How much time do we have? (David)

 On Monday, January 27, Joyce will return to the Mayo Clinic for follow-up imaging and an appointment with her oncologist to discuss the findings. Our hope is that she will continue tolerating the Selpercatinib even at the higher dosing and even after tapering corticosteroids. The goal is to see “response to treatment.” Best case scenario would be No Evidence of Disease (NED). Worst case scenario would be rapidly growing tumors in new locations. Not to be too morbid and melodramatic about it, but this is basically real-life “Squid Game.” Response to treatment in the current quarter means we get to keep playing another round. The more of those successful quarters we can string together in a row, the better chance that reinforcements will arrive in the form of new and better therapies. Progression doesn’t exactly result in “sudden death,” but it means that the clock is running down faster and the options available are likely to be more invasive and less effective.

As the husband of someone who has to face life with so much uncertainty, it has been very difficult for me to adjust to these new rules to the game. Time management is kind of my thing. I will never forget playing against the fifth grade “Chess Grand Master” of Pilgrim Lane Elementary and realizing that even though I was beating him, the fact that our coaches hadn’t invested in game clocks meant that our contest would end in a draw. It was a lesson I would never forget. Even as a college student I had already mastered Steven Covey’s concept of “Quadrant II.” My investment portfolio would become a finely tuned balance between equity and debt instruments after I discovered the importance of the “time value of money.” I have watched with great interest over the years as so many NFL teams have executed a flawless playbook for 3 ½ quarters only to fail in the end due to poor clock management. And of course, nowhere has this asset served me with more effect than in my career as a cardiac surgeon. Time under anesthesia matters, but not as much as time on the heart lung machine, and even that is trivial in comparison with the aortic cross clamp time when the heart is deprived of oxygen. Figuring out how to structure an operation to minimize each of these risks is fundamental to patient outcomes.

With so much of my approach to life anchored on the assumption that we can make decisions based on a fairly constrained expectation around survival, it now feels like I’ve been transported into a Christopher Nolan film. Like Cooper traveling through the planets of “Interstellar” where time passes along different dimensions or Cobb experiencing time dilation when moving between the different dream levels of “Inception,” I began 2025 watching on YouTube as the ball dropped in Times Square and the chimes rang out on Beg Ben, wondering if this whole idea of linear time is just something we dreamed up. Albert Einstein certainly thought so. A believer in the concept of a block universe, he once stated that "for those of us who believe in physics, the distinction between past, present, and future is only a stubbornly persistent illusion."

Illusion or not, I have found that the concepts of past, present, and future are actually very useful in restructuring our lives around this new reality. It is very easy to become overwhelmed with visions of a future in which my children have to stand at the bedside of their dying mother. In times like these, I have found extraordinary help in remembering Jesus’ words from Matthew 6:34: “Therefore do not worry about tomorrow, for tomorrow will worry about itself. Each day has enough trouble of its own.” As long as I can just stay focused on whatever it is I need to be doing right in this moment, life gets a lot easier.

But getting it right in the present is entirely dependent on a proper understanding of both the past and the future. The past is full of my mistakes—all the things I would take back if I knew then what I know now. Nobody understood the value of these regrets better than Linda Ginzel at the University of Chicago. Drawing on a concept from the negotiation literature known as the Pareto frontier (in which the optimal outcome occurs when no money is left on the table), Ginzel views the lessons of the past as data which can be studied and reflected on to help each of us become wiser younger (https://www.youtube.com/watch?v=gsdtHYaITGM). As I cherish each moment that I get to experience life as Joyce’s husband, it’s extremely useful to reflect on what has worked and what hasn’t in my previous efforts to show her how much I love her.

Perhaps the most important and challenging part of the new terms we’ve been dealt involves how we look at the future.  I enjoyed reading Oliver Burkeman’s book, “Four Thousand Weeks: Time Management for Mortals,” in which he persuasively argues that we will never achieve all of our dreams in this brief life, so we should accept this reality and focus on what really matters. Burkeman doesn’t offer much advice on what it is that really matters, leaving that to the readers to figure that out for themselves, but in his essay “The Weight of Glory” C.S. Lewis takes a pretty good swing at it:

“A cleft has opened in the pitiless walls of the world, and we are invited to follow our great Captain inside. The following Him is, of course, the essential point... It may be possible for each to think too much of his own potential glory hereafter; it is hardly possible for him to think too often or too deeply about that of his neighbour. The load, or weight, or burden of my neighbour’s glory should be laid daily on my back, a load so heavy that only humility can carry it, and the backs of the proud will be broken… remember that the dullest and most uninteresting person you talk to may one day be a creature which, if you saw it now, you would strongly be tempted to worship, or else a horror and a corruption such as you now meet, if at all, only in a nightmare. All day long we are, in some degree, helping each other to one or other of these destinations. It is in the light of these overwhelming possibilities, it is with the awe and the circumspection proper to them, that we should conduct all our dealings with one another, all friendships, all loves, all play, all politics. There are no ordinary people. You have never talked to a mere mortal. Nations, cultures, arts, civilization—these are mortal, and their life is to ours as the life of a gnat.”

 I doubt if the duality of finitude and eternity have ever been expressed more clearly than in a song that was recorded in 1969. John Barry was tasked with composing the soundtrack that would play alongside the final moments of “On Her Majesty’s Secret Service” as James Bond attempts to comfort his dying wife after she has been fatally shot. In an effort to “deliver the title line with irony,” Barry selected an iconic jazz star who would perform the song in what became his last recording session due to failing health. Louis Armstrong passed away four years before I was born, but I’m still singing along with him today on Spotify knowing that whatever happens, “We Have All the Time in the World.”