Reemerging from the pandemic: How do we restart?

The title of this Presidential Address is “Reemerging from the pandemic: how do we restart?” I originally thought that I would speak about several different topics. One of my original thoughts was to speak about vascular surgeon-scientists, a profession and topic near and dear to my heart. I will only encourage you to look at JVS-Vascular Science, our newest JVS family journal dedicated to the best of vascular science (available at: www.jvsvs.org). Another thought was to speak about vascular surgery heroes, perhaps to be somewhat inspirational. However, Stanley Crawford spoke about this in the Seventh John Homans lecture, and I commend you to his interesting 1992 JVS paper.¹ However, with the continuation of the coronavirus disease 2019 (COVID-19) pandemic beyond 1 year, I thought that I must say something about it. Many of you who know me well also know that I tend to shy away from discussions of contemporary events and politics; they are not even in my top 10. However, I felt compelled to say something about this important and timely topic. Perhaps I learned this from my mother, who never shies away from public speaking, or my wife, who fearlessly discusses all contemporary events and politics.

The questions really distill down to “What is the meaning of life? How do we return to what is meaningful? Is what is now meaningful the same as it used to be? Are our principles of meaningfulness existential? What is truth? Can we ever achieve meaning, satisfaction, and nirvana?”

My disclosure is that I am not a philosopher, and, thus, I turn to Monty Python, who in their 1983 comedy, The Meaning of Life, answered the question very succinctly. The meaning of life is: “Try and be nice to people, avoid eating fat, read a good book every now and then, get some walking in, and try and live together in peace and harmony with people of all creeds and nations.” If only it were that simple.

The pandemic

This is the issue. We are still in the COVID-19 pandemic. The scientist within me would love to discuss the science of the coronavirus, but I will leave that to Dr Akiko Iwasaki, the Yale immunologist who is unraveling these mysteries. The pandemic has filled our intensive care units and exhausted every medical person, especially our emergency room and critical care colleagues. Many have died, and many suffer with long COVID. Recent numbers tell us that >44 million Americans have been infected with COVID-19 and >700,000 people have died. This is unfathomable in 2021, but I thank Dr Albert Ko, our Yale epidemiologist, who helped coordinate the Connecticut and regional response to COVID-19, saving lives and helping us open up as expeditiously as possible.

SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2) has taught us that we must have humility. We still do not understand all of nature’s secrets. Also, unfortunately, we are actually in the midst of two pandemics, one of COVID-19 and one of ignorance, stupidity, and denial.

New England has been hit hard, especially early in the pandemic. Although we have done relatively well in more recent months, our lives have been changed in ways that we do not yet understand. Many have changed homes, many work from home, many have lost their jobs, their livelihoods, their security. We vascular surgeons as a group have been quite fortunate; we are generally blessed with security, enough financial support to afford the basic items, and even some luxuries. Many, even some in this room, cannot.

Edgar Allen Poe described the devastation of plague in his 1842 short story The Masque of the Red Death: “And now was acknowledged the presence of the Red Death. He had come like a thief in the night. And one by one dropped the revellers in the blood-bedewed halls of their revel, and died each in the despairing posture of his fall. And Darkness and Decay and the Red Death held illimitable dominion over all.” Death is the ultimate mediator of equity and inclusion.

Coping

Some of us pine for the past, the “good old days.” If only it were like it used to be. This is natural. We are frequently nostalgic for what we used to have. Some of you in this audience who are religious might remember the message of King Solomon in the book of Kohelet, or Ecclesiastes. Enjoy the simple pleasures in life such as eating, drinking, and taking enjoyment in one’s work. Savor the moment and live in the present. Make the best of what we have now and do not dwell in the past. This philosophy is also known as “carpe diem,” seize the day, originally attributed to the Roman poet Horace. Personally, I prefer the words of the great Persian polymath, mathematician, and philosopher Omar Kahayyam: “a jug of wine, a loaf of bread—and thou.” I also give you the words of Tolkien.² In response to Frodo’s wish that the finding of the terrible ring of power “need not have happened in my time,” Gandalf replied: “So do I, and so do all who live to see such times. But that is not for them to decide. All we have to decide is what to do with the time that is given us” [emphasis added]. These are wonderful words of advice. Find your inner strength and live for today. Do your best with what you have. There is no destination, only a journey.

However, we ask: the pandemic continues and is likely to continue for some time. How do we carry on? How do we establish our new normal? Indeed, what is normal now? How do we get back to our lives? Do we want to go back to our previous lives? How do we determine what are our new lives and habits? How do we restart?

As I was trying to answer these questions, one morning I read a lovely article in the New York Times, by Cameron Walker,³ entitled “How to Get Things Done When You Don’t Want to Do Anything.” The article had several suggestions in six discrete headings. First, tiny, well-timed treats. Although rewards are not best for long-term motivation, they are excellent for short-term motivation. A cup of tea frequently serves well. Second, find your why. What is your sense of purpose? Third, go far together. Connect with others, because social connections rekindle motivation. Fourth, a friendly game of motivation. There is nothing like a little competition to motivate oneself. Fifth, have some compassion. Sometimes, competition just does not work, and self-compassion is a better route to motivation. Finally, sixth, we are not alone. Pay attention to the world around you, and you will see we are all in it together. This was a very inspirational article, but I was searching for more. What truly motivates us? How can we sustain motivation in the long term, in the face of insurmountable odds and overwhelming despair in the world? I think we can relate to these people (Fig 1 ). They do not just want “well-timed treats” and a cup of tea; they struggle and need long-term strength and long-term solutions.

Fig 1.

Medical workers take a break at a makeshift hospital in Wuhan, Hubei Province, China. Fei Maohua, Xinhua News Agency; South China Morning Post. Available at: https://www.chinadailyhk.com/article/126633. Accessed October 13, 2021.

Using art to learn from history

Although we like to think of ourselves as living in a unique time, we are not. Many pandemics have occurred before this one, and quite likely many more will occur in humanity’s future. I would like to know what our ancestors were thinking when the Black Death rampaged through Africa, Asia, and Europe between 1346 and 1353, about 670 years ago. Those 7 years were the most fatal pandemic in recorded history, with an estimated 75 to 200 million lives lost. Is it possible that perhaps our ancestors who survived and restarted had words of wisdom for us?

The painting, The Triumph of Death, has always been one of my favorite paintings (Fig 2 ). The Triumph of Death was painted in 1562 by Pieter Breughel the Elder, perhaps the most significant artist of Dutch and Flemish Renaissance painting. This masterpiece has resided in the Prado Museum in Madrid since 1827, and I had the privilege of seeing this painting in person a few years ago, and it did not disappoint. This is a fantastic, apocalyptic landscape. An army of skeletons wreak havoc across a desolate field; fires burn in the distance. The living flee in terror or fight back in vain; they are caught in nets and herded into a coffin trap. The details are magnificent and are worth the effort. All people are represented, from peasant to a cleric to the king; death is rampant and indiscriminate. No person is immune from the plague and death. Taking in the landscape, it is a statement of the pandemic. Death is all around, and bleakness and hopelessness and despair are profound. Just as some would relate to today. We get it.

Fig 2.

Pieter Breughel the Elder, The Triumph of Death, 1562. The Prado, Madrid, Spain. Available at: https://en.wikipedia.org/wiki/The_Triumph_of_Death. Accessed October 13, 2021.

I want to draw your attention to the lower right-hand corner (Fig 3 ). In the larger view, one could miss this important little scene. Almost imperceptible, in the lower right corner are two lovers, blissfully unaware of the surrounding turmoil, death, and devastation. What is Bruegel trying to show us? Is this an answer? Blissful ignorance? Intentional ignorance? Or, perhaps, focus on one’s purpose and joy?

Fig 3.

Detailed view of the lower right-hand corner, The Triumph of Death. Available at: https://www.pieter-bruegel-the-elder.org/The-Triumph-Of-Death-Detail-C.-1562.html. Accessed October 13, 2021.

Sylvia Plath⁴ wrote about these lovers in her poem, Two Views of a Cadaver Room, the second poem of her book The Colossus, published in 1960:

In Brueghel’s panorama of smoke and slaughter

Two people only are blind to the carrion army:

He, afloat in the sea of her blue satin

Skirts, sings in the direction

Of her bare shoulder, while she bends,

Fingering a leaflet of music, over him,

Both of them deaf to the fiddle in the hands

Of the death’s-head shadowing their song.

These Flemish lovers flourish; not for long.

Yet desolation, stalled in paint, spares the little country.

Foolish, delicate, in the lower right-hand corner.

Beautiful words describing a scene of devastation and horror. Can we not relate to this paradox? I believe the lower right-hand corner lovers are Breughel’s essential message. Please remember that Breughel painted this scene more than 200 years after the Black Death pandemic had ended. However, this painting appears fresh, almost with new lessons Breughel wishes to teach. The plague pandemic had a profound impact on peoples’ daily lives for centuries. Yet Breughel, in his painting, says: “Do not look at the armies of death. Look at the lovers. Look at their focus and flow. They are not unaware, nor are they ignorant. But they are focused, intent, purposeful.” We need to focus as they do.

Focus and flow

I am grateful to both our Yale Dean, Dr Nancy Brown, and our Yale Surgery Department Chair Dr Nita Ahuja, because they have both called attention to the book Drive by Daniel Pink⁵ and inspired me to read it. Many of you know this book, because it focuses on motivation. How do we motivate ourselves? How do we motivate others? It is a classic in the business world and has many lessons for leadership. But I bring it up now to learn, not about motivation theory, but about what we can learn practically to restart our lives after the pandemic.

Drive teaches us that the secret to motivation is to cultivate our intrinsic priorities by emphasizing our senses of autonomy, mastery, and purpose. We must set our own goals and remember our own intrinsic priorities. For us, New England vascular surgeons, I believe this is relatively straight forward: be the best surgeon you can be. Do not focus on your compensation, but remember why you entered this noble, revered, and sacred profession; to help others and advance the art and science of healing for patients with vascular disease. In these paths, nothing has changed during the pandemic; we need to continue to focus on our goals and direct our own lives; this is autonomy. We need to extend and expand our capabilities and mastery—and we need to live a life of purpose.

These are wonderful lessons, but I want to emphasize another point that Daniel Pink discussed and I believe is perhaps the most interesting part of this book: the discussion of flow. “In flow, people lived so deeply in the moment, and felt so utterly in control, that their sense of time, place, and even self, melted away.” Flow is when we are totally invested in the experience and perhaps the most satisfying experiences we have. If you have lost track of the time during this address, you have been in flow.

The concept of flow belongs to Professor of Psychology Mihaly Csikszentmihalyi.⁶ As surgeons, we all experience flow when the operation goes and 7 hours pass without a thought or attention to the telephone ringing or even an urge to eat or pee; it is why we are all terrible judges of the time we spend on a case. Flow is the lovers in the lower right corner of the painting by Breughel the Elder. It is what we all hope to experience, and what my father told me is the best part of the day. I also tell my students that operating is truly an escape from the outside world and a sincere pleasure. My wife can tell from the look on my face when I come home what I was doing that day; being a surgeon in the operating room, in flow, helping another person through their vascular issues, saving limb and life. This is why we all do this.

So how do we restart? Although I do not have the answer, I have a suggestion. Do what we do best. Take care of our patients, get into the operating room, and become lost in flow. It is satisfying and wonderful. The outside world melts away with your focus. It is what we all love. Here was a recent patient whose cephalic vein aneurysm we resected (Fig 4 ). It reminded us of a heart, and we were brought into flow as we spent 4 hours resecting this monster. The time passed quickly; we did not feel it pass; and the patient was grateful. Also, for about an entire day, the whole team did not remember the pandemic.

Fig 4.

Preoperative (Left) and intraoperative (Right) views of a left cephalic vein aneurysm.

If you do not spend much time in the operating room or with patients, as some career directions sometimes evolve, find the activities that give you flow. Perhaps it is writing; teaching; bicycling; watching a movie cuddled up with your favorite person or pet or pillow. Seek flow and the time will not only pass, it will run away.

Flow has been used to increase productivity. Kara Cutruzzula is a motivational author and has given several TED (technology, entertainment, design) talks, including one on flow.⁷ Although a full discussion of harvesting the power of flow is not my purpose, her suggestions are worth mentioning: “Identify when you are naturally in your flow state. Learn how to get into it by working backwards. Understanding the benefits of flow can reinforce the habit. And start trying to shift into your flow state on purpose.”

Time is our most precious commodity. We cannot invent more of it. We can make more money, exercise to gain strength, even make or adopt or marry into more family members. We can buy another home and certainly fill it with more “stuff.” We can learn a new skill. But, we cannot make more time. There is no bargaining. There is no arguing. There is no more time than what you have. The Moody Blues told us we only have “22,000 days, it’s not a lot, it’s all you got; time’s the only real wealth you have.”⁸

Restarting

So, how do we restart? How do we maximize our flow in our limited amount of time? We need to value what we have, and learn what gives us flow; to learn what gives us the ultimate satisfaction to enjoy our time on this earth with our loved ones. Once we learn what are our priorities, everything else is easy. Flow gives us the energy and grounding to restart, and restarting enables us to focus to find flow. It is a positive feedback loop. It is a journey, not a destination.

Many people ask me why I am an optimist, and my answer is usually the same. “Because it is not me on the operating room table.” This attitude gives me perspective. We, in this society, all know sickness, and pain, and blood, and death. It is in our territory and in our daily struggles for our patients. Michael Belkin⁹ told us, in his 2013 Presidential Address to this society, that we are the “firemen of the OR.” We know the limits of human endurance. But we must remember our own limits and, thus, our own priorities. My answer is not your answer; we all have our own individual answers. This is what makes us unique and diverse and is exactly our strength in this society. We will all restart after the pandemic in our own ways, which gives me optimism.

I can only commend you to restart with the sage words of Cinderella in the 2015 Disney movie, “Have courage and be kind.” Finding one’s priorities and one’s flow is not easy, and takes courage and persistence; it takes self-reflection to achieve self-awareness. We can all be kind to each other during this process; this journey requires patience and humility.

Sir William Osler said, “The practice of medicine is an art, not a trade; a calling, not a business; a calling in which your heart will be exercised equally with your head.” We in this society are focused on bringing the best vascular care to our patients, and this society continues to lead; we continually reinvent ourselves and our field of Vascular Surgery to provide empathetic, patient-oriented, and personalized care to our patients, who continue to put their trust, limbs, and lives in our care. We can restart our lives not after the pandemic, but right now, as the pandemic continues. We can achieve flow, and all else will follow.

I am privileged to give this message of hope and optimism. Some people question these times; however, I draw inspiration from our country’s sage Benjamin Franklin, in his final remarks to the Constitutional Convention as he observed the President’s chair (Fig 5 ), “I have often looked at that picture behind the president without being able to tell whether it was a rising or setting sun. Now at length I have the happiness to know that it is indeed a rising, not a setting sun.” Indeed, this is my message today.

Fig 5.

Close up view of the President’s chair. The Wall Street Journal. Available at: https://www.wsj.com/articles/SB10000872396390443389604578024270194333456. Accessed October 13, 2021.

Thus, I conclude by showing you a rising sun of hope and optimism over my hometown of New Haven. Find what brings you flow; for me, it is my family, which includes my sisters and brothers in this society. Thank you for attending the 2021 New England Society for Vascular Society in-person annual meeting. I sincerely thank you for the honor and privilege of serving as your 48th President.

From the New England Society for Vascular Surgery