Archive for July, 2009

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After our customary tea and chit-chat, and a leisurely dinner, we gathered in the sitting room, arraying ourselves on soothing leather sofas, colorful floor cushions, and straight-backed chairs. Several of us were fortified with mugs of tea, and one or two watched over a stray cookie or brownie. The rules of the group were simple—each member was to have a turn, and no one was to interrupt, or give advice, unless solicited. There was no time limit or prescribed order for the speakers. One commentary often sparked another, dragging a forgotten morsel up to consciousness and segueing from one person to the next.

Our topic for the coming month was selected at the end of every meeting. Recently we’d discussed ‘difficult patients’, ‘difficult doctors’ (only fair, we thought, to do both), problems with our office staff, and all the ways our professional lives were beggaring our personal ones. After this run of downers, we needed a more positive topic: it was fun, and absolutely therapeutic, to vent and share the misery, to hear each other bitch and moan about how awful that person or that thing was–but we wanted to reclaim the spirit that held us here, in the trenches, in spite of all the fear and loathing. We thought ‘mentors’ would remind us of the reasons why we stayed.

Mentor, as you may recall from high school, was a friend and advisor to Odysseus who became tutor to his son, Telemachus, while Odysseus was away fighting the Trojan War (and finding his extremely long and roundabout way home afterwards). Athena, the goddess of wisdom, appeared to the youth in Mentor’s guise throughout The Odyssey to give him helpful hints, and Telemachus grew under this tutelage from a callow child to a strong and capable adult. Mentor’s name is now synonymous with a wise and trusted counselor or teacher, as the dictionary tells it. Given the sheer number of years we’d spent in school and training, and the throng of classmates, professors, and colleagues each of us had accumulated, how hard could it be to come up with a couple of wise and trusted teachers—individuals who’d shared their experience with us, who’d helped to shape and encourage us, from any stage of our career?

The amazing thing, and to me the most disturbing, was just how hard it really was. We all struggled, some more and some less, to come up with people who’d been positive role models. This was true despite having been given the assignment a month ago, and pondering it in the interim–and lord knows this was no room full of slackers! Not only that: when many members spoke, there was a hesitancy about whether the individual they described had really been a mentor, or just someone they found congenial in some way. It felt as though we were reluctant to commit, to name the experience as mentoring, for fear of being wrong, which would leave us unmentored, orphaned, and totally self-made. Only one of us admitted that she’d never had a mentor—this from a physician years in practice, esteemed by patients and colleagues alike, who now mentored others. How tragic, I thought, that we are so adrift and isolated and unsure.

Perhaps most surprising to me was the near-complete absence of positive influences during medical school—the period in our long careers when we are most malleable, most enthusiastic, and most willing to learn. Several of us had been mentored by people prior to medical school, often a physician-parent or family physician who’d taken a particular interest in them at an early age, and several told of people they’d encountered during residency or once out in practice. There was the family practitioner who’d been encouraged to go into medicine by two family docs from his hometown he’d known since early childhood, and the woman who still views her father, now a colleague in family medicine, as a sounding board and source of wisdom. And the neurologist who’d finally—and happily–found a senior colleague to challenge him and test him, and model sincere and sweet compassion for his patients, unafraid to speak his mind and do what’s right. One member, an oncologist, spoke of a resident who’d inspired him to care for cancer patients and their families—a path filled with loss and heartache, but also love and empathy. An iconoclastic family doctor who cared for indigent patients recalled a bilingual mentor devoted to his Spanish-speaking patients, who worked punishing hours and was never unavailable, a role she herself had now assumed.

The common traits or behaviors of the mentors we described were not mysterious or magical—they were caring and not afraid to show it, they were ‘good’ with patients (a subjective quality, eluding definition but easily recognized, much like pornography), they were skilled clinically and technically, and they were patient with trainees. They made themselves available, encouraging and challenging the ‘mentee’ to grow and learn.

One woman, a gynecologist, commented that some of her mentors had in fact been nurses, not other physicians. A male group member expressed surprise, stating that in his experience nurses were cruel to female doctors. At first this did not resonate with me, but on reflection I realized I had seen this, many times. It was the female docs or med students who were the prettiest, and the ones who threw their weight around (like so many male doctors did—and do), brusquely ordering the nurses about, who received the worst treatment. I recalled one RN commenting to me, after being treated dismissively by a female resident, that it was bad enough she had to put up with that from the men, but that ‘women should know better’—the betrayal was heavily tinged with disappointment. Some nurses may also feel that female doctors were, by choosing medicine instead of nursing, denigrating their own choice and somehow labeling them as ‘less than’. As for ill-treatment of the most attractive female students and physicians, well, many of the younger nurses were single and may have viewed them as competition.

The saddest realization of the evening was that so many ‘anti-mentors’ sprang readily to mind for each group member. These were the evil ones, the residents who pilloried us for not knowing some obscure and useless fact or lab result, the attendings who yelled at us in the ERs and the ORs and the patients’ rooms, the professors who preferred to hole up in their research labs and couldn’t be bothered to teach effectively, the rogue colleague who engaged in passive or active sabotage to advance his or her own interests. Nearly everyone felt a pressure to discuss these anti-mentors, to paint the harsh and angry pictures that were so much more vivid than the soft pastels and muted oils of the mentors we’d gathered to honor and remember.

How sad for medicine that we do this to each other, that we torture and exploit and demean, that we have not moved beyond hazing and initiation to a nurturing, cooperative, and beneficial system. How sad that we recall so much more easily the horrors we have suffered than the moments of connection, joy, or discovery. And how sad that we must struggle with these wounds as we seek to heal our patients, to nurture them, and ease their sufferings.


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Every CT I read today is bad, bad news: livers pocked with mets the size of melon balls, or limes, or grapefruit; errant lymph nodes bulging from a neck, a groin, an armpit; masses mired deep in a frontal lobe, squeezing the hapless cells around them into mute submission. So many ways to call down death, artillery falling on the night-time tents of unsuspecting infantry—this is friendly fire, the body turning on itself and running rampant.

You’re going along with your life, things are more or less OK, then one day you notice it: a finger twitches when it is not called to do so, or you have a pain in your side on taking a deep breath, or any of a thousand other little signs. So you get a test, sure that it is nothing, that your doctor will be reassuring and set you back on your path toward whatever future you’ve been planning. But today is not a good day for that CT, because today it’s raining cancer, with loud thunderclaps and blue, crazed lightning cracking all around. Boom! There go your plans, your life, your dreams.

I can’t help thinking this when I see an unsuspected finding that is not good news, that I know will wreak havoc on the patient and disrupt an entire way of being. The next thought that comes is, admittedly, a selfish one—thank god, I say silently, that I don’t have to be the one to tell him this, to deliver this unwelcome and unlooked-for news. In medical school and internship, I was often the one—and it did not get any easier with time, or practice. This, I think, is right: it should never be easy. It should be wrenching, torturous, and thought-provoking, every single time.

Perhaps, as a radiologist, I should distance myself more, restrain my imagination, and just not think about the implications of the images parading through my reading room. That would be safer, easier, and no doubt more efficient—no time wasted feeling sadness, fear, or dread for all those folks I’ll never even meet—but I believe it would also be wrong. So I’ll keep standing in the dark, devastating rain, umbrella furled at my side, dodging the wild lightning.

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AIDS, part 4

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OK, you’re probably wondering what happened to parts 1, 2, and 3. I’ll get to those. But this one, another Parkland story, is the most powerful.

He looks like a giant yellow toothpick, randomly adorned with crusts of blood to mark the places where they’d tried to get samples for the lab, or to start IVs when another one gave out. His bones stick out like signposts under his frail skin, announcing his condition with more clarity than any other indicator. They remind me of the photographs we’ve all seen, the liberation of the concentration camps, or perhaps Biafra, Ethiopia, Somalia. No matter where or why it happens, the devastation wreaked on human flesh by starvation and disease is unforgettable. In Africa they call this “slim disease”, because it takes its victims’ substance long before it takes their spirit, leaving wan, bony shadows where there should be youth and vigor.

He is this eerie hue because his liver has grown tired of fighting back: under siege from chronic hepatitis, it is in the final stages of defeat and can no longer rid his body of the byproducts and toxins that are part and parcel of our daily lives. He got the hepatitis, like the AIDS, from transfusions many years forgotten but vital, at the time, to save him from the hemophilia and the bleeding. Now he has turned 22, his body wasted to a reedy 75 pounds, and he is dying. It’s hard to say from what, exactly, because so many things are fighting over him: the AIDS, the hepatitis, hemophilia, tuberculosis, and who knows what others not yet manifest.

I think he knows this, but I’m not so sure his mother does. As he floats in and out, she becomes the one to make decisions, and so far she has not permitted one whisper of retreat from our aggressive path: do everything, try everything, hope everything. It’s understandable, and I cannot say I would not do the same in her place, but still I look at G and wonder: is this really what he wants? Is this how he imagined it would be? Would he say yes, fight on, give me every drug, every test, every transfusion that will let me hang on for another precious day — or would he say enough, give me a little peace now, I have had enough? He cannot tell us, for his mind drifts lightly on each passing breeze, ever farther from this room, this death. I cannot guess, because I have just met him, and I never knew the life he used to have, before all this was visited on him.

I am here because his veins have failed again: used too many times for transfusions or for drugs that turn them into hard, impenetrable cords, they can no longer be his lifeline. I am here because his doctor has asked me to put in a special type of IV line, a thin tube that I will thread through a small vein along the underside of one arm all the way into his chest, where it will spill its contents harmlessly into his heart. The tube is put in through a tiny cut in the skin, no bigger than the nick you might get from a razor wielded in the careless light of early morning. As the catheter moves up his emaciated arm, I track its progress on a video display that uses x-rays to highlight it against the bones. I have already determined how long it should be, and trimmed it to the proper length. Maneuvering it to the right spot is easy now, and it is done before he even stirs to ask me if I’ve started yet. “Yes”, I tell him as I sew the catheter in place and clean the antiseptic from his arm, “it’s all done now”.

Back upstairs in his room, I tell his mother everything went fine, and in fact it did. The tube is in position, prepared to serve whatever goal his doctor has in mind. I do not tell her what I really want to say, or ask her what I really want to ask. Is it time, I wonder, to let him go? Will you be ready, when you have to do it? From this distance it is easy to say that we should stop and let him die — or to say I would not want this unrelenting onslaught were I the one slipping from reality a little more each day. But in fact I do not know what I would do if I were in that bed, or how badly I might crave just one more afternoon or evening. So instead I help the nurses get him off the stretcher, and focus on completing my notes in the chart. This done, I glance over at his mother and see that she is questioning, unsettled. Perhaps the awful litany of potential complications I’d reviewed with her beforehand was still running through her head. Perhaps she waits for me to tell her he will be all right, now, that he isn’t dying after all. Perhaps she wishes, as do I, that I could restore her sweet son to his young life, which ought to be so full of future.

“He did great”, I say to her, setting his chart down on a nearby chair and meeting her gaze. “He sailed through it like a champ, no problems whatsoever. The catheter is good to go, whenever Dr. S wants to use it”. She offers no acknowledgment, and as my heartbeats pass uncounted, I begin to wonder if she heard me. At last she smiles, a silent heaviness escaping her like morning fog from the cool earth, and murmurs “thank you, doctor. Thank you very much”.

It’s only seven words, and it isn’t very loud, but it conveys her understanding of what’s happened here today, and what will keep happening until this illness claims him. I don’t have to accept it, her eyes tell me, but I know this is our new reality.

‘You’re very welcome,’ I reply, hoping my words too convey a deeper message: I wish I could do so much more.

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A slightly lighter tale, from my years as an attending physician at Parkland Hospital in Dallas while I was on the faculty at UTSW’s medical school.

It had been three years, he said. Three years since he’d last taken clippers to his toenails, because they’d grown too thick and stubborn, and he didn’t have a cutter that could handle them. So here he was, now, in the Parkland ER, to have us do it — with the cast saw! This notion is not really so outlandish: the cast cutter is a power saw that only cuts when faced with firm resistance, stopping when it finds the going suddenly too easy. I suppose this safety feature, perfect for cutting plaster casts away from soft-fleshed legs or arms, just might work on toenails, but the ER docs were less than eager to experiment.

His feet didn’t look too bad, for 80, though he said they pained him, so x-rays were ordered. On the films, his bones were white and fine, the joints free of encroaching spurs, the soft tissues plump and well-apportioned. All things were in order, that is, except those toenails. Like the vacant dwelling of a long-dead nautilus, each one flowed out from the margins of his flesh in a graceful spiral, curling back on itself, then out again, in ever tighter arcs. Against the shadowy soft tissues, the nails seemed to spring directly from the underlying bone. I was quite impressed to see how well they showed up on the image: nails contain no calcium, being made up as they are of only protein and dead cells, but because they were surrounded on all sides by air, which poses no impediment to passage of the x-ray beam, they stood out clear as day.

Our nails evolved from the claws of lower mammals, birds, and reptiles into thin, flat plates that have little use in self-defense or killing prey but do serve several other purposes. They are useful for protection of the digits, and for scratching that annoying itch. More importantly, they enhance dexterity and the sensation in our fingertips, allowing us to carry out fine movements and manipulate small objects. They may serve a cosmetic role as well, or communicate one’s social standing. In Imperial China, long nails were a signal of distinction, and wealthy noblemen allowed their fingernails to grow unchecked to showcase their freedom from all drudgery. Nowadays most people trim their nails to keep them functional, though I have seen women — and the occasional man — with fingernails of epic length, or sometimes just one nail allowed to blossom out in strange excess. I am always amazed at this, because I wonder how such people dress themselves, how they hold a pencil or fork, how they wash their face or use a typewriter. But perhaps they do not have to do these things, I think, or they have found a way to get around their self-imposed imprisonment that escapes my own imagination.

Though not what I would call a window to the soul, nails can reveal much about the one who bears them, including clues about the personality. There are nail biters, who trim and chew relentlessly, gnawing at their cuticles until they bleed, and there are those who let their nails grow to monstrous lacquered talons, or have synthetic ones affixed if their own should prove deficient. There are clean, straightforward nails, neither pampered nor ignored, and there are nails that tend to either one of those extremes. There are broken nails, or nails that have been ripped from their tender beds, that signify a certain type of trauma, and perhaps a certain type of life.

The nails also tell a set of tales about a person’s occupation, intake of drugs or toxic chemicals, or nutritional state. The nails of butchers may turn white, while those of vineyard workers become yellowish and those of woodworkers who handle ebony turn brown. Poisoning with arsenic can yield brown bands that run the length of the nail, or white ones that run horizontally. Carbon monoxide turns the nails a cherry red, while mercury transmutes them to a greenish black. Paraquat can lead to softening of the nail, or cause it to fall off entirely; crack cocaine can give a bluish tint to the nail bed as it constricts the flow of blood and oxygen. Overdose of vitamin A produces brittle nails, while gelatin accelerates their growth. Vitamin B12 deficiency turns them bluish-black, and more general malnutrition can make them concave in the center, slow-growing, and susceptible to fissures, or thin and soft.

There is a host of illnesses that leave their mark upon the nails of the sufferer, from superficial skin conditions to hormonal imbalances, cardiac disease, or gastrointestinal disorders. There are diseases that give rise to ridges, pits, or white or colored lines in the nails, and some that turn them clubbed or spoon-shaped. Still others lead to color changes, and lines of hemorrhage beneath the nail plate, or thickening. There are congenital syndromes that produce abnormal nails as well, usually one of many outward signs. In one rare inherited condition the nails may be completely absent, leaving the digits oddly unadorned and soft, as I imagine the new toes of the little mermaid must have been when she first stepped onto land.

Whole textbooks have been written on the nails (there are 26 listed in the online catalog at the local medical library), because the skin and its appendages often yield the only signs that something grave may be amiss. Astute physicians, if they are well-versed in the reading of the nails, can seem as awesome and all-knowing as Hercule Poirot or Sherlock Holmes. Grasping the hand lightly on first meeting, they introduce themselves and then proceed to lay out all the patient’s secrets. You are a coffee roaster, one might say to a man whose nails are brown, or perhaps a gunsmith or photographer. You have been traveling in malarial domains, to a woman whose blue-black nails fluoresce under ultraviolet light from taking prophylactic quinacrine. You have been eating far too many carrots, or taking too much beta-carotene, to someone whose nails are colored yellow-orange. Or, to one whose lunula, the “little moon” that rises at the pink horizon of the nail, has turned a bluish cast: you have Wilson’s disease, an inborn error of copper metabolism. Leukemia, heart failure, cirrhosis, certain malignant tumors, and syphilis are but a few of the many other visitors that can announce their presence through the nails. Sometimes, as with the old man who showed up in the ER this morning, there is nothing more nefarious at work than mere neglect.

The ER docs and I looked at the old man’s films and shook our heads in wonder: how can anybody walk with nails like that? How could he wear shoes? No wonder his feet hurt, I thought — mine would too, if I had such toenails! Unfortunately, the cast cutter never was designed to handle such a task, so he was sent away unsatisfied, clutching an appointment slip for his date with the foot clinic in two weeks. I expect they’ll hardly bat an eye when he arrives: they know from toenails, I am sure.

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Here’s a story from my radiology residency days that’s still completely relevant: more than a bit discouraging to see how little medical culture has changed since then.

One Saturday in the ER, a friend of mine came into the reading room and put a chest x-ray on my viewbox. Another routine consultation, as far as I could tell.

“Do you see any rib fractures?”
“No, looks pretty much OK. Nothing broken.”

Instead of taking the films down, he left them up and sat in the chair beside me, one arm perched atop its back. “Let me ask you something,” he said. Oh no, I thought, what is this?! His face was very serious, a rare departure from its easy-going norm. “Sure,” I said with growing trepidation. “What is it?”

“How do you count ribs?”

I wasn’t sure I’d heard him right: counting ribs was so basic any first-year radiology resident could do it in her sleep. Surely my friend, a sixth-year surgeon, knew how to do this. He knew what I was thinking, though I didn’t say a word. “I never learned to do it right, and I always have trouble telling which is the first one—they’re all bunched together up there at the top—so I just count up from the bottom, which I know isn’t as accurate. But who could I ask? I’m supposed to know this by now.”

He had a point: medical training is anchored in the assumption that the next guy up the ladder knows what you do not, and that he will teach you. For the senior to admit unfamiliarity with something basic, no matter how irrelevant or small, and ask the junior to explain, would shake the founding trust of this relationship. By the same token, my friend could never confess ignorance to his chief resident, the man one year ahead of him, because that would label him as marginal. Clearly not a viable option for a bright, ambitious surgical resident. And where was he to find the time to read about it?

We tend to trap ourselves in quandaries like this throughout our training when we fail—for whatever reason—to master something at the time it’s first presented. We let it go because we’re busy, or because it doesn’t seem critical, or because we’re afraid to ask a ‘stupid’ question. “I’ll sit down and read about that later,” we tell ourselves, and of course we never do: later brings something else to read, do, learn, all just as pressing. For each of us the sticking point is different: for my surgeon friend it was rib counting, for me it was reading ECG’s, for another friend it was neuroanatomy. The problem doesn’t end once a doctor begins practice—if anything, it’s even harder then. You’re done with training, after all, so shouldn’t you know everything? And of course you want your patients to have confidence in you.

There’s a point beyond which it’s not acceptable to admit ignorance, so we often act as if we know. Any physician who is honest and self-knowing will recognize the hand-shaped bricks that form this wall of assumption and appearance. Dismantling the wall is difficult, reinforced and defended as it becomes over time, but it can be done.

The first step, and probably the hardest for many doctors, is being able to say, simply and honestly, “I don’t know.” This goes against the dense, exacting grain of medical culture, and is threatening to our concept of mastery. At the same time, though, it’s oddly liberating to acknowledge that you aren’t perfect, and don’t need to be. It’s a lesson I relearn often in radiology, a field so vast that no one person can possibly retain it all. Knowing you’ve got a resource, whether friend, mentor, textbook, or search engine, is the key that unlocks the shackle. I was honored that my friend had trusted me to be his resource, and impressed that he’d had the guts to ask.

I raised my left hand to the film and traced along the patient’s spine with my index finger. “You don’t want to count up from the bottom, because not everybody has twelve ribs, and that can really screw you up. So you need to start at the top, and the best way to find the first rib is…”

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I’ve been groping for the right metaphor to describe my feelings on the current debate over health care reform. As a physician, and a specialist rather than a primary care ‘provider’, I’m watching with great interest and no small degree of inner conflict.

The first image that came to mind is a ringside seat at a cage fight, watching the contenders beat each other senseless and possibly getting splashed with sweat, blood, or the occasional liberated tooth. But that isn’t right: spectators at a fight don’t really have a stake in it, unless they’ve placed a bet, and they’re free to leave if the gore exceeds their comfort level.

Next thing that occurred to me was the movie “Speed”, where a lunatic places a bomb on a city bus that will detonate unless the bus maintains a scary, breakneck speed that is itself unsafe. Passengers on the bus have a stake in the outcome, for sure, and have to work to defeat the evil mastermind. But who is the bad actor in the health care debate? There isn’t just one, and I don’t really believe any of them are evil—just self-interested, like all of us, and short-sighted, like all of us at times.

Then I thought about air shows, those extravaganzas where the Blue Angels or similar groups of daredevils streak around the sky in perilously close formation and do assorted jaw-dropping tricks…..but every now and then, one of them crashes, and sometimes a spectator gets boxed in the process. The risk is low, but it could be any spectator, not necessarily those in the front row, that gets taken out. NASCAR races are in this same category, though the chances of a serious mishap seem to be greater than at air shows.

The ancient Mayan ‘game’, where players struggle to pass a ball through small hoops high on the walls of an elongated court, presented itself as well. The game symbolized epic battles that took place in the underworld, and the stakes were high: depending on which source you read, the captain of either the winning or the losing team was decapitated in a ritual sacrifice. Fascinating, but too murky—and this fight has way more than two teams on the court.

This brings home the real question—and the conflict. What does ‘winning’ this debate mean—for the country? For me, this year? For me, ten years, or 20 years, from now? These spheres intersect but do not overlap completely: my future as Venn diagram writ large.

Clearly the country needs health care reform, and it needs it now. I know this, and I feel it as a health care consumer. The best thing for the country is for major reform to pass this year. This largely coincides with my self-interest long-term, which would be best served by a single-payor system or some other setup wherein individuals could easily purchase affordable coverage that’s not tied to employment. My shorter-term interest is for nothing to change, because I’m looking for just 2, maybe 3, more years in which to maximize my savings—and realize my dream of breaking free from this profession before it saps my soul completely. For that to happen, my income needs to stay near current levels—which will almost certainly not be true under any major system overhaul.

It’s hard not to feel I’ve earned this chance, after giving nearly 30 years to medicine—yet I know I am more fortunate than most, and will remain so whatever happens with reform. I voted for Obama, not against McCain (OK, definitely against Palin), for this above all other reasons: we need to treat each other more humanely. That means a stronger safety net, of which meaningful health care reform, whatever the cost to me personally, is no small part.

In the end, perhaps the running of the bulls at Pamplona fits the bill most closely: el encierro has me in its grasp, running for my life before a force I cannot hope to control. I hardly dare look over my shoulder, as hoofbeats and snorted breath sing ever louder. Just keep scrambling forward, that’s all there is as the bulls—bearing me no personal malice—act out their nature. I am swept along, admiring their strength and feral beauty–and hoping desperately they won’t trample me. Or am I one of the hapless bulls, caroming off the barricades in terror, not sure exactly how but knowing that my world will soon come to a grisly end? Ya veremos.

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The price of eggs

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One of my colleagues, call him X, is trying my patience. He’s smart, observant, and possessed of newfound eagerness to be green. The last is not unexpected for a new arrival to Santa Cruz, a city where folks strive mightily to out-green each other, but it’s such a contrast to his mindset in a prior life that sometimes it takes me aback. I can handle that, though.

What bugs me is the bright line he seems to have drawn in the green sand: for X, it all comes down to cost. He’s willing to do the right thing, and tell everyone he’s doing it, as long as it doesn’t cost him extra….or not too much extra, anyway. But make a bit more of a demand on his wallet, and the shutters come crashing down.

The example that comes most readily to mind is eggs. I buy eggs from a local farmer, whose hens are never caged and seem pretty darn happy with their chicken lives. Not only do they taste better, recent studies have proven eggs from pastured hens have a better nutritional profile than those from caged hens, typical of factory egg farms. They have: 1/3 less cholesterol, ¼ less saturated fat, 2 times more omega-3 fatty acids, 3 times more vitamin E, 4-6 times as much vitamin D, and 7 times more beta carotene—all fantastic. And there’s no guilt involved: cruelty-free, as I’ve seen for myself. Since he’s worried about heart disease, you’d think the nutrition stuff would hit home—but you’d be wrong.

The catch, of course, is price. These eggs cost $5.00 a dozen (another local farmer charges $6.00 per dozen for eggs from similarly indulged hens)—and X’s response is simply, flatly, that he can get a dozen eggs at Costco for under $2.00. End of discussion—what more could there be to consider? Costco.

This infuriates me because he is intelligent enough to grasp the concept of downstream or ‘external’ costs—things that go into production of a commodity and aren’t included in its price but have to be paid for somehow, by someone. In the case of eggs, that’s everything from pollution and marine dead zones caused by waste from factory farms to antibiotic resistance resulting from profligate dosing of confined animals with powerful drugs also used to treat human disease. The degree of animal suffering is nontrivial as well. Finally, he understands the need to support small local farms if we want to have fresh, quality food going forward. These things, however, do not move him. He acknowledges their validity, but just doesn’t seem to care.

If he had limited means, I wouldn’t blame him for focusing so much on price. But he makes a more than decent living, better than the vast majority of Americans, and can absolutely afford $5 for a dozen eggs. I worry that if X, a highly educated, intelligent, well-meaning person in the top tier of earners in the US, isn’t willing to spend an extra 30 cents per egg, we are all doomed.

What will it take to get us to realize we’re being penny wise and pound foolish? Why do Americans have such a perverse relationship with food, preferring quantity over quality at every turn? Is there any hope for a return to sanity, to appreciation of food and what goes into its creation, to a bone-deep belief that in truth ‘you are what you eat’? I wonder. In the meantime I’ll keep pounding away at X, like water against sandstone, hoping that persistence will eventually be rewarded.

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