Every year about this time I send out an unofficial end of year investor's letter -- "unofficial" because 1) it does not get sent to my investors and 2) it usually has little to do with investing.
I’ll get to the funds’ performance in a bit. First, let’s pick up where we left off last year.
You’ll recall that Priya, Nikhil and I survived Tarana’s trip to the bridal gown store in the mall in Dartmouth, Massachusetts to buy a prom dress. More about that later.
Years ago a friend sent me a copy of a book with a “read this chapter” note. The important part was a story about an old man who liked to dance. If I remember right he used to go to a community center or some place like that and, no matter what kind of music was playing, he would go out on the dance floor and close his eyes and spin around and do whatever the music made him feel like doing. The way the old guy danced was nothing like the move-as-little-as-possible, keep your hands at your sides and, heaven forbid, don’t let anyone think you are enjoying yourself style that I had perfected years ago. His way was better.
I read the story, put the book on the shelf and figured I’d come back to it another time.
My father gave me a piece of advice: sometimes it’s best not to let everyone know what you’re thinking. I took that advice to heart. Maybe I learned it too well. I missed the part where if sometimes its best to keep things to yourself, then ― at other times― letting the world in is okay, and sometimes it’s a lot better than ok. Nikhil always understood that. A good example: we stopped at a town square during a festival in the Netherlands on our way to Kröller-Müller and Van Gogh a few years back. Nik and I wandered to the bandstand as the music started. His dancing involves a lot of jumping and pretty soon he had a bunch of bikers in leather jackets over black t-shirts, with long beards and dark sunglasses, leaping up and down with him to the beat of what was actually a pretty good band playing old Motown. A few songs, lots of spilled beer (theirs, not his) and many high fives and fist bumps with his new Dutch friends later, we were off. He was about fifteen the time.
I still have my friend’s book, which I have read through many times, and it’s easy to bring back the image of the old guy out on the dance floor. I thought about him again a few weeks after the David’s Bridal Shop episode.
The after-prom party for the Chapin class of 2018 was held in someone’s parents’ second or third house’s huge backyard, somewhere up in horse country. I think the story included shuttle buses and an enormous sloping lawn and a big tent and paper lanterns. Not burdened with the awkwardness of boyfriends and girlfriends and the before the after prom issues of is this a date date or a prom only thing (I am making this part up and it may have no relation to reality), the girls were free to be happy and to be loud.
Only not too loud. There was a neighbor and a phone call and maybe a police car, and the sound system, probably louder than Woodstock, had to be turned off. But the story ends well: a Bluetooth system switched on, dozens of headphones handed out, and the class of ‘18 and their guests spread out over the lawn dancing with abandon, neon glow sticks around their wrists and in their hair. To those of us watching from afar, a silent dance party on a starry starry night, a marvelous night for a moondance.
Oh yeah, before I forget, both funds did just fine this year.
Jumping the gun to wish you a great end of 2019 and happy, prosperous, and a choreographed with abandon 2020.
The American Society for Reproductive Medicine kindly invited me to give a keynote address on The Business of IVF. A video of the talk can be found here:
A few words about sixty. But first, a story.
During internship, if I was fortunate enough to have slept during a Friday or Saturday night on call, I'd bike across the park the next day, to 65th and Broadway. There was a theater on the east side of the street that ran Eric Rohmer and Stephen Frears films. Shakespeare and Company was a few blocks north and Lincoln Center was a few blocks south, and right across the street was an enormous Tower Records where you could lose yourself for hours, in rock or Broadway, pop or jazz or classical, each type of music in a separate area, arranged with glass walls and sliding doors and on different floors, so that one type of music never drowned out another. Bernstein's quartet from West Side Story here and Talking Heads there. Classical downstairs, the cello solo from Brahm's third piano quartet, the CD box on the counter underneath a cardboard sign with "now playing" written in black magic marker. On a Saturday afternoon I could discover REM or hear Chopin for the first time, or rediscover Billy Cobham or Larry Coryell until fatigue sent me to the cashier and back out onto Broadway where I unlocked my bike, reattached the front wheel, and pedaled back back to York Avenue, where I carried the bike on my right shoulder into the elevator, a bright yellow plastic Tower Records bag swinging from my left hand.
There was one problem. 1980's compact discs sounded terrible, their highs clipped indiscriminantly, the sizzle of the cymbals traded away in exchange for the disappearnce of a little background hiss that we had already trained ourselves not to hear. They were also too small and too shiny, so we hid them on little mechanical drawers that disappeared into the front of the CD players. And they only had one side, with no break in the middle.
We made a bad trade when we switched away from record albums, which we rightly encased in artwork, handled with an almost religious gentleness, touched only on the edges and not on the grooves, cleaned with velvet Dustbusters and D3 fluid. Watching the record spin was as much a part of the experience as hearing the music, the tone arm balanced, barely touching the vinyl, the signal whispered from needle tip to cartridge to preamp to amp to speakers, every tone, music or pop or scratch, reproduced without judgement, somehow landing in the room as if the musicians themselves had knocked on the door and politely asked if they could come in, set up and use your apartment to practice.
And all the albums had a beginning (side one), a middle (turn the album over) and an end (side two), and the middle, the moments when you lifted the tone arm, flipped the record, dusted it off and lowered the needle to play side two were the filled with the best, purest, most sublime sense of anticipation. The best of those feelings came the first time you played a new album, something you only got to experience once per record, once in your life. You heard Baba O'Riley for the very first time. You turned over the record not knowing that Won't Get Fooled Again is on the other side. You listened in wonder as you first hear Kitty's Back-- having no idea that Incident On 57th Street and Rosalita were just a few minutes in the future. You flip over Sergeant Pepper. Could you possibly have imagined A Day In The Life?
All you had to do was turn over the record.
You can get to sixty from anywhere. It's divisible by 1, 2, 3, 4, 5, 6, 10, 12, 15, 20 and 30. Multiply just about any two or three small numbers and eventually you'll land on sixty. But like forty and fifty before it, sixty is not a destination. While you're there, its just the middle, coming after what came before and coming before what will come after, which may still be new and different and great. There are even more directions away from sixty as there were paths to it.
Time to turn over the record and hear what's on side two.
1) Espresso is single task.
2) Espresso should only be poured into a glass.
3) Espresso is never ordered to go.
4) In the Nicomachean Ethics, when Aristotle discusses magnificence on a small scale, he means good espresso.
5) Second espresso, clean cup.
6) Espresso is best consumed in a coffee shop that does not have a kitchen.
7) You can make good espresso or good tea, but not both.
8) Do not look at your phone while drinking espresso.
Every year about this time I send out my unofficial investor's letter -- "unofficial" because 1) it does not get sent to my investors and 2) it usually has nothing to do with investing.
I’ll get to the fund performance in a bit. First, a story.
We spent a long weekend in Newport back in May, and a heavy downpour that Saturday led us to the Dartmouth Mall in New Bedford, Massachusetts. More specifically, and improbably, it led us to David’s Bridal Shop.
Tarana’s school has a formal graduation ceremony, with hymns and speeches and limited seats for parents, grandparents and nannies (you need tickets to get in), and a commencement address, and each girl wears a long white dress. By tradition each dress is unique (there was a scandal involving a duplicate dress this year but I am not allowed to talk about it) and as March became April and April turned to May, finding the right dress rose higher and higher on the to-do lists for the members of the Chapin class of 2018.
Priya and Tarana were on top of this, but Nikhil and I were blissfully (and appropriately) unaware. The occasional white dress reference over dinner was easily lost in other transition talk as our family planned for both kids to move out of the apartment later in the summer, Nik into his own place and Tarana off to college.
For me, with the kids leaving, this was a year of vigilance for signs of overwrought sentimentality, which, whatever “overwrought sentimentality” means, sounds like a good thing to avoid. I kept an eye on myself for new obsessions and the emergence of odd hobbies. Indeed, I developed a passion for swapping out hard drives and upgrading RAM in old computers, but otherwise showed few signs of decompensating.
I dropped Priya and Tarana at the store and drive off to the far reaches of the many-acre parking lot, hoping that it would take so long to park that by the time Nik and I walked with our umbrellas back to the store, the dress would have been chosen, bagged, and paid for and the two guys in sandals, shorts, and hooded sweatshirts with Montauk printed on the front (Nik’s in green, mine in blue) would not have to see their daughter and kid sister prematurely wearing a wedding dress.
It was not to be.
David’s bridal is the Library of Congress of wedding dresses, rows and rows and rows. There were lots of fitting stations, each with a three-fold mirror and platform, and each with a little bleachers section so that the bride-to-be’s entourage could watch and weigh in. The women (all women, at each station, no best guy friends like in the movies) were split into two groups. One group, usually the mother and one best friend, gave their opinions right away, before the bride. The rest waited until the core group made up their minds, then cheerfully reinforced whatever was already decided. Dress after dress was unwrapped, modeled and rejected, until “the one” emerged, eliciting a roar from the bleachers, hugs and tears and the ringing of a loud bell (Nikhil and I laughed when we heard the bell the first time, drawing angry looks.)
But all of this activity faded when we reached the back corner and found Priya and Tarana and a saleswoman in cat glasses. I felt a sense of relief, because it looked like Tarana was playing dress-up, pulling costumes out of a fake cardboard storage chest in a friend’s attic. Nikhil and I looked at each and exhaled. The foundations of our existence remained intact, unthreatened by images of a future we were not yet prepared to see.
Then all of a sudden “the one” emerged, and we were no longer in someone’s parent’s attic. The women in next fitting station turned their heads towards Tarana and nodded and smiled and raised their eyebrows, the saleswoman put the right earpiece of her glasses to her lips, and Priya took a picture, then another one.
For Nikhil and me, the image we had feared was indeed remarkable, but it revealed the present, not the future. It was a graduation dress after all, found in an unusual place, but for worn for the right reasons at the right time. There were hugs but no tears.
And no one rang a bell. Nik and I made sure of that.
Regarding the fund: it was indeed a year of living (a little) dangerously. That said, the fund has done just fine.
My dear friends and colleagues – wishing you happy holidays and the best for 2019
(Below: Tarana is far right, second from the top; below that — Nikhil and I having survived David’s Bridal)
Eat Drink Son Daughter: A Saturday Morning In The Kitchen
It’s a recent September Saturday morning and I’m by myself in the kitchen thinking about a 1990’s movie from Taiwan. The sun is up, a window is open. The sailboats from the 79th Street boat basin are moored well past 100th Street, and the West Side Highway is weekend morning quiet.
I’m making an omelette, eggs scrambled into a mixing bowl, the other ingredients chopped or sliced in their own little plates waiting to be poured into hot oil one after the other, the order and timing based on size, protein and fat content (how quickly they cook), trying to coordinate each being done just right so the ingredients in the omelette will arrive at done-ness all at the same time.
Kitchens are the best chemistry labs. All of the ingredients are in the pan now, melding together. Fatty acids separate from glycerol from contact with the hot oil. Proteins unfold and unwind in what used to be the nuclei of the eggs. I lower the heat, run the edge of a spatula around the perimeter of the pan to keep the omelette from sticking, turn on the ventilation fan, open another window and hit the button on the Nespresso machine, pretending I’m making espresso with a burr grinder and the real Gaggia machine that I struggled with for years before sticking it in a high shelf in the pantry. I flip one half of the omelette onto the other, trying but not quite succeeding to make the edges match so that the top melds to the bottom, making it into one.
In the movie, a father prepares dinner for his three adult daughters. It’s a Sunday, he does this every week. While he collects vegetables from his garden, strips leaves from various plants and grinds them into spices and arranges a drum set’s worth of kettles and pans and pots over the stove over a huge stove, we learn about each of his daughters, and the challenges they face. Gradually each makes her way home. They eat together, plates of food and words and smiles and raised eyebrows crossing the table rapidly, managing never to collide.
I’ve seen the movie a couple of times. It’s more of a still photo than a film for me, the four characters pausing life for a couple of hours and recharging their energies together. It’s a beautiful image, and one that means much more to me now than in 1994, three years before Nikhil and six years before Tarana.
It’s a good omelette. I clean up and head out, feeling content in that sunny and breezy September morning way. Nikhil and Tarana are both settled in their new homes, working and studying and moving forward. I’m thinking about cooking and kitchens and making sure that they keep coming back.
A Violent Encounter With Transparency And Other Adventures In Biotech Fund Management: My Unofficial Investor Letter 2017
Reliable Deli is on the north side of East 54th Street, midway between Park and Madison. It has a rust-colored awning with white lettering, with a string of Christmas lights strung around its edges that blink on and off year-round. I've gone there four or five times a week to take out breakfast or lunch for the past 8 years. It's a bustling place, one of those places where you can get hot food, cold food, toothpaste, batteries, boxes of cereal, sandwiches, wraps, spicy Korean chicken, fake crab meat, and real duck. Deep metal pans under heat lamps. Sneeze shields over the buffets.
You get the idea.
Reliable has two tall glass doors that can swing in or out, like saloon doors, only much thicker and much heavier. One day this summer I must have had difficulty deciding which way I wanted to open the door so I just walked into it as if it wasn’t there. Right knee and forehead met the thick, thankfully shatterproof glass while I accelerated from a standing start. I bounced off the door, shook my head back and forth like a puppy hearing itself bark for the first time, while soaking up the collective concern and secondary embarrassment of everyone inside.
The staff sprung into action. A small stack of clean napkins was quickly applied to my forehead. A first aid kit appeared, its contents probably long expired. A heavily accented New York voice repeated over and over: “Get him to an emergency room. He needs an MRI. I'm a nurse. I know”
I had no intention of going anywhere except back to my office across the street. I felt okay. I am not a stranger to concussions, having suffered one while ice skating with my son years ago, and I somehow knew that the door had enough give to have not made my brain rattle around inside my head. The skin on my forehead, however, was not so fortunate. Just to left to the midline on the mild frontal bossing over my eyebrow there was a terrific gash, the result of the impact followed by a little bit of a smush and tear. I folded the stack of napkins to hide the soaked-through part, applied pressure again and this time successfully exited Reliable Deli.
I was quite a sight in the elevator, going back to the office, holding a white plastic bag containing the styrofoam container with my lunch in one hand and the other hand pressing the folded stack of bright napkins against my forehead. Thirty minutes later I sat in the exam room of a nearby urgent care center. A half hour after that I am back on the sidewalk, having replaced the paper dinner napkins with a folded stack of sterile gauze pressed against my forehead, dismissed from the Urgent Care Center and directed to the nearest emergency room. (“Too deep. And you need an MRI.”) I stood on Second Avenue, left hand against head, right hand holding cell phone, speaking to a helpful representative of my insurance company, who reassured me that as far as United Healthcare was concerned, I could choose between the equidistant emergency departments of Cornell Medical Center and NYU Medical Center, confident in the knowledge that my co-payment, deductible, access to care for the rest of my life, and future list of pre-existing conditions would be the same.
I went north to Cornell. “I used to work here,” I said over and over, eliciting a flash of semi-interest from the security guard at the door, the triage nurse, the admitting nurse, the intern who took my history, the attending who retook my history, and the volunteer whose job seemed to be to observe me for any signs of rapid cognitive decline.
I turned down the MRI and was content to let the intern place four interrupted stitches (it may have been silk or vicryl but I forget) into my forehead, although I was offered a plastic surgery consult. At that stage in my training, I could have thrown those stitches in my sleep. The intern’s handwriting was good so I figured his hands were steady.
I returned to the office with a bandage wrapped tightly around my head, returned to the ER a few days later to have the stitches removed, filled out a nice evaluation online about the quality of my treatment at the hospital, and ignored the monthly solicitations for donations that came for the rest of the year.
The next day, I was a celebrity at Reliable. Breakfast was on the house, as was lunch. The cashiers, the short order cooks, the stock guys all greeted me with warm smiles and curious glances to the scar on my forehead. Menus were taped on the glass doors at eye level.
I made a point of joking about the incident and repeating over and over again that I had been careless and preoccupied and stupid and that it was my fault. And that I was fine, no crazier than before, no ringing in the ears, and certainly no intention of talking with a lawyer.
After a few weeks, the menus came off of the glass doors, and the customers of Reliable Deli were again trusted to use their hands or back sides to enter and exit. The scar slightly to the left of the midline just above my eyebrow faded away. The Intern, who by now has rotated to the Intensive Care Unit or to one of the med-surg floors, had done a good job. Whatever acute or chronic damage that my brief violent encounter with the glass door may have caused will forever remain undetected by the MRI scan that I refused to have done.
Every semester, as my students get to know me better, their questions get more and more personal. Towards the end of each semester I get asked wisdom questions, about success and happiness. I’m no expert, but I do think that humility and the ability to laugh at yourself are good places to start. Also: the fund did just fine this year.
(A speech I gave to the American Fertility Association in 2000.)
In planning to speak about advances in the field of assisted reproduction I have two conflicting images in my mind: the first is filled with impressive slides and graphs, detailing what is new in ART and, more importantly, what is coming. The second, and more real, is the disturing and disquieting image of a detached doctor, close in proximity but miles apart from the hearts and minds of his patients.
I spend many nights staring at the ceiling, thinking about the two challenged that face RE's. The first and obvious challenge is pushing closer and closer to the holy grail of our field, that of a reliable, predictable procedure with low risk and consistent outcome, one that is easy enough to place on an actuarial table so that insurance coverage becomes not only an easy ethical choice but an easy business choice as well. We have taken many steps in that direction over the past few years, and we can be justifiably proud of the development of ICSI, blastocyst transfer, single sperm freezing, preimplantation genetic diagnosis, assisted hatching with fragment removal and cytoplasm transfer.
But to inch closer to where we need to be, to the only truly acceptable set of goals for our science, we need to find some huge pieces of the puzzle. In the short term, we need a better means of assessing whom we can help and whom we cannot help. Two years ago I wrote an internet piece on FSH testing and our means of assessing eggs, in which I lamented the limited means we have to counsel many of our patients on what we can do for them. Every RE who will speak to you today knows that it is far easier to counsel an auditorium full of 500 couples on their chances of a good outcome than the one couple who sits across your desk.
In the longer term we need to better understand what makes some eggs, and some sperm, "good" and others "not good" and find ways to either rejuvenate those with lesser potential or make new eggs de novo. Now there are people, none of whom probably need this type of technology, who get uncomfortable with this type of talk. Some of these bold steps might need to use "cloning" technology. And we all know that anything that needs cloning technology, or even brings us to the possibility of speaking about the need for cloning technology, or even makes us think about the need for cloning technology should be banned and outlawed and never spoken or thought of again. Or should it?
A thirty one year old woman sits in my office, a survivor of leukemia or lymphoma or some other disease whose treatment left her not only infertile but menopausal. She and I discuss the very real and wonderful possibilities of her onceiving through egg donation, and we both silently say thanks that we live in the year 2000 and can offer this possiility to her. But what of the undeveloped option of using her "own" eggs? But did we not just say she has no eggs? And since women are born with all the eggs that they will ever have, how can we even think about or talk about using her own? Well, why don't we make new ones? Now, thankfully I have already passed my reproductive endocrine boards so if any board examiners are in the audience I cannot be blackballed, (at least I hope I cannot.) But let's for a moment propose for one of our long term goals the development of techonology that allows us to not only swap the nucleaus (and therefore the genetic material from my patients' eggs to donor eggs) and therefore make new "good" eggs but to swap a brand new nucleus from a stomach cell (yes, I know it has twice the needed number of chromosomes and is **gasp** technically a clone cell) and then zap it with electricity or an enzyme or two so that it DIVIDES and becomes.... a new egg. And my lovely thirty one year old patient can now have her own babies.
But we have used cloning technology! We have stepped onto the slippery slope that will lead to an Orwellian nightmare of genetic engineering and online ordering of blue eyes and perfect skin and high SAT scores. Or maybe we have just refined a technique enough to allow my 31 year old to have her own babies. And if, in so doing, we have allowed 41 year olds to have their own babies more rapidly and with higher percentages, than I am all in favor of that too. And if it allows us to say to our patients with really high FSH levels who cannot respond to stimulation regimens or to women whose endpometriosis has aged their ovaries by an extra two decades to have their own babies then that's a good thing too. But but but... if you can take the cell from a woman's stomach and make an egg with her chromosomes and she can get pregnant and have a baby when before she could not, could you not take the nucleus from a man's stomach and make an egg for him too? uhhh,, yeah. So we're perfecting a (**gasp**) cloning technology and we're allowing men to have eggs and we're supposed to let this just happen, knowing full well that we have stepped onto the slippery slope that will lead to an Orwellian nightmare of genetic engineering and amazon.offspring.com etc etc etc....
No, we are finding ways to help couples to have babies where before we could not. In 1995 we started larger scale use of preimplantation genetic diagnosis for the detection of abnormal numbers of chromosomes. If I can manage to deliver some reasonably well matured eggs to Dr. Cohen's lab, and he can grow the resulting embryos for three days and deliver one good cell from that embryo to Dr. Santiago Munne, then Dr. Munne can tell me and my patient and her partner the likelihood that that embryo will have an extra number 21 chromosome, or only one X and no Y chromosome, or pass on Muscular Dystrophy. We can also do, with pretty much 100% accuracy, sex selection.
With the enormous amount of information that we will soon have from the human genome project we may be able to greatly reduce the risk for breast cancer within a family, or the risk for diabetes. But this uses a technology that allows accurate sex selection, which as you all know, is a step onto a slippery slope that will lead to Orwellian nightmares of.... oh forget it.
The point I am trying to make is that there are enormous opportunities to help people and locked inside some of our more "dangerous" technologies. The challenge is not to suppress the technology, or to outlaw it; the challenge is to use it well. Just as we can choose to use a sharp object to remove a diseased appendix we can use a fluorescent in situ hyridization probe to prevent the passage of disease. And we can use intracellular manipulation to help families have babies.
That's the future-- now what about the present? A long time ago I wrote an article called "Reflections of an RE." It probably should have been called observations of an RE because that's all it really was, but a lot of my patients read it and commented on it. I had noticed certain periods during infertility treatment that tended to recur one patient to the next-- I called them emotional crisis points. They are pretty obvious: a first failed treatment cycle with injectable medications, a painful diagnostic test, that sort of thing. In discussions with my patients after that, we looked at another side: strategies for infertility treatment survival. To finish my talk today, I would like to share some of the lessons I have learned from my patients.
Ten tips for surviving your IVF cycle
1. Take yourself off the hook. Recognize that there is nothing you can do the will screw the process up. Entry fee to the "I screwed up my own IVF cycle" club:
2. Don't sweat the small stuff. Realize that there is no one right way and that a minor deviation from what happened last time can still be ok. There are a hundred valid ways to overlap lupron and the birth control pill. 10,000 units of HCG is probably 5000 more than you really need, so if a tiny drop dribbled down the side of your rear end it will not make a difference.
3. Lower the bar. Remember when you thought that your Algebra II final exam was like your final grade in Life? Your IVF cycle and its outcome are extremely important and you have invested tremendously of yourself in doing it. It is not everything though.
4. Repeat after me: the limitations are in the technology. If my IVF cycle cannot use your eggs, the problem is my IVF procedure, not your eggs.
5. Be as stressed as you want to be. Recognize that a major dose of stress is unavoidable during your treatment cycle. Don't try to deny it away and don't let its presence become a further source of stress for you. Look stress in the eye and keep it in its place.
6. Speak your mind but keep your composure. Remember "please" and "thank you" and if you page your doctor in the middle of the night, preface your question with, "I am really sorry to disturb you." Don't do this for the doctor. Do it to show him or her, and the rest of the world that even though you are going through IVF, you are dealing from strength.
7. Win both ends of the IVF cycle doubleheader. The greater goal is pregnancy and children, but a short term goal is to beat the evil treatment itself. Infertility treatment can chip away at self-image, can rob of us our positive self-image and cause us to question some of the more important decisions we have made as to how we run our lives. Let your actions show the world that you will not let the uncertainty turn you around. (h/t to Jackson Browne)
8. Let yourself be amazed at how well your spouse is putting up with everything. Be over the top in the way you support your spouse. Say nice things to your friends about him or her within his or her earshot.
9. Don't save up the love and attention. It is not going anywhere.
10. Take a crayon and draw a picture of yourself getting a progesterone injection. Make yourself look really silly. Take another crayon and draw a picture of whatever sperm collection technique you employ. Make everyone look really silly. Next take another crayon and a piece of paper and draw the head nurse talking on the phone. Give her really big hair and a cartoon balloon coming from her mouth and make her say, "blah blah blah blah blah blood and ultrasound" and make her look really silly. Next take another crayon and draw a picture of your doctor doing an ultrasound while you, the patient lie on the table with a thought balloon in which you hit him or her over the head with the probe. Make yourself look really powerful and make him or her look really silly. Then hang the pictures on the refrigerator with magnets.
The most impressive part of the advances in reproductive technology is the way IVF patients channel their strength and determination into grace, humility and humor. The rest of us can learn a lot from you.
A couple of decades back, a senior surgeon handed me a scalpel, addressed me as doctor, and told me to make my very first incision. My hand and the knife then hovered over the patient's abdomen like a helicopter over a traffic accident before finally taking a timid swipe and barely scratching the skin. My colleague waited patiently for me to shake off my nervousness, and a couple of hours later, the patient and I—an intern—were both in stable condition in the recovery room.
Now I sit at my desk—a grid of PowerPoint slides on one computer monitor, my course outline on the other. I am a novice again, midway through the 28 lectures that I will present this spring. Only for the moment, I'm doing a lot of staring and very little PowerPointing, and the prospect of teaching an entire course for the first time seems far more daunting than performing surgery. Medicine is a teaching culture. Second-year students show first-year students how to throw square knots, interns give impromptu seminars on fluid management during quiet moments in the intensive care unit, and bow-tied internists happily demonstrate the secrets hidden in the patterns of filling and drainage of neck veins to the first orderly or flower-cart pushing volunteer who happens to walk by.
I left medicine a few years ago but continued to teach: an occasional hospital grand rounds where I had trained or lectured to science or business students. Now I agonize over decisions that experienced instructors take for granted. In a few weeks I will teach my "Entrepreneurship in Biotechnology" students the 10/20/30 rule of effective presentation: 10 slides in 20 minutes using a 30-point font. Of course, my first lecture has 33 slides, but I rationalize that the first few are throwaway office hours / grade consists of / last day for drop-add types. Lecture two has only five slides so far, but I need to leave time for student presentations. Each presentation should last one minute, followed by two to three minutes of discussion. Four minutes per student unless the discussions get detailed and deep—but what would be wrong with that? Nothing—but what if the discussion is superficial and belabors the obvious? Or what if there is no discussion at all, just the kind of sinking silence that happens in comedy clubs when the comedian completely loses the audience, and everyone knows that he can't win them back but also knows that he has to try and that they have to sit through it?
Tonight I struggle with week one. The slides are unformatted black on white, with a little line at the bottom with the course number and "Columbia University GSAS" in small font. The slides appear in neat rows across the screen, but their concepts and ideas somehow remain hidden—the presentation a puzzle with all the pieces the same shape and no clues as to their correct order. One of the business-world clichés that I will relate (though not necessarily endorse) is that a presentation needs to be delivered 25 times before it makes sense. I am unwilling to sacrifice coherence for my first 24 semesters, however, so I devise different practice methods. Most often, I lecture to two dogs in an otherwise empty room. Weeks one and two are almost ready, but week three is not even close.
My students-to-be are an extremely smart group: a mixture of undergrads, masters, and Ph.D.s in the sciences, hoping to cram as much of a business education as they can into one semester. I worry about letting them down. I focus on them and try to anticipate their expectations. I stop polishing my delivery and start listening for clarity. Suddenly the teacher's block breaks, and a few of the slides almost jump off the screen and beg to be moved elsewhere. Quickly, week three is almost clear—its transitions logical and its conclusions evident.
My process is evident as well: course outline on one screen, slides on the other, practice out loud in an empty room, dogs optional. Listen for what your students will hear, and make it logical for them to understand. Repeat as needed.
Ray Bradbury once said that living at risk is jumping off the cliff and building your wings on the way down. I used to think that cliff jumping was a young person's sport, but I still find myself walking along edges, blueprints in hand.
I arranged for BIOT 4180 to take their final exam on a survey site on the web. Half the class sat in front of me in Hamilton Hall; the rest took the exam wherever they wanted—dorm room, Starbucks, London. I activated the page at 4:00 and planned to close it two hours later. Not too pressured but not too easy. Every student had my email address and cell phone number if a technical problem arose.
I watched as the site tabulated the responses. The exam grew harder as it progressed but the percentage of correct answers stayed well above 90. As they had through the entire semester, my students exceeded my expectations.
The delivery log from my first night as an attending obstetrician lists two vaginal deliveries and a cesarean for a footling breech early in the evening, followed by my outcome code: HMHB—healthy mother and healthy baby. My role was to supervise the residents and the midwives. I remember thinking about the on-call room and sleep.
“Doctor Sable—in here. A shoulder.” Sleep would have to wait.
The room was old-fashioned, not one of those “birthing rooms” with flowered curtains and a foldout sofa. No, this was a real operating room. Thankfully. The shoulder was a young woman, first baby, pushing and breathing. The baby’s head was out.
And the baby was stuck.
At 4:45 the survey site instant messaged that it would terminate the exam in five minutes. A countdown clock appeared. I linked to technical support and typed “survey termination.” Technical support recommended I upgrade to “Pro” level for longer duration surveys in the future.
My phone rang. A little red circle appeared at the upper right hand corner of my computer mailbox: 2 messages. The countdown clock showed reached four minutes. The red circle showed 12 messages.
BIOT 4180 had 65 students.
Every oral board exam in ob/gyn includes a shoulder dystocia case, and every obstetrician can recite the steps: extend the episiotomy, press on the abdomen above the pubic bone, have the mother flex her hips and pull back on her legs, pass a hand along the baby’s back and press the front shoulder to an oblique angle, rotate the posterior arm in front of the baby’s chest and out.
Break the baby’s collarbone.
I muted the phone, googled “screen capture mac,” and email-blasted “Plan B coming.” I text-searched my hard drive for the words “final exam.”
A gown found my arms. Gloves found my hands. The apprentice midwife stepped aside and nodded. The baby was blue. I figured I had ninety seconds.
I extended. I pressed: nothing.
She flexed. She pulled: nothing.
I felt the back and rotated the shoulder, gently bringing the upper arm along to avoid fracturing it, just like the textbooks say.
The countdown clock read “0:25” by the time I had compared the draft copy of the final with what I had put on the survey site, updated it, cut, pasted, formatted it into an email (“Plan B as
promised”) and hit “send.”
I unmuted the phone.
I had never broken a collarbone, had never seen a doctor break a collarbone. I was one maneuver away from learning the hard way.
I felt for the posterior arm and gently passed it in front of the baby’s chest. The arm popped out. The back shoulder slid forward. The front shoulder slid under the pubic arch and the body landed in my hands. Blue face turned pink and the baby cried.
HMHB. Healthy mother. Healthy baby.
Sixty-five completed exam emails arrived, all completed within a time-adjusted two hours. My students, as usual, exceeded my expectations. I could only hope that I had met theirs.
David Sable MD
writer, teacher, fund manager and retired reproductive endocrinologist