Say Yes to the Dress is a reality show on TLC, the same cable network that brings us Here Comes Honey Boo Boo and Cake Boss. TLC originally stood for The Learning Channel but now focuses primarily on reality-style series. Say Yes to the Dress, which originated in New York at Kleinfeld’s Bridal, is in season six.SYTTD is ostensibly all about wedding dresses, choosing one, buying one, the subsequent fitting, and even the occasional wearing of one. A typical episode begins with the introduction of two new brides, each with an entourage. A short interview ensues in which we learn about the potential groom, how they met, and the type of wedding they’re planning. Then we meet the entourage. This might consist of a mother or step-mother or both, a sister or two, a friend or three, an aunt, a mother-in-law to be, Joan Rivers, quite possibly a father or grandfather, a fiancée or baby-daddy, some brothers, and any number of gay men. A brief description of the dream dress follows. We go into the stock room to browse. To my eye, the dresses all look remarkably the same. And from fifty feet I bet they’re indistinguishable. The tops are mostly strapless, but the bottom shapes differ somewhat and it is imperative to learn the lingo of skirts: mermaid, trumpet, ball gown, etc. They all cost a fortune. I think you can probably find a dress for under $2000, but if you have something unique in mind, you can spend up to $30,000. It’s pricey to play princess for a day.But the real story, the reason I watch, is the subtle way the show reveals the relationships between the bride and the people she loves. We carefully read their facial expressions as she tries on dresses, hoping to understand the differences between what the bride wants and what everyone else wants for the bride. As different body shapes are forced into sample sizes, disaster results. Families focus on the neckline, the skirt shape, the ruching, and the rhinestones. And as they supposedly fixate on the dress, we register their disapproval, expectations, uncertainty, hopes, divisiveness, even contempt—all of which show up in the faces and comments of moms and brothers and sisters and friends within moments of seeing an ill-fitting gown clamped to our bride. It’s a fascinating lesson in family dynamics, and it’s definitely not just about the dress. It's about every aspect of womanhood. Heartbreaking back stories are tossed in to add texture. But somehow all of life lurks in the subtext of this strange reality program under the auspices of clothes shopping for one of life’s biggest events. What isn’t said in each episode could provide another season. While the show inadvertently focuses on the nature and intricacies of family and weddings provide the context, marriage itself is the elephant in the dressing room. Marriage is, incredibly, irrelevant.You can’t help but wonder if the search for the perfect wedding dress, despite the declarations of modesty (“I don’t want the girls hanging out!”) or its opposite (“My fiancée has a hot bod and I want everyone to know it!”), hasn’t become the objective correlative of a very different discussion we’re almost having on national television. The dress is a substitute for hope, a hope that is, like most things American, commercialized and available for purchase according to your budget. Televising the process of purchasing hope in the form of a dress you wear once provides obvious revenue for the wedding industry. Lots of people are profiting here! In our nominal summaries of how the couples meet, we learn that grooms are “awesome”, “best friends”. But we don’t actually care about the grooms. All the focus is on the event and the bride as centerpiece (the money parts), not on the couple, not on the marriage. These women aren’t Bridezillas, for the most part. They often just trying to please, trying to lose weight, trying to make the most people happy, or satisfy the one who’s paying. Sometimes they speak of the wedding symbolically, as a gift. It makes you wonder how they arrived at the decision to marry. And then you find yourself studying a bride’s face to see if there’s any indication she might know there’s more to it than a great dress and a party.In the real world without reality-TV, women worry about the choices they’re making. Moms and Dads worry about their daughters’ choices, brothers and sisters worry about their sisters’ choices. In the non-televised world, women worry more about the men they marry (and vice versa) than what they’re wearing that particular day. That’s the subtext of the show, which has deconstructed the process to simply choosing a gown, as if getting that part right guarantees success in all else. If a decent marriage merely depended on finding the right white dress for five large, I’d fly to Kleinfeld’s in a New York minute.As my own daughters begin to talk (theoretically) about marriage, the dress issue becomes relevant and SYTTD almost addictive. I see myself in the show as a (albeit unlikely) bride, a mother, a sister, a member of many different wedding parties. I hope I don’t manipulate my daughters in any way and fear I might. I remember my own wedding and my own dress. In late 1981 when I became engaged, I saw an ad for Estée Lauder’s fragrance, Estée. The model wore a white lace gown by Chicago designer Becky Bisoulis, photographed by Skrebneski. I showed it to my mom who thought it looked terrific. Mom was an experienced seamstress, but had never worked with lace. She and I took the picture to a dressmaker in Blue Island who told us how much fabric to buy and where to buy it. She charged us $100 to create the gown. It had no beading and no train. Just lace. I wore flowers and a ribbon in my hair.A few years after I married, I gave anesthesia to a woman who wore the same gown for her wedding. Later we became friends and are still friends to this day. Only she wore the real Becky Bisoulis gown. I never asked what she paid for it. We’re both divorced now, each after twenty-some years of marriage. While I don’t think the dress had anything to do with our divorces, I suppose it was, in a very small way, a symbol of hope. But maybe not. Maybe it was just a dress which is why I’m glad I only paid a hundred bucks to have it made. In the big scheme of things I think there are better ways to spend money. But in the world of reality TV, it’s nice to know you occasionally get more than you bargain for, and there’s more than what appears on the surface. SYTTD is one of those rare shows that makes you think. How often does that happen?

It’s hard to believe nearly a year has passed since my book Good in a Crisis was published. Like many authors, I thought publication would change my life. I suppose it did change, but some things improved and others got worse more or less simultaneously so that I can say, overall, things pretty much stayed the same. I learned a lot though. I remember hoping that net-net, I’d see an improvement. But in fact it turned out to be character building instead. That goddamn character building really sucks and I am sick of learning life lessons. How old do you have to be to be for it to stop? I’m 54! Enough already. Unfortunately, I suspect it will never end.So, in fact, life hasn’t changed much despite accomplishing this huge goal. Publishing the book was a kind of a microcosm of living in general—not what I’d hoped for, but beneficial in ways I never imagined. I learned new lessons about what assholes look like (I didn’t know this already?), and yet I was thanked profusely over and over by strangers from around the world for having written my story. I met many wonderful people. I found gratification in unexpected ways. So a balance—of sorts—has been struck. Yes, assholes seem to predominate in our world. But maybe they’re just louder or more annoying than regular people. It turns out that real people with real problems read books and respond to honestly written stories. Thank goodness. I think that’s what will save books, and authors, in whatever form they deliver their goods.People I know constantly ask how my book is selling and I tell them I have no idea. I don’t look and I don’t ask. My stock answer is that FOUR people have read my book. That’s a joke, of course. But I have never once looked it up on Amazon. One time in the past year I asked my agent. And I instantly regretted it. The numbers were not impressive; they made me feel as though I should have been actively publicizing the book. Instead, I’ve spent the past eighteen months working on the next book when I wasn’t working. There are only so many hours in the day. And I would rather write than try to publicize Good in a Crisis. While I’m proud of it, and I think it’s a wonderful book, I’ve moved on to the next thing.The holidays are a difficult time of year. In my field, everyone wants to get their elective surgery in before December 31st because their deductible will kick in again in January. You can’t blame them. Our days are crazy right now. Busywork for our malpractice carrier and continuing medical education credits come due, and the obligatory holiday parties pile on top of one another. Christmas shopping and gift giving and wrapping and the usual end of year tallying for businesses all join together to make this a less than festive time. And in the Midwest, the weather settles in for a long dreary spell. So what is there to look forward to?Personally, I look forward to the New Year and to a happy look back at a particularly good year. I look forward to a time of calm and quiet when I can gather some wool, gather my thoughts, and finally make some progress on that next book. It feels more important to me than the last one. I have something new to say. The lessons learned have given me ideas, and I’ve built on them. Isn’t that how we move forward? By taking on the next project? By learning from what was not quite satisfying enough, and moving beyond it? I think that’s the joy and the job of the New Year. I’m looking forward to it. I have more goddamn character now. And that character has something to say.

My daughter Liz called me the other day. She is in her first year of medical school and had attended her first code blue a few hours earlier. A person died as she watched. She wanted to talk about it. She felt helpless, useless. I told her she was just learning, that her job was only to observe at this point.Codes are not much different in 2012 than when I attended medical school. Changes have occurred every few years in the American Heart Association guidelines to CPR and Advanced Cardiac Life Support (ACLS), which dictate how we resuscitate patients. We do the same general things and, although the drugs and the details of CPR/ACLS have changed somewhat, the protocols have actually gotten less complex over the past thirty years as the AHA researched what works and what doesn’t. Despite that, survival has not improved much during the past forty years. At best, it hovers around 17% overall and drops significantly with age. Only 6% of patients over the age of 85 who die are successfully resuscitated, meaning they go on to leave the hospital.Nowadays I regularly attend codes when I’m on trauma call at my hospital. In an average twenty-four hour shift, I might be paged once or twice to a code blue or I might be asked to intervene before the patient gets into real trouble. My role as an anesthesiologist in these situations is to ensure that the patient’s airway is secured and that they are breathing adequately. Usually that means inserting an endotracheal tube into the trachea in order to attach a ventilator to mechanically breathe for the patient. Sometimes patients are intubated electively before they stop breathing; sometimes things deteriorate quickly and the intubations are emergent.But a major change that has occurred recently is that families are now present in the room during the resuscitation efforts. It occurred where Liz saw her first code blue. The family was understandably distraught. This was just one aspect of the event that proved unsettling to her. And it was new to me.A chaplain is typically present with the family in times of crisis. In the past, family members—if they happened to be in the hospital with the patient when the arrest occurred—were escorted out of the room while the patients underwent CPR and ACLS. The gruesomeness of the process cannot be overemphasized. The dying dusky and then blue. They often regurgitate stomach material during chest compressions. Secretions fly. Ribs are broken. The patients are repeatedly jabbed for intravenous and arterial catheters. A dozen people stand around the bed discussing drugs, heart rhythms, timing of dosages and the sequencing of events. Electrical paddles are applied to the chest and shocks are given which cause seizure-like jolts to the patient. The individual’s eyes are typically half-open, unseeing. An anesthesiologist such as myself comes to the head of the bed and sticks a long metal instrument into the patient’s mouth, suctions out secretions, blood, gastric contents, then inserts a breathing tube. As I said, it’s gruesome. Liz summarized a code as being “not for the faint of heart.”I suspect the transition from performing these heroics behind closed doors to doing them with family present reflects not so much an act of compassion as it reflects our current era of transparency and the legal climate that brought transparency into fashion. I can only imagine that the thinking goes like this: the family, having witnessed the resuscitation efforts, knows that everything was done to save their loved one. Perhaps we will avoid lawsuits with this approach. And perhaps we will cause some new cases of post-traumatic stress disorder in the survivors.After doing a little research, I’ve learned that this is being done in more and more institutions, including my own. I simply hadn’t witnessed it. My initial reaction was that having family purposefully present for codes seems absurd, cruel, and certainly ill advised. I would not want to witness the resuscitation of one of my children, or my partner, or my sibling. I would not want that memory haunting me. But in my heart, I know memory doesn’t work that way. And after mulling the idea over, I’ve changed my mind. I believe the time has come to stop isolating the public from death, as unappealing as that sounds. And if this is one small way in which we might do that, I think it’s a good idea.I have not spoken to any administrators about this new policy, so I do not know the details. I suspect that families are given the option of staying or leaving when the resuscitation begins. I certainly hope they have the choice.But we certainly need change in healthcare. We need not just economic change, and change in methods of delivery, but we need conceptual and philosophical change. Perhaps it will take a generation to achieve it. Perhaps it will require that more and more individuals witness the indignities that can befall them in the hospital environment so that they choose to die at home, choose to take more control over their lives and their health and their deaths. The default setting right now is to do everything to everybody. Until that default setting gets altered, we will have too much medical care for too many until too late in the game. And that’s painful for everyone.

In an ironic turn of events worthy of a novel, my mother died four months after I finished writing Good in a Crisis, my memoir about loss. Consequently, I found I had more to say. My sisters and I had cared for Mom during her last few years and it seemed only natural that my next book would deal with end of life issues. We had faced those issues with my father in 1998 when he died of cancer, and they frequently presented themselves in the hospital environment where I work as an anesthesiologist. As a result of this unhappy immersion, I have spent the past two years reading almost exclusively about healthcare—including the politics, ethics, and economics. I attended an executive education program on healthcare and worked for eighteen months on a manuscript that tells our story while promoting a major economic solution—the palliative care/hospice care movement—in a way that is positive, persuasive, even funny. But the rhetoric of the 2012 election and the political climate of our country have made me believe, despite my best intentions, the healthcare situation is unlikely to be fixed. And it’s depressing.After months of research, study, thinking, listening to individuals' stories, and attending various lectures, my goal was to incorporate what I’d learned into all that I’ve experienced in the course of my twenty-five year medical career. I would integrate the critical time spent with my parents in hospice when I learned more about being a physician than in any given year practicing medicine at any hospital. I would write a compelling and persuasive narrative about the importance of having a well-thought-out and individualized plan as we approach our later years.But this is a story few are ready to hear.It is a well-documented economic fact that roughly 80% of our Medicare dollars are spent in the final six months of life. As an anesthesiologist, I take care of a lot of elderly patients during those last six months. It is also known that while 70% of Americans want to die at home, 70% actually die in the hospital or in nursing homes. So there is a huge disconnect that is occurring—patients are receiving more care than they want and are not dying where they want to die. How and why this disconnect occurs has been the focus of my research and personal experience. We—physicians—talk patients out of their advance directives and Do Not Resuscitate orders. The public doesn’t want to know that. And we don’t want the public to know that we do it. But we do it and the costs—human and economic—are enormous. The reasons are complex, of course, sometimes unavoidable, but not always. We do not analyze how often patients who did not want their lives extended by “artificial means” get exactly that. To examine how to change this requires a paradigm shift in our analysis of end-of-life care. It requires that we take a close look at how we earn our pay, at how we take care of patients, and at how we manage expectations. It requires an analysis of the earliest stages of care. More importantly, it requires that individuals decide for themselves (while healthy) how they want to die. Then they must obtain the tools to enforce those decisions. They do not have them now.Work is being done at places like Harvard (Susan Block MD) to promote palliative care. Elder care is written about exhaustively in periodicals like the New York Times with its New Old Age blog (begun by Jane Gross). The Huffington Post has a Post/50 section. Joe Klein wrote a widely read piece in Time Magazine about the hard decisions he made for his own parents. The topic is ubiquitous. Baby Boomers bury their parents every day but before they do, they often spend years taking care of them. And while they care for their parents, they ponder the implications—financial, ethical, and logistical—of how that care occurs and what it means for their own futures. For the most part, when money is an issue, end of life care is an unholy mess. Even when money is not an issue, complex family dynamics combine with the moral and financial imperatives of medical practitioners (not just physicians) to provide too much care for too long for too many. We do no favors to the elderly by prolonging death. We do no favors to those with dementia. We do no favors to the families or to the economy. You only have to ask yourself two questions: who benefits by providing too much care? And do they have a lobby in Washington? Patients who die well usually have an advocate by their bedside enforcing their previously expressed wishes. Yes, patients change their minds, but it is often under duress and with incomplete information.I have come to the conclusion that organized medicine cannot fix this problem, though they need to be part of the solution. The government should not fix the problem—it is far too political, too politicized, too driven by special interests. And no one who makes a profit from patient care can fix this problem. The solution must be driven by a social movement, by the consumer. My goal has been to write that book, to drop that bomb, which would demonstrate this need and lay the groundwork for such a movement by sharing my own experiences both with my parents and in my work.But I worry the current political environment is too fragmented. Too hyperbolic. Too sanctimonious. You cannot drop a bomb into an already polarized society ignorant of the ways of health and healthcare and expect something positive to come of it. The public has become insulated from the reality of death. What happens in the hospital stays in the hospital. We in medicine have done you no favors in that sense. Because once you cross the threshold of the emergency room, the IV gets inserted and you are placed on the conveyor belt of Medical Care. You lose control and then you lose more control until you reach the point where your family must withdraw life support. Death occurs as a prolonged act of omission. But the better alternative is acting in accordance with your previously expressed wishes--a completely different process, better for all. And research supports this. Should support be initiated from the very beginning? And where is the beginning? It is usually assumed that full out Medical Care is the proper thing to do. It isn't. Healthcare professionals can intimidate family members who question them. Because we see death as a failure, a blemish on our record, we are loath to admit that death is the final step in this process we all experience, this life.Social movements based on common sense are going nowhere right now. And self-determination for healthcare appears to be a political football instead of a civil right. In the hospital, patients and families are talked into surgery and feeding tubes and IV’s that prolong life and suffering for weeks or months. Only the timing and location of death are changed; the outcome remains the same weeks later in a nursing home. The cost is astronomically higher; the deficit soars.But here’s the thing: physicians take the Hippocratic oath and we declare we will do no harm. Perhaps it is past time to parse out the meaning of harm. There are so many ways to harm another. We find new methods every day. That’s the downside of technology, and standardization, and of approaching healthcare as though it’s a big-chain restaurant. It is the downside of automaticity. Non-medical people do not understand how much suffering we can and do inflict and medical people take it as a matter of course. I suggest that we stop and reorient ourselves. Medicine has taken the tack of more is more for far too long. At the end of life, and there are very clear ways to determine when the end of life is near, maybe less is more.Above all, do no harm. Shouldn’t that be everyone’s oath?

(The following was originally written for a Writer's Digest Guide to Literary Agents Blog. It was never used, and I've adapted it for my own blog.)While in graduate school for an MFA, I wrote a work of nonfiction. The manuscript combined dramatic essays about my experiences as a young physician with the story of my father’s death from cancer. But I was trying to tell a larger story—one about the awakening of compassion, about recognizing the importance of patients’ rights, and my own coming-of-age as a physician. It took over three years to write the thing. A year and a half later I found an agent for the manuscript; he shopped it around to publishers. No one bought it.At the time, I was crushed. I’d put my heart and soul into this work. But in retrospect I’m lucky it wasn’t published.Between the time I wrote the manuscript and had it rejected, I suffered from a serious illness. That experience changed me; it changed my perceptions of medicine, of patients, and of myself as a physician. I realized I would never write the same book after my illness that I’d written prior to it. The illness had changed me as a writer and as a person. When I read through the manuscript today, it seems as though someone else wrote it.After the rejections, my agent at the time suggested I work on it. I tried for about six months and returned it to him. He said, “Nah, it’s not there yet.” I gradually realized I couldn’t fix it, but I might be able to learn something from it.I sent it out for an impartial evaluation by a professional at Creative Nonfiction. The woman sent me a written report that told me what I had instinctively known, but never articulated exactly. She addressed all those niggling doubts that had plagued me for two years, but I’d hoped no one would notice. They were hard to pinpoint. They were problems that are easier to avoid in the first place than to fix, such as inconsistency of voice, inconsistency of pacing, the why of the book (arc and cohesiveness) and ultimately the question of who should care, or engagement of the reader.My manuscript was a failure, plain and simple. I never had command of the material. It lacked an arc. The transitions didn’t quite work. It lacked cohesiveness. The themes didn’t carry through to the end. The story I was trying to tell was not clear to her. That made sense, because I had taken too many detours to get there.When I saw her words on the page, and I finally let go of my own attachment to the book itself, I knew she was correct. My manuscript would never be a published book. But it was a terrific opportunity for me to learn from my mistakes.When I started writing my second book, Good in a Crisis, I kept those issues in mind throughout the process. I did not begin until the voice and viewpoint was clear to me, until I knew the voice was strong enough to carry the story all the way through. I knew how it would be begin and how it would change. I had a strong sense of the arc of the story. As I put the book together, I kept in mind my previous difficulties with transitions and attempted to make them less jolting, more organic. With each edit, I wove the themes into patterns that worked their way through the story. I looked for opportunities for humor and added them when and where I could. When I finished my first real draft, I felt as thought I had command of this book in a way I never had command of my previous book. I was in charge of the material.I found a different agent for Good in a Crisis. Both agents were great, but agents don’t tell you how to write a book, or how to fix a book that doesn’t work. For me it has been trial and error.It has been over two years since I completed this book, six months since it was published. The publisher has moved on to publicize other products. While GIAC hasn’t sold very well, I’m proud of my first book. And I’ve changed again, in the interim since I finished writing it. As I read out loud at book events, I sometimes cringe, knowing that if I were to write it again today, it would be a different book. I learn something every day. I like to think that writing reflects that knowledge.I wrote the best possible book I had in me as of August, 2011, when Good in a Crisis went to press. I know more now. But I believe in bringing everything I know to bear on my writing and in making it as clear as possible. If there's an easier way to say something, I try to find it.So here's my advice since I was supposed to give advice to writers: Tell a story that interests you even though you know the story and have read it a hundred times. It should still be compelling to you, if you expect to sell it. Whatever you send to an agent should be nearly flawless. If it isn’t, don’t send it. Some things can be fixed. Some can’t. If your gut tells you that you have something really good, stick with it. If your gut tells you there are problems, then there are PROBLEMS! Sometimes putting a manuscript away, learning from your mistakes, and starting from scratch is the strongest and most positive act of writing there is. Ideas can be restored. Bad writing can’t.