Tuesday, July 31, 2012

The medical merry-go-round

Caught in referral hell

It seemed a good idea at the time. Heck, it still seems like a good idea. People did try to help out and some leads were followed. So they turned into dead ends. Whose fault is that? Everyone who offered suggestions deserves thanks.

I prefer to blame the doctors.

Frankly, it's like they're playing a game of keep-away with a friend of mine. However, instead of swiping some short kid's cap and tossing it back and forth over his head, it's more like they're lobbing his medical file to and fro: “Here! You take it!” “Hell, I don't want it! You take it!”

I get it. They can't figure out what's wrong with him, so they ignore him as much as they can (this part is easy, because they are actually very busy people with easier cases to consider) and then try to make him someone else's problem when he gets to be a nuisance. My buddy wouldn't mind this latter part so much if at least someone in the long-running game of tag-you're-it could actually make sense of his situation.

As previously reported, one of my good friends (we go back all the way to the height of personal computer fun, West Coast Computer Faires, and user groups) is suffering from a combination of symptoms that include ferocious migraines, loss of voice, and a strangling sensation of throat constriction. Doesn't sound like fun, does it? Initially it seemed like his lymph nodes were going crazy, but now it appears the swelling and constriction must be from some other cause. His thyroid levels were messed up, but medication to bring his numbers under control had no impact on his other ills (even though the thyroid tests got back into the normal range). It's as puzzling as ever. Here's his most recent update:
I have seen three different otolaryngologists in three different clinics: One at UC Davis, one at UCSF, and one at the Sacramento ENT clinic. No one could find a cause in my throat. I followed up by seeing an endocrinologist at the UC Davis Elk Grove clinic. He ruled out my thyroid causing the problem and also ruled out Riedel’s thyroiditis as a potential diagnosis. On July 26 I saw an allergist at UC Davis and she ruled out allergies as a cause because allergies come and go. She suggested I go back to the UC Davis ENT clinic because the doctor I saw at that clinic said that I should see them again if the problem persists; the allergist said I should see them for voice and swallowing problems. I told her that would be useless because all the doctors I’ve seen are trying to address the symptoms, not the cause.

The swelling continues to grow in several places that have been swollen for a while, and a new area of swelling appeared on the back of my neck in the last week.  I’m starting to feel more pressure and pain on my throat when I lie down, which makes it even harder to get comfortable when I need to sleep. Twice this week I’ve slept for 8 hours at a time only to wake up exhausted. I still have no appetite and I’ve lost nearly 19 pounds since this started 4.5 months ago – I was at 163.8 pounds when I started and I’m now down to 145.2 pounds. I’ve asked my current primary care physician about next steps including a PET scan and a follow-up ultrasound scan. I’m currently looking for a new PCP.
He doesn't mention it, but his PCP's referral to the UCSF otolaryngologist provoked an irritated response from the latter, whose specialty is oncologic surgery; he was clearly irked at being sent a patient with no indications for cancer. The wasted trip to San Francisco was further evidence that his primary care physician is out of ideas and is randomly sending him around, hence the search for a new primary. And for a new referral that finally produces results.

Anyone out there have any ideas? Are you a retired diagnostician with time on your hands and an itch to solve an intractable problem? Everybody needs a hobby!

The situation gets monotonically worse, with neither diagnosis nor remedy on the horizon. What can we do to get this guy out of purgatory?

And please don't suggest prayer.

Sunday, July 29, 2012

The great white hope

Darn! Missed again!

San Francisco Chronicle writer Jon Carroll has a quirky way of signing off at the end of  each of his columns. He embeds his e-mail address in a pithy literary quote. Here's an example from Carroll's July 3, 2012, installment:
The weight of this sad time we must obey; speak what we feel and not what we ought to say. The oldest hath borne most; we that are young shall never see so much nor live so jcarroll@sfchronicle.com.
Do you recognize the quote? It's from the end of King Lear, which Carroll has long been mining for material. And now it had run out!
Well, that's that. "King Lear," the story of a foolish old man and the terrible price he pays for his folly, is concluded, a sentence at a time with a few omissions, and now we turn somewhere else for our e-mail line at the bottom of the column. But where?
Carroll solicited suggestions from his cherished readers for a new public-domain source of meaty tag-lines. Naturally I hastened to his assistance:
Dear John:

A modest suggestion:

Call me Ishmael – or jcarroll@sfchronicle.com.

and perhaps

No need of profane words, however great the jcarroll@sfchronicle.com.


Cutting up the fresh blubber in small bits, thrust it through the jcarroll@sfchronicle.com.


Does it not bear a faint resemblance to a gigantic fish? even the great jcarroll@sfchronicle.com?

until, finally,

And I only am escaped alone to tell jcarroll@sfchronicle.com.

That could keep you in sign-off lines for a good while, no?

Of course, if you were hankering for something more contemporary, I could – in a self-promotional move – kindly offer my new novel, beginning with

Greetings! We who are about to lose salute jcarroll@sfchronicle.com.

and ending with

“We have a winner,” he murmured to jcarroll@sfchronicle.com.

Unfortunately, debut novels by math professors turned writers are too obscure to give your readers the desired literary frisson, so I stick with my recommendation of the great white whale.

“There she blows! there! there! there!”
Nice, huh? A good suggestion mixed in with a judicious dash of self-promotion. Carroll wrote back:
Nice stuff ...
I was excessively pleased, so imagine my reaction when I read Carroll's next column and saw this at the bottom:
There's Melville, of course, and Lewis Carroll, and more Shakespeare, and nursery rhymes and old-timey proverbs, all of them candidates for the words before the e-mail line, which is jcarroll@sfchronicle.com.
Of course, there was no guarantee that Moby-Dick was uniquely my suggestion, but it didn't matter. However many of us recommended Melville, there he was, leading all the rest. I was most entertained. Alas, it was not to be. Carroll pondered his options during a vacation from column-writing and somehow settled upon the runner-up in his list of candidates. The first column after his return ended thus:
Alice was beginning to get very tired of sitting by her sister on the bank, and of having jcarroll@sfchronicle.com.
Oh, no! “We're through the looking glass, people!” (Of course, that's an allusion to Oliver Stone's epic fantasy movie JFK.)

Friday, July 27, 2012

The polite student

A cure worse than the illness
An armed society is a polite society
—Robert A. Heinlein
The weight of events was heavy on our thoughts. The news reports were frightening and the college district had reacted. Department meetings featured safety lectures and the college had conducted an “active shooter” drill, in which the campus cops and local law enforcement rehearsed their emergency response procedures and tested their readiness for a Virginia-Tech-type situation.

It was not unusual for a student to approach me before the start of class for a private word, although it was just a bit strange to have one standing so close. I knew him better than most students. He had been enrolled in one of my classes before. He was unfailingly polite and applied himself diligently to his work. He spoke very quietly, so it helped that his lips were close to my ear.

“I don't want you to worry, Dr. Z, if any of the students give you any trouble,” he said.

I raised my eyebrows.

“Thanks,” I said, “but that hasn't really been a problem so far.”

“That's good,” he replied. His eyes flicked toward his classmates who had nearly filled the classroom. “It's just that I know some students get resentful when you're a strict grader and these days you never know how they might react. I just wanted to say that I've got your back.”

His coat was unzipped. With his left hand he pulled it open slightly so that I could see the holster nestled near his armpit.

“I've got a concealed-carry permit and you can rest easy. I've got your back.”

Hoping that my face did not show my surprise, I calmly replied, “Thanks. Thanks for letting me know.”

Mission accomplished, he returned to his seat.

The class continued without further complications, but every so often I threw an extra glance in the student's direction. Everything seemed the same on the outside, but the entire atmosphere of the room was changed for me. While my rational brain had reasonably reassured me that the active-shooter scenario was merely an extremely remote possibility (how many colleges are there? how many of them got shot up? we're talking good odds here!), my animal hindbrain insisted on stroking the panic button. Now, however, there was some additional solid data to process: A loaded gun was present in my classroom.

While gun-rights advocates like to quote Heinlein's aphorism about gun-mediated courtesy, they appear to care little for simple numerical arguments. Guns are an accelerant. People without guns can scream at each other and live to argue another day. Put guns in their pockets and the odds that someone will get hurt skyrocket. If a gunman strides into a movie theater and starts to shoot innocent bystanders at random, an armed citizen could presumably take him out, save lives, and be a hero. On the other hand, the result might just be more people killed in a crossfire—especially in a darkened theater and especially if more than one armed citizen joins the fight. And when the police arrive, at whom do they shoot?

I didn't feel safer with an armed student in the class, even though he was ostensibly “on my side.” He just made me nervous and acted as a constant reminder of worst-case scenarios. The worshipers of the Second Amendment extol the etiquette-enhancing qualities of firearms, but they ignore the risk-impact of the proliferation of guns while focusing on the deterrence of rare and extreme events. Their grasp of probabilities is shaky.

Still, it's not as though there is no evidence on the side of the gun advocates. History suggests that Tombstone was a very polite town. Quiet, too. At least over at Boothill.

Friday, July 20, 2012

Subatomic subgenius


Leon Lederman has a lot to answer for. He famously branded the hypothetical Higgs boson as the “God particle” in the title of his 1993 book on the subject. As a stroke of marketing genius, however, it's undoubtedly had him chuckling all the way to the bank. It follows that recent news from CERN has resurrected the divinely-inspired term, as well as rousing into action the usual crowd of scientific illiterates. A representative of that obscurantist cohort popped up in the letters column of the July 7 edition of the San Francisco Chronicle:
The sages have been telling us for many, many centuries that God or love dwells within our hearts as ourselves. This is found in meditation and costs nothing.

The physicists' instruments have cost millions and are just getting a little glimpse of what is found in totality in meditation.

GVM, Gilroy
Oh, yes. Meditation and occult wisdom long ago revealed the essence of the Higgs boson and its function in the Standard Model of particle physics. We could all save a lot of money if high-energy physics research budgets were devoted instead to the purchase of floor mats and incense sticks. No doubt.

I fired off a response, which the Chronicle did not see fit to publish. Here it is, in full:
I eagerly await GVM's elucidation of the difference between bosons and fermions. Surely he must know.
Stay tuned for the next exciting breakthrough in meditation physics. I predict thrilling new insights into the nature of the bozon, the long-posited fundamental particle of clowning. One hears that the elusive mote might yet be detected with bubble chambers filled with super-cooled seltzer!

Friday, July 13, 2012

The long-delayed procrastination report

Perhaps I'll do it later

Years ago, while first reading The Autobiography of Benjamin Franklin, I was quite taken with his program for self-improvement. He worked up a list of virtues—thirteen in all—and set himself the task of fully embracing them. Franklin did not, however, want to get carried away:
My intention being to acquire the habitude of all these virtues, I judg'd it would be well not to distract my attention by attempting the whole at once, but to fix it on one of them at a time; and, when I should be master of that, then to proceed to another, and so on, till I should have gone thro' the thirteen; and, as the previous acquisition of some might facilitate the acquisition of certain others, I arrang'd them with that view.

I have entertained even more modest objectives. In particular, having confessed to a particular gift for postponement and inanition, I have striven to raise my level of productivity and reduce the amount of time devoted to languor and lethargy. I chose three goals, thinking that they were eminently achievable and not unduly ambitious. Nevertheless, as I will now report, the results have not been impressive.

Ice cubes

To begin with the best, I am pleased to declare that the ice-cube initiative has been a brilliant success, although I fear this indicates that only the most trivial tasks are within my grasp. Having observed that I was too often reaching into my refrigerator's freezer compartment to find the ice bucket empty, I decided that this should no longer occur. Hence I resolved never to take the last cube from the bucket without replenishing it from the ice cube tray. (No, I don't have an automatic ice maker.) Without exaggeration, I can state that it has been more than two years since I have found the bucket empty. My steadfast resolution has not wavered and the bucket is never allowed to sit empty. Let us raise a toast to my success! (Would you like some ice with that?)

The dishwasher

The kitchen counter gets crowded when cups and dishes and silverware are allowed to accumulate. Surely it would be better if used items were deposited in the dishwasher instead of added to the unsightly counter clutter. Of course, this is difficult to achieve if the dishwasher still contains the clean contents of its last wash cycle. The obvious solution was a solemn vow to fully empty the dishwasher and move its contents into the cupboards at the earliest opportunity. Should I find, for example, no clean glass in the cupboard, I should not reach into the dishwasher to extract one. No, that should be the signal for unloading the device and thus ensuring its readiness to receive the used glass once I am done with it.

My success in this endeavor has been only partial. Half a dozen glasses have been known to gather together on the kitchen counter before their number suffices to impress upon me my neglect of my resolution. (And, no, hiding a couple more in the sink itself does not excuse my behavior.) If there were a report card, the entry for this item would carry a “needs improvement” annotation.

The laundry

Surely it is unseemly and an indication of some residual barbarism to pick through the basket in the laundry room each morning to find the day's ensemble. Civilized people, it seems certain, have their garments on hangers in closets or folded in drawers. At least, I have certain vague recollections of this practice. Nevertheless, there is a measure of convenience in the fact that one's favorite pants and shirts tend to be near the top of the basket, the simple consequence of being most often worn and washed. While it's true that delving deeper may occasion the discovery of some lost-lost item deserving of being restored to the rotation, it's also a bit of a bother. The course of least resistance is lined with khaki trousers and blue button-down shirts. A scandal on multiple levels, I know.

Since I am aware of the situation, even as it persists, I have taken the bold step of designating a laundry-folding day in hopes that a salutary force of habit might develop. Franklin kept a little notebook in which he charted his successes and failures (“I was surpris'd to find myself so much fuller of faults than I had imagined”). I have a little whiteboard in the hall outside my bedroom. Every day it reminds me that Friday is folding day, and now that I think of it, I do believe the last time I emptied the laundry basket and folded clothes it was indeed a Friday. Back in May, perhaps.

Oh, look. It's Friday again. Hmm.

Tuesday, July 03, 2012

Not lost in space

The Infinite Tides

The traumatized astronaut is not a new theme in literature. In nonfiction, we have the example of Buzz Aldrin's Return to Earth, which deals with the alcoholism and depression of the second man on the moon, and Brian O'Leary's The Making of an Ex-Astronaut, which chronicles the less dramatic frustrations of a scientist-astronaut who never made it into space. Science-fiction author Barry N. Malzberg penned The Falling Astronauts, in which astronaut Richard Martin gets bundled up by his crewmates after his breakdown and hauled back to earth as a basket case. More famously, Arthur C. Clarke created some extremely stressed astronauts in 2001: A Space Odyssey.

So ... been there and done that. Besides, the Space Age is old news and these days no one interrupts regularly scheduled programming to report on rocket launches or spacecraft landings. Therefore it might seem just a little surprising that a new author should choose a distressed astronaut as the protagonist of his first novel. What was Christian Kiefer thinking when he wrote The Infinite Tides?

The author shared some of his thought process during the SummerWords conference, which he and his English department colleagues at the American River College organized last month. (Yours truly attended and was most likely the only mathematician in the crowd.) At a session on researching one's story, Kiefer mocked the “write what you know” straitjacket, preferring instead the “write what you can find out” approach. Thus he plunged into astronautics and mathematics, dredging up the information that would give his high-flying protagonist substance and credibility.

Kiefer also talked with the Sacramento Bee, explaining the genesis of his novel to reporter Allen Pierleoni:
Part of it was listening to the news and beginning to feel I might be the only man in America who still had a job. Then sitting at Starbucks (grading papers), watching other men at other tables looking through the want ads, then drifting to the sports pages, then to the funnies, then finally to the front page. Basically using the hunt for a job as a way to fill the endless hours of their otherwise vacant days.
It's pertinent to note that people who have academic jobs teaching math and English—subjects deemed indispensable at college—have a security that is rare in the modern world. We are a privileged few. Who else is so lucky?

Astronauts, perhaps. The men and women of the space program comprise an elite corps of over-achievers. They have reached a literal apex of accomplishment as they leave the earth on their missions. What would happen to an astronaut if he were to find himself grounded, his life and career in ruins? That was the question that Kiefer asked himself and he explores the answers in The Infinite Tides.

Astronaut Keith Corcoran is a genius at math and engineering. His goal is to go into space. Corcoran's entire life is devoted to achieving his goal, even to the point of estranging his wife and daughter. Corcoran notices and regrets the increasing distance between himself and his family, but can't see a way to resolve it without jeopardizing his career. He's actually rather irritated with his wife, who once seemed so supportive, but he plunges ahead regardless.

When it all comes apart in tragedy and illness, Corcoran finds himself alone. Stripped of flight status and living alone in an empty house in a half-built suburban development, he has nothing but time—and nothing to fill it. Having lived all his life with a keen sense of his mathematical trajectory through spacetime, Corcoran struggles to reassess the axioms of his existence. Vectors are mathematical entities possessing both length and direction, telling you both where and what. They beautifully model things like velocities, expressing both where you are going and how fast you're going to get there. For Corcoran, they were real and gave shape to the way he moved through life. Vectors were both tools he used in his engineering work and dynamic forces that drew him through reality.

Tragically, his sense of mathematized reality was one that he had in common with his daughter Quinn, but which also estranged them. While Corcoran lived within the coordinate grid of spacetime, his daughter was not embedded in the same way. While Quinn perceived the same personalities and characteristics of numbers that her father saw, she was nevertheless a different person. She had the gift of being able to live among the mortals, to be popular and social. Instead of jumping at the opportunity to enroll in an elite school to hone her extraordinary gifts, Quinn preferred to stay in a regular high school and join the cheerleading squad. Thus she became a disappointment to her father, who had already mapped out the inevitable trajectory of her life and could not come to terms with her deliberate violation of deterministic fate.

The Infinite Tides is an engrossing book. I read the entire thing over a single weekend, rarely putting it down. Keith Corcoran is a fascinating character, often maddening, whose sense of place and purpose is wobbling out of control. When he starts interacting with the neighbor woman whose daughter reminds him slightly of Quinn, you expect certain things to occur, and some of them do—but never in quite the way you were anticipating. The surprises keep you off balance and make you all the more sympathetic to Corcoran's disorientation. You begin to wonder how the author can possibly bring the book to a satisfactory resolution.

And yet he does. In fact, the final pages of The Infinite Tides bring Corcoran's story to a cusp, where many different things become possible. There is no pat happy ending, but rather a blossoming of choices. The man who lived in a mathematical framework that had become a deterministic cage begins to grasp the key that his daughter had found.

A divergent coda

Having traversed the trajectory of my review, I find myself left with notes and observations that did not fit into the flow. I offer them here as a collection of tangent vectors.

The Infinite Tides is a stunning accomplishment and I exhort people to read it and watch for future works by Christian Kiefer. The man has staying power. What's more, his capacity for assimilation of background research is prodigious. He admits to being relatively innocent of mathematical knowledge, yet he absorbed what he needed and magisterially portrayed the life of a brilliantly obsessive-compulsive mathematician.

I suspect that people who disdain math might occasionally recoil from Keith Corcoran, who tries even a mathematician's patience as he relentlessly invokes “equations” (one of the book's most frequently appearing words) and their solutions. Everything to him is a math problem, but that idée fixe is the protagonist's defining characteristic, the leitmotif of his life.

There is one bobble in the discussion of Hilbert's hotel, a warm scene where father and daughter are sharing a joyous discovery about the paradoxical nature of infinity. Suppose you have a hotel with infinitely many rooms: Room 1, Room 2, Room 3, and so on, going forever. Suppose the hotel has no vacancies, infinitely many guests being in residence. Suppose infinitely many new people show up, all wanting rooms. What is one to do? Quinn suggests a solution to her father:

“They ask every other guest to move down one room.... If n is a room with a guest the n moves to n plus one and then—”

Her father quickly understands. Unfortunately, Quinn should have said that n moves to 2n, not to n + 1. If the occupant of Room 1 moves to Room 2, and the occupant of Room 2 moves to Room 4, and the occupant of Room 3 moves to Room 6, etcetera, then all of the original guests end up in even-numbered rooms, leaving the infinitely many odd-numbered rooms vacant to accommodate the infinitely many new arrivals.

I doubt the matter will cause much distress among Kiefer's readers, but the mathematically inclined may wrinkle their brows.

My other reservation relates to astronomy. For an astronaut, Corcoran is remarkably ignorant of elementary astronomy when he converses with his Ukrainian neighbor. When Peter explains that he likes to look at Messier objects, Corcoran says, “I don't know what that means.” But Messier objects are an Astronomy 101 topic, a catalog of celestial objects that could be mistaken for comets when viewed through a telescope. The Andromeda galaxy is M31 in the Messier catalog. Even more unlikely is Corcoran's ignorance of the W-shaped constellation Cassiopeia. One expects astronauts to know such configurations for purposes of stellar navigation if the computers fritz out and the sextant has to be dragged out. (This was actually a consideration during the Apollo 13 mission and a factor in the crippled spacecraft's safe return to earth.)

Perhaps Corcoran was exempt from such lessons since he was an engineer-astronaut instead of a pilot-astronaut, but it struck me as unlikely.

I mentioned 2001 in the opening paragraphs of this article. It appears that Kiefer included a related joke to amuse close readers of his novel. At one point, a man named Campbell says to Corcoran, “I'm a busy man. I have the whole day scheduled to sit here on my bony ass and listen to Frank Poole bullshit about the good old days. Let's get out of here before that old windbag shows up.”

No wonder HAL 9000 killed Frank Poole when he went outside the Discovery to repair the AE-35 communications gyro.