards are way way more full of tears, and there’s something about grief and trauma that keeps drawing me towards it. Are these the tears of beauty? Or is it just looking for pain?

Like I’ve said before, lots of people go into their particular field of medicine with a resolute intention to contain or even frankly avoid strong emotions, and some of them show up to work and do their jobs every day. And depending on the number-needed-to-treat of their particular intervention of choice, some of them may do more good in the world than I do.

For those who did go towards the pain: I think some of them go to fields like critical care; others to oncology; some palliative care; and still others in corners of medicine, like the one I’m in now, with problems that are driven by more social and political forms of trauma and despair. And, I sometimes think that if I had a different set of political impulses, but carried my same emotional hardware, I’d be a leukemia specialist somewhere, overhearing my resident on the phone to someone going, “Yeah, I’m on liquids, it’s so brutal, just a week of this left.” Whatever the board certification I ended up with, I’d still be in a place full of pain and drama, but also of shared purpose. Of a shared fight for life. But let me tell you about a fire, that should make you suspicious of going towards the pain.

* * *

Back a long time ago now, my girlfriend (now my wife) and I lived in an apartment building that was partly consumed by fire. We were out in the street, having lost our home. And it’s a story for another time, but getting out of the building was not a straightforward story. It was stressful and traumatic, especially as we were standing out on the street after it was all over, letting what just happened sink in. We were both medical residents, and we had supporters, and paychecks, and we were going to be able to deal with being without a home for a while; but still. It was shocking.

We were out on the street, and I remember our fierce little cat squirming around in her carrier bag that was slung around my wife’s shoulder, and then mine. We called our respective chief residents to tell them we weren’t going to be able to come in the next day. There were all these fire trucks, and the smell of smoke from the fire now being fully extinguished, and the old lady from upstairs had been taken off to the hospital, and we were trying to figure out what to do next.

A small group of Red Cross volunteers were going through some kind of disaster response inventory, and making us register for something before they would do something else for us. So, not knowing what we were going to do next, we registered, only to find that the something else they would do was in fact, nothing else. Probably they were perfectly nice, but our reaction was eventually: these people are useless. And yet they seemed full of a sense of the urgency and importance of their mission.

Of course, my wife, now a medical school professor somewhere respectable, doing respectable things, would surely never have said, with a bleak and definitive dismissal: “Those people get off on this.”

So it must’ve been me who said that.

Anyway, we’ve seen it in our colleagues, and recoiled from it whenever we started to see it in ourselves: going towards grief and pain for the wave of emotion it brings the observer. Medical ghouls looking for suffering, for the realness, for the intensity, for the drug of other people’s unsolvable pain. After standing there getting nothing useful from Red Cross volunteers who seemed to be inspired by their own feelings of sympathy for our pain, I think both of us have ever since looked at certain kinds of “medical humanism” with a deep suspicion. Because being there for people’s pain can stand right on the line of being either the noblest part of humans as social animals, or—

—it’s such a thin line—

just low-down vampire hunger.

Feeding off the intensity of other people’s circumstances is a way to substitute other people’s strong emotions, or the emotions they inspire, for our own emotional state. It allows clinicians to have strong feelings without having to feel our own experience, without having to delve into the complexities of our own circumstances and histories. We can feel a version of the pain itself, without the bitter notes like shame or guilt that accompany our own personal pain. Other people’s pain is simpler than our own. Shoot it into your veins: here comes the rush of realness, without having to feel your own real.

But the Rule of Tears does not have to lead towards pain. At its best, it has led me towards beauty. And the places of beauty, found amidst pain, are most often the places where my patients are at their most powerful, their most human, where I am genuinely humbled by them. It is not a coincidence that beauty-amidst-pain is usually the theme of the movies and the music and the art that makes me cry, what makes me hold a song closest to my heart. This is my wiring; and in my work, it is where my true gifts can best be found.

Of course—don’t tell me you’ve never seen this in a doctor!—a pose of humility can be the half-conscious sly prowl of an emotional parasite, oh, gosh, I’m so humbled by my patients, as I am becoming filled up with a feeling of significance—oh! shoot it into the vein! Gosh, thank you, dying person, for what you’ve given me today.

Sorry, although your home caught fire, I have actually provided you nothing of value, but I was here, when the firefighters were here, and I am now driving back home humbled by the awesome importance of what I just did, and thus, my own importance.

Right now, clinically, I fill mu-receptors. Or rather, I try to persuade people to fill their mu-receptors with a partial agonist that will block pure agonists. Simply making the effort to start people on buprenorphine is associated with a reduction in mortality of at least 50% in people with a prior non-fatal overdose in Massachusetts, people who have a startlingly high risk of death.

There’s more to it than that, of course, but I like this central and basic task for being concrete and useful. I would like to think that, if I make people register for something, and sign up, and wait to see me, well, I get them at least part of what they’re looking for.

And there is so much pain in people who shoot dope—it’s why they started doing it in the first place—that it can seem like the tears I cry are all about pain. But I know I’m better off when I’m not looking for tears from pain; but tears from beauty. I still find them, when I start making real connections to people; when they’re telling me things that are painful but they’re also sliding a joke in there; when we literally can laugh and cry together over time. I think of patients like that later, and—there it is. The Rule of Tears. I’m still where I’m supposed to be if that’s still there.

This is the spiritual meaning; this is the work. Not the substitution of one person’s pain for my own; but the mutual search for humanity, for some truth in our own experience and what we bring to each other, for a sense of purpose. And this won’t be just my purpose, or just theirs. It will be a combined sense of purpose that we will—starting with the task of figuring out how to swap in buprenorphine for street dope—try to find together.

I found it a couple of days ago. For whatever reason it had been a little while; maybe I’d been going through the motions. And then someone from a while ago showed up. And I can’t say the details. But we laughed. And could’ve cried, but didn’t right then. And, we just shared a common purpose, and we got it done, and it felt good to everyone involved. And I got a little bit teary afterwards, thinking about it. There. Rule of Tears.

* * *

If that Red Cross volunteer I still think of had any time or ability to get to know my wife and me on the night of the fire, even a little, we might have made him sad; but we would have probably made him laugh; and he would’ve seen our strength, too. He would know he wasn’t talking to victims, but to people with stories. Even if he couldn’t find a room for us and our cat, he could’ve at least laughed at our bitter jokes. And we could’ve been quiet together for a minute. And, even if all he’d done for us was to say, well, good luck, take care, I do think that if we thought he’d seen us for who we were, his presence could’ve meant something to us.

As it was, we suspected him of being some pre-med getting a cheap rush from going out in the middle of the night to a fire, and I don’t know what became of him, and to be honest he’s probably a perfectly nice person who just didn’t have a hotel room for people who didn’t really need it anyway. Traumatized people not infrequently read me as just a vampire who isn’t helping them. It probably happens to the best of us. But I hated him in that moment, so I’d like to think he’s an attending physician, in a field chosen for its prestige rather than any particular gift he brought to it, trying to fill his inner emptiness by writing cheap essays about how suffering people taught him what a special person he is.

Meanwhile—hey! let’s stop being such a little bitch, and start returning to our own true spiritual impulses!—this is a year that I assertively need to remind myself of why I’m here.

If I’m still following the Rule of Tears, I do find my tears amidst the pain; but it is not the pain itself I need to cry for. It’s the beauty. If I’m just crying for the pain, I probably need to go follow the Rule of Tears somewhere else. Somewhere more beautiful.

therapy

There’s a Twitter thing right now where a lot of attending physicians are talking about how they benefit from therapy and/or antidepressants; so, my version is:

I've benefitted greatly from therapy at various times in my life, including currently. In a trauma-filled environment, with more and more people working under my supervision, I realized my team needs to hear that, more than I need to keep it private.

And, many of us who are drawn to respond to the suffering of others are also wrestling with some s**t of our own, and sometimes trying to unconsciously work part of it out through our work with patients. It is our obligation to our patients to be mindful of what we carry.

We can heal with our patients, but it's not fair to our patients (and it doesn't work) to try to heal through our patients, or to use our patients to heal. When we start looking at that for ourselves, it often goes deep and there are good odds that we need help with it.

There are plenty of doctors who are actually seem to be just content and balanced people; but many of the rest of us are more complicated. Some of us need to "fix"; or to "be perfect"; even tho the world can't be fixed, and is imperfect. Me? my thing is to go towards trauma.

That impulse to go towards the pain, to respond to suffering, can be legitimately framed as a moral choice; but it can also come from our own pain. The difference between moral bravery, v. just working out our s**t through other people, can be surprisingly hard to distinguish.

Plus, depression is literally an occupational hazard. The intern health study (https://srijan-sen-lab.com/intern-health-study…) looks at specific circumstances of interns--by annually re-creating new cohorts of people who have reliably high incidence of depression.

I'll never forget reading a study thinking it was about interns and realizing, no, it's using interns as a model to ask questions about susceptibility, because it's a high-incidence population where you can get statistical power to ask that question. I mean, we have a profession where we create depression year after year after year, so reliably that you can create statistical power for subtle questions about susceptibility. And then, then!… we also stigmatize real solutions to depression and other mental health challenges.

The profession's solution to this tradition of creating mental health challenges and then stigmatizing them should be clear: stop seeing mental health challenges as a hindrance to professionalism, and start seeing treating them as a key component of professionalism.

This is distinct from how we should contemplate this personally--which can just be personal, and not for our patients. But professionally, part of the reason we need to talk about this differently is b/c doctors who don't deal with their s**t aren't good for patients.

shame, part 117

image: South Bay House of Correction, Boston

The best advice I give my patients, I typically realize later, is the advice I need to hear for myself. Including my most persistent theme: "Your shame isn't helping you." I tell them, "I promise you, if shame worked, I'd shame you." I say it again and again to people.

I say, "I know I seem like some nicey-nice do-gooder doctor working at Health Care for the Homeless, so you're thinking, of course I would say that s**t. But: what happens when you beat yourself up and decide you're a bad person? Does that make you not want to use?"

No, we agre–and sometimes that question even gets a laugh, because the answer is obvious. No. When you're someone who does dope, when you decide you're a bad person, it makes you want to use. To numb the pain of shame. 

Shame, and accountability for the wrongs you've done or mistakes you made, are not related; in fact they are opposite. Shame is broad and full of dread and can't be fixed--it clings to us like skin. Accountability is specific. It can be addressed in specific ways.

And sometimes I just say to people, "Look, you don't have to redeem yourself. You're worthy right now." I've sometimes said that at times that make both my patient and me cry in the room together. But... I always think I'm tearing up for my patient. And, I am, but, I think I'm just in that moment, also believing it for myself just a little bit, but not really admitting it, just like my patient is going to believe it for a minute and then not really believe it later in the day.

You're worthy right now, I say. 

I come back to this again and again: how do I believe this advice I give to others, which I fervently believe for them, but don't seem to consistently be able to believe for myself? I don't even know, most of the time, why I'm carrying shame; I just know that I do. And, just like with my patients, it paralyzes me from acting. It keeps me in my habits. Not in as self-destructive a way; my shame does not weigh as heavy as their shames do, and I've found ways of carrying mine in a sort of functional way.

But my shame does not help me. 

It doesn't make me more accountable for the things I do wrong. It doesn't make me create positive change in my own life, or in the world. It holds me down and slows me down. 

""I promise you," I say, "I'm a nicey-nice guy but I'm a professional first and foremost, so if shame worked, I would feel the obligation to shame you. But it doesn't work." I say it again and again.

I try to ask questions more than instruct, but when I give advice, I should probably be figuring out how I can take it too. My advice about shame applies to my own life; to politics; even to how I respond to racial injustice. Shame doesn't work for me. Accountability is different. For my patients and me both, the struggle is how to get past the feeling that we deserve to be ashamed; and at the same time, make the changes we need to make.

Sho Madjozi

Sho Madjozi just signed a major label deal in the US so it’s probably right around your last chance to try to look cool and act like you knew her when.

Feel your weight, the remix

This song was pretty good the first time around, on Rhye’s album Blood. Then there’s this remix by Poolside (who describe their vibe as “daytime disco”), from Blood Remixed, which amps up the song’s sexeh-sexeh bass and also turns a shy little melodic riff into, like, a full-on roller rink.

In fact, if this song hits you where you live just as hard as it did for me, you will not just be feeling “poolside”, but poolside on a pool that’s actually on the top deck of an exclusive cruise ship. Which sounds like I hate it.

No.

No, madam. I do not hate it. I love it. This is not some kind of Scientology cruise ship being quarantined for measles. No this is a very different kind of cruise indeed. It is sexeh-sexeh. This song is like the hook-ups that might occur on that cruise ship, if it held a bunch of “brand ambassadors” who had to leave their cell phones at the dock, and just hang out with each other, having only their mysteriously compelling sexeh-sexehness and beguiling but slightly corrupt personas that helped them become brand ambassadors in the first place. The flirting these people would do—it might have this bass line.

This bass line is so precisely targeted deep into the pelvic mid-line that it will wordlessly remind you that you can improve your sexeh-sexeh dancing solely by focusing on moving your hips to the bass melody. Maybe only this bass melody, though. Even if you’re dancing to a different song. Just keep moving your hips to this song, and you’ll probably still be coming out ahead. Because… Feel your weight.

Love and clinical practice, part 2: number needed to treat

What’s the value of the work I do? What’s the value of me becoming a specialist in addiction medicine? I’ve written thousands of prescriptions for buprenorphine, for hundreds of people. What has it added up to?

I started doing this work because this was where people were dying. Where the overdoses were. And so I decided: I would not stay in the place down the road where our waiting room was safe and quiet. I would run towards the fire. To the pain. To the place where I could matter most. I’m a decent all-around doctor. I spent a few years trying to prove that to myself as an attending in the primary care clinic where I’d trained as a resident. I think I did OK. They gave me a party when I left, anyway, and they had cake.

But what I’m good at, and occasionally very good at, is being present for people’s pain and then, with the trust I earn from that, helping them learn to use new tools for health and for change. Also I knew that I liked taking care of people who use drugs, for what reasons I am not totally sure—and just liked a lot of those patients much more than did most of my colleagues. So an overdose epidemic was a good place for me to be.

Someone asked me, not long after I’d started the job I have now, to write a mission statement for myself. Easy, I said: “I am a doctor who responds to epidemics of early death.” That came out in an effortless tumble. I’d come from HIV work—which had brought me to medical school and then helped define me after residency. I had started doing Hepatitis C treatment. And I was in my new job partly because the mortality rate among homeless people in Boston was the same in 2003-2008 as it was before effective treatment for HIV. The mortality rate had stayed the same even though AIDS deaths were way down, because overdose deaths had nearly directly replaced them. And we knew in 2014, when I was contemplating taking this job, that overdose deaths had increased sharply since 2008. They increased more after 2014, largely due to fentanyl.

Now it’s been a bit more than four years since I started my new job. I know a lot about how to do this work. Though a lot of my colleagues do a lot of addiction work, I’ve become a specialist even among those specialists. I am a doctor for people with dope problems. And right now that’s almost all that I’m doing.

I went to the fire. And I’ve stayed there.

Here’s the thing, though. If you’re honest with yourself as a clinician for individuals, with a public health argument for your work, you have to sometimes reckon with the obvious:

If you’ve got one hose and the whole building’s on fire, the building is going to burn down with or without you. So maybe you’re just impressing yourself. Wear your fire helmet. Spray the water. Take your medals for heroism. The building is turning into ashes either way.

In my work, mortality in my patient population is probably less likely to be determined by what I do, than by how some middle-manager in a drug trafficking organization sets up the cut for the fentanyl-heroin combination, and how sloppy or precise they are in regulating the proportions of fentanyl to the rest of the mixture. In other words, in the absence of larger policy changes that would bring a regulated and reliable supply, the true public health hero might be the drug dealer who insists on creating a consistent and predictable product.

Meanwhile, consider the much lower-level drug seller walking around my neighborhood saying “sobos sobos sobos” as a way of advertising buprenorphine (Suboxone) for sale. Is that person, distributing stacks of Suboxone in our neighborhood, accomplishing something different than what I do? I’d like to think so. I’d like to think that regular monitoring, checking in, coaching, empathetic listening—that it all means something. And there are various things I do to try to help people increase the amount of time they’re on buprenorphine and decrease the amount of time they’re using dope.

But I’ll be the first to tell you that the most important part of what we’re doing by prescribing buprenorphine is blocking mu-receptors. This biological effect of buprenorphine is why it works to prevent deaths, which is the main outcome I care about. And the biology is the same whether you pick it up from a pharmacy as the result of a prescription from me, or you buy it off some guy who’s also selling “pins” and “dines” down by the Mass Ave Connector.

Even if you look at the frightening mortality statistics among my patients, the number-needed-to-treat is still probably pretty high to prevent one death. There are many ways to do this math, and not enough data to be sure of my particular answer even if I could do the math. I think my ballpark guesses mean I’ve saved some lives, but in four years that number could still be in the single digits. What’s enough? The answer can’t be, just one is enough.

A good part of the worth of what I do is probably more intangible—and harder to measure. It’s something about human connection. Maybe even a spiritual kind of love. Maybe it’s about inspiring people or helping them believe in their own worth. Maybe you can believe that with persistent loving kindness for my patients I address the root of the problem—that I’m doing something to heal the open wounds of traumas that lead people to use drugs in the first place. But if I invoke love or inspiration or kindness when I’m hedging about my value as measured by epidemiology, I think you would have every right to suspect that I’m some kind of do-gooder grifter. Even if the intent is deeply felt. It can’t be just one person I saved and a lot of loving kindness I dished out to everyone else. Because as a public health mentor of mine used to say, paraphrasing an old article: “Whenever I hear someone say, ‘If we just help one person, it’ll be worthwhile’, I know I’m looking at a failing program.”

When we sell ourselves on individual connection as the social value of what we do, we’re blurring the lines between two different kinds of work: the work of caring for our fellow humans, and the work of actually helping them survive. These two kinds of work are both important, but one can be quantified, and the other can’t. And to the extent we can look at either process, in the caring part we’re considering what the doctor does, and in the epidemiology part, whether the patient survived. Any truly caring or decent person should favor the epidemiology, right?

I followed my work towards the epidemiology. To where the fire was. To where the most people were dying early, and to where my skills would save the most lives. But now that I’m here, I can only estimate my effects in the broadest terms, with a good deal of uncertainty. So now I’m trying to make sense of patients I’ve lost, setbacks I’ve watched, the constant grind of the tough world I visit regularly, and I’m asking myself—what is it I’m doing here exactly? Not like I’m about to quit doing it. But I’m trying to figure out what I’m up to.

Amidst that questioning, I’m asking myself whether maybe this work is really some kind of spiritual mission about loving my fellow humans. Maybe that’s an important personal realization. Maybe it’s just an excuse. Most confusingly? I feel almost certain that it’s some combination of both.

Truly (Twin Shadow)

If you’re an intermittent moper, a melancholic stay-up-late dork like myself, then maybe you’ll go deep into this vibe, sway a little but basically stay in mope mode, and then be gently startled out of your nonsense whenever the drum on the chorus kicks in. Full track available on streaming service of your choice, or in the audio-only here:

Not a doctor for social justice.

Some of my colleagues seem possessed of more sincerity and conviction than I can find for myself. They are true believers, and I envy that quality. I am not a believer. I hear medical students or doctors talking about medicine as a project of social justice. I know what they mean, and I admire their conviction and I even think many of them accomplish more in the way of creating justice than I do. But my deep and deepening conviction is simpler: there is no justice.

Everything I earned through my hard work also rests on a foundation of unearned privilege built on hundreds of years of theft and murder. At various times in my life, I’ve contemplated whether I might give away my possessions or somehow try to trade away my privileges. I have usually chosen against either. I am not sure what the most self-sacrificing choices would accomplish except a bleak moral satisfaction for myself. But more importantly, I care about my child more than I care about other children. I care about myself and my family more than I care about anyone else. This is human. And most of us forgive each other for hoarding, and for valuing our own children above others. But against the backdrop of my history as an Anglo-American, I don’t expect that forgiveness from everyone.

I do not enact justice. I care for homeless people who use drugs. I am drawn to this work for reasons of my own, most of which I likely do not understand. I have some small comfort in using the tools I learned in institutions of the wealthy, to serve the impoverished; but let us not mistake that for justice. It has the satisfaction and the impact of a doctor’s middle finger raised to a bomber flying 35,000 feet above.

If you seek justice, you might find the pain of the world while you search. You might join those who try to heal that pain a little bit. That pain is vast and deep. Seeing the pain, and responding to it with kindness and even love, is good work. But treating pain does not in itself bring justice.

My expectations for change are modest: I think that a greater share of justice could come with mildly redistributionist social policies. I love Ayanna Pressley for saying “Those closest to the pain should be closest to the power,” and if I have a political agenda left in the remnants of my hope and the often-hidden embers of my anger, that is its best summary. But the work of a doctor for the impoverished and shunned travels in the opposite direction: I hold power, and go close to the pain. It is the small work of kindness for the suffering. It is good work. But it is not justice.

Historian (1929-2019)

Ernie was my stepfather since I was four years old.

I’ve been a more than a little raw and exposed lately, for this reason and others. So when I was explaining my absence to a patient of mine who I see every week on the van, I told him who died. More than I intended to say in the clinic. It’s not about me. Shouldn’t be about me.

But he’s an avuncular guy, full of declarations and opinions, and when he sees how I’m doing:

“That’s your FATHER,” he said, “No STEP-father about it.” A kindness. And in Roxbury, also a way of saying with emphasis that a father is the guy who shows up and does the fathering. Well, I have a father too, I explained; but, yeah.

I’ve been seeing with greater clarity the things I learned from him, unconsciously imitated, semi-consciously emulated. Good things and not as good; kindnesses, adventures, aesthetic choices; ways of arguing or avoiding argument with my wife; procrastination; the shirts I buy, how to make chicken soup. Frederick Douglass; race and slavery as central organizing principles of American history.

My biological ancestry is mostly Anglo-American going way back on both sides of my family; still, my mom was laughing at herself and him too, because when I met my wife, they were both apparently wondering, “But is she Jewish?” before they registered how absurd this was. Ernie was completely secular, and neither of the women Ernie married were Jewish. (And no, indeed, my wife is not Jewish either.) But the question wasn’t about Jewish heritage or intermarriage; it was about, will Joe’s family still carry this part of Ernie?

There’s no Shabbat at my house. But I carry other things. He was a morning person, and my mom wasn’t. He and I both wanted to be quiet in the morning, just eat breakfast. “Hi Ern,” I’d say. “Hi Joe” he’d say. We’d be quiet together, him drinking his coffee, me eating my cereal. And when I sometimes just sit quietly with my daughter I think of this. That this presence, asking nothing, but being present and kind and calm, is one part of how I hope my daughter might remember me as a father. No step-father about it.

Bye, Ern.

"Let me live my life" / "Toast to Our Differences"

I can't entirely justify my affection for this song or this video.

I mean, I gotta figure that there are angry anthropology and cultural studies majors, across the Western world and beyond, dissing Diplo (the white guy who organized Major Lazer) every time it's term paper time.

And with good reason.

But hey--Diplo still has to bow down before Rihanna even when she dismissed a track of his as "reggae at the airport" so, it's not like he's in charge of music. Plus Rudimental is part of it, and I adore Rudimental; I've got nothing against Anne-Marie; I'm not such a global hipster that I'm like oh yeah that guy Mr Eazi, whatevs; and a lot of incredible people got to cash a check from this video and/or this song, and maybe some publicity for what they do. 

Amazingly, Ladysmith Black Mambazo have a vocal moment in this joyfully shambolic collage of a pop song, which feels like a cheeky "whassup you gotta problem wi that" nod to any critics of cultural appropriation. LBM sort of famously got their start on the international stage from Paul Simon. Who for all of you children who may not be aware, was like Diplo for baby boomers, except with better lyric-writing skills and less political consciousness.

So, I dunno, probably one doesn't want to make a habit of this kind of thing. But, enjoy it for a moment, because hey, it's a mega-meta-global-youth-anthem with a generic message any kid can get behind. I mean, other than a kid majoring in anthropology or something.

* * *

A post-script: here's a different Rudimental video without Diplo involved. Given that Rudimental is also commercially huge (at least in the UK and Europe!), working in a related musical space, and always relies on vocal collaborators, the two videos are like a tutorial in the difference between cultural collage or appropriation on the one hand; and multiculturalism on the other. And yes, I'm an unabashed Rudimental fan. 

sublime skate

This video is sublime. 

Part of what makes it sublime is that Bianca Chase, the videographer, must be as good a skater as the people she's shooting, given how the camera moves. Another part is these two gorgeous pieces of slow move-your-hips music that I can't even find on Spotify because I am not cool enough except just to watch this video again and again. And... I don't know. Just, look at it yourself. 

Check https://vimeo.com/chasebianca for a handful of other videos of this (mostly) black rollerskating scene in different parts of the country; and she has some gorgeous photography on her website http://www.chasebianca.com/blog/ 

And yes because I am an old white man I found this by starting here and then wondering about here and then somehow the magic of the internet brought me here.

LOVE IN CLINICAL PRACTICE (part 1)

In my first years as an attending physician, I would sit in a workroom and listen to residents tell me about the patients they saw. And sometimes it was clear that the resident found a patient especially emotionally challenging. And as we got up to go back and see the patient together, I would tell the resident: “OK, let’s go bring the love.”

The way I said it back then had the wry, tossed-off feel of the language of doctors-in-training and doctors-just-done-with-training. In that time of our lives, many of us say things that we mean deeply, in a tone that suggests nothing is all that important. When you’re just starting out, you’ve either got to act like the weight is less than it is, or sink under it.

Later we get used to the idea that everything is important. We accommodate ourselves to the weight of the work. We just say it. And the learners tagging along with me these days can do with that phrase what they will: we’re going to bring the love. Without irony or apology.

Since then, some increasingly serious and earnest version of “bringing the love” has become ever more central to how I think about my practice. And yet I struggle with how to talk about love, and how to express and use it in my work.

For many clinicians, technical prowess is nearly sufficient, and the simple consistency of good customer service makes up the rest of the balance. In fields of medicine that allow for this, clinicians may be more efficient, less exhausted, and at least as useful for their patients, if they lack spiritual aspirations or leave them mainly for family and community. One need not speak of love if you can just show up to work and do the job.

And yet in at least some areas of practice, sufficiency of technique and service seem somehow still not sufficient. People drawn to these areas of practice are often clinicians who seem to feel some kind of calling, some aspiration emerging from a sense of purpose not focused on competencies but on connection.

Such clinicians have the potential to be terrible for their patients. Connection without competency, in the clinical setting, is a pernicious scam.

But let us presume, for the moment, technical competence. What is the rest?

Some portion of the remainder resides in the territory of spiritual love. It has something to do with what bibles of the 16th and 17th century translated as “lovingkindness”, a translation also used for overlapping Hindu and Buddhist concepts. All of them add up to some broad feeling of unconditional compassion.

And yet it is also more specific than that: I search for it deliberately and intensely for my patients in a way that I do not for other people; and in a way that other people do not for my patients. If there is a broad spiritual element of this feeling of love, it is also true that there is some special type of effort required to create this particular love, specific to a professional relationship with a particular person. I seek this kind of love with my patients, and my patients only.

Let us assume I can remove any hint of sexual desire or agenda from the relationship; failing to do so is a betrayal. 

And not incidentally, since I take care of a patient population with a horrifyingly high prevalence of past and current sexual coercion and violence in their histories, to express a professional love is both dangerous-feeling and also deeply important.

So, it should go without saying, but is nonetheless worth restating: there can be no mixing of types of love. Love, if it is part of why and how I do my work, must be completely compatible with my professional role. Meaning, it is what I should bring to the work regardless of who you are; it is ideally what you get by hiring me for the job of being your doctor. And if the best waiters and bartenders and school bus drivers can bring the love in their daily work, so should I be able to follow their examples.

Still, how do I dare speak of love? Even without sex mixed in, love can feel dangerous and unpredictable. This is because love is mostly perceived as an individual relationship; and indeed, if love claims to be unconditional, it almost never is. There are rules of engagement. You have to follow the rules, or the most important ones anyway, to get the love. 

Even when love is steady, it is difficult for either the giver or receiver of love to distinguish between some hard-to-reach, hard-to-define ideal of enlightened spiritual love on the one hand, and an easily-perceived warm individual relationship. If it’s about two people—and not about a doctor trying to bring love to all of her or his work—then it also has some degree of conditionality, and thus a greater possibility of pain, sewn into it.

Even when love is not painful, it is a drug that some people grab at for longer than is good for them. In this way, a gift of love can expose a bottomless need in its receiver.

And love can be a trick: unkept promises of love, and convincing illusions of love, are insidious tools of manipulation and power. 

Love appears in advertising slogans for everything from all-wheel-drive station wagons to Latin American despots. It is easily grabbed at and waved about by those whose true motives are not love. 

Even leaving aside pain and need and deception, the very idea of love is inevitably vague and imprecise. At best, to speak of love in any of its forms is to risk sentimentality and treacly irrelevance.

In the clinical setting, to talk seriously of love, to organize oneself around love as an idea, is probably an act of hubris. If as a clinician, I say that I want to bring love to my work, how do I explain the accumulated hours of my day in which I was distracted, overwhelmed, barely present, irritated, frustrated? If I fail at love more than I succeed, how much can I pat myself on the back for "bringing the love" when I manage it?

And let me set aside one other form of love. Some of my patients are so deeply soaked in shame, in a feeling of worthlessness. that I feel the need to somehow convince them that they are worthy. If I were a more religious person, I could simply tell them that they are God's children, or that Jesus loves them. I know that even though I was not raised in the church, and am not a church person now, some of how I think about love in my clinical work comes from Christian tradition. But this gesture, even if I were qualified to make it, would risk making the medical visit the tool of evangelism, instead of at the service of the patient. It is not love if I give away buprenorphine to sell Bibles.

But for all this, I find that when I can find my compassion and loving kindness, my sense of love for my fellow human, it does actually influence the relationship and makes me a more powerful and trustworthy clinician. I remember one conversation recently where the person I was talking to was becoming more and more frustrated, focused on achieving a goal he'd come to get me to help him with that I wasn't going to help him with, and I found myself getting into that defensive mode, starting to get ready to push back.

And then I consciously remembered: bring the love.

And I quietly, not so he would notice, took some slow breaths and I looked at him and tried to summon up love for him. And over the next few minutes, the conversation turned. I brought something else to it, something more believable; he visibly calmed and began trusting me just that little bit more; and we ended up talking in a collaborative and more honest way. A close replica of love can certainly serve as a successful clinical tactic. But it is not love if it is just a tactic. For a clinician who can operate this way, one might hope it could become a way of life, a force of spirit and power of intention that moves past the electronic medical record, peels away the billing codes, gets to what's important.

Many clinicians find and work with love in clinical practice from time to time, golden times, complicated times, It is important to many of us. And it is especially important with those who society has pushed aside, the people who stand alone, who have beaten and exploited and abused, who doubt their worth. The people who need the love.

Yet, as I think about all of its problems and caveats, love as a part of clinical practice remains difficult to achieve, and it is undoubtedly full of treachery and problems.

In other words, when love becomes a professional aspiration, I think it should inspire suspicion and skepticism. 

And yet, I still can’t shake the feeling that, on a good day, it’s what I come to work to do

.

(...probably to be continued.)

* * *

In a different context, Robin S asserted, 

"Words are so easy to say; you've got to show me love.

"

Massive early 90s gay club hit. Still a groove to be reckoned with, in my medical opinion.