Saturday, December 5, 2015

Last photograph with my parents

Here is the last photograph of my parents and me together, 2004. My father, who was a physicist at the National Physical Laboratory, died last year. He just turned over in bed, and then he was gone. And my mother died today. Her apartment, where she lived alone after Dad died, caught fire while she was sleeping and she died of smoke inhalation. Her body was found in the bathroom, with one hand on a bucket. She was 83, and part way through a book she was writing.

Here is a news announcement about Mom. There was also a notice about her cremation. And finally, prayers were held at the Arya Samaj temple in Delhi on 13 Dec 2015.

And here is the last photo of all the five sisters (Mom was the oldest) together. This was taken at a family reunion this year:

This poem by Larkin comes back to me.

Aubade (Philip Larkin)

I work all day, and get half-drunk at night. 
Waking at four to soundless dark, I stare. 
In time the curtain-edges will grow light. 
Till then I see what’s really always there: 
Unresting death, a whole day nearer now, 
Making all thought impossible but how 
And where and when I shall myself die. 
Arid interrogation: yet the dread 
Of dying, and being dead, 
Flashes afresh to hold and horrify. 

The mind blanks at the glare. Not in remorse 
—The good not done, the love not given, time 
Torn off unused—nor wretchedly because 
An only life can take so long to climb 
Clear of its wrong beginnings, and may never; 
But at the total emptiness for ever, 
The sure extinction that we travel to 
And shall be lost in always. Not to be here, 
Not to be anywhere, 
And soon; nothing more terrible, nothing more true. 

This is a special way of being afraid 
No trick dispels. Religion used to try, 
That vast moth-eaten musical brocade 
Created to pretend we never die, 
And specious stuff that says No rational being 
Can fear a thing it will not feel, not seeing 
That this is what we fear—no sight, no sound, 
No touch or taste or smell, nothing to think with, 
Nothing to love or link with, 
The anaesthetic from which none come round. 

And so it stays just on the edge of vision, 
A small unfocused blur, a standing chill 
That slows each impulse down to indecision. 
Most things may never happen: this one will, 
And realisation of it rages out 
In furnace-fear when we are caught without 
People or drink. Courage is no good: 
It means not scaring others. Being brave 
Lets no one off the grave. 
Death is no different whined at than withstood. 

Slowly light strengthens, and the room takes shape. 
It stands plain as a wardrobe, what we know, 
Have always known, know that we can’t escape, 
Yet can’t accept. One side will have to go. 
Meanwhile telephones crouch, getting ready to ring 
In locked-up offices, and all the uncaring 
Intricate rented world begins to rouse. 
The sky is white as clay, with no sun. 
Work has to be done. 
Postmen like doctors go from house to house

Friday, July 10, 2015

Review of Midnight's Furies by Nisid Hajari

Anyone growing up in India during the 1960s and 1970s has probably heard the horrifying stories of the events surrounding the 1947 India-Pakistan partition. The most scary ones I remember are about trains packed with dead bodies coming into Lahore (dead Muslims) and into India (dead Hindus). My own parents lived in Lahore, or in the part of Punjab that is now in Pakistan; they were lucky to avoid the massacre---they used to spend their summer in Shimla, and had moved en masse in June, so that when August 1947 came around, they escaped the killings. They left their Lahore home in June, for the summer holidays in Shimla, and never went back---the Pakistanis who took over the home kept their clothes and possessions in a trunk for them to retrieve decades later. My mother's father, Shyamlal Meini, an industrialist, made many dangerous car trips between Shimla and the to-be-formed Pakistan during the summer of 1947 to move his money out of there to India.

And then there were the wars with Pakistan. I remember when we were instructed to paste brown paper on all glass windows to block the lights out during nighttime, in case Pakistani bombers attacked Delhi. I think I was seven or so, and although it was fun to stick rectangles of brown paper on all the windows, it didn't really sink in what a bombing would do. My father (he died in September last year), was a physicist at the National Physical Laboratory in Delhi, and was also involved in R&D related to the war, although I don't know what exactly it was about.

The Khalistan movement and the terror the Sikhs unleashed in India is another salient memory from my time in India.  A turning point came when Indira Gandhi was assassinated by her Sikh bodyguard, and the population of Delhi started to systematically kill Sikhs and their families in retaliation; Sikhs were strung up to hang on a bridge right on the street outside our apartment. It seems like the only response we have in India, despite our supposed 5000 or whatever years of culture, to injustice and brutality is more brutality. That's how the partition played out, and that's how 1984 played out. And there have been more such killings since then. The hatred seems to be passed on from one generation to the next; I recently met a childhood friend who invoked the partition and what the Muslims did to his family to justify his feelings about the fate all Muslims should experience.

The partition seems to control our attitudes and beliefs even today. A lot of Punjabis moved into Delhi, replacing the refined and restrained Muslim culture with a new, brash, and VERY LOUD, aggressive Punjabi style of doing things. At least until I was in India in the early and mid 1990s, it was fashionable to make fun of Punjabis for their brashness and aggressiveness. I had Jain and Muslim friends who openly mocked Punjabis in front of me, and mocked me for being Punjabi (and yes, I am as brash and aggressive as they come---and believe me, I am holding back). Using words in Hindi that are derived from Punjabi is a sure way to elicit derision from one of these groups. Punjabis were and maybe still are considered fair game in Delhi, by non-Punjabis of course.  The Hindi language changed after the Punjabis arrived in Delhi; and purists from central India routinely make fun of the way Punjabis like me pronounce certain words like "read" (paRa, not the correct paRha), occasionally introduce tones and odd accenting patterns into Hindi, and use the ergative case marking incorrectly, almost certainly a borrowing from Punjabi. Sneering at groups other than one's own is an Indian speciality, and the arrival of the Punjabis in Delhi provided a lot of free mocking-value for the other groups who thought themselves superior to these barbarians. It didn't help that the Punjabis ended up dominating many aspects of the economy in Delhi. Of course, the Punjabis sneer at others too, for being Merchant caste money-grubbers and weak-minded ditherers, among other things. So nobody really is blameless in this culture of defining one's cultural "team".

This book, Midnight's Furies, by Nisid Hajari, is an astonishing chronicle of the events that led to the partition:

Fantastically fast paced and well written, I had a very hard time putting this book down to work during the day. The main thing I learnt, which I didn't know much about until now, was the sheer incompetence and short-sightedness of all parties involved in the partition: Nehru, Gandhi, Jinnah, the entire British imperial machinery, Churchill (Hindus: "a beastly people with a beastly religion"). Jinnah and Nehru are both blamed in this book for making the situation worse and for precipitating the partition. I can see how that might happen; even if they had been more accommodating with each other, and just mildly rational human beings, they had no experience in nation-building. I can imagine that anyone who has to deal with a situation like this is going to make mistakes.  What surprised me was how badly the British---who have some experience in nation-building from scratch, especially other people's nations---handled the hand-over of India to the Indians. I guess the British didn't even see the Indians as particularly human ("a beastly people with a beastly religion"), so it didn't really matter to them either way whether they lived or died.  The big lesson I learnt from this book was that leadership matters. If you are leading the way, whether it's something big or small, you have to be bigger than yourself. You have to put aside your sense of self-importance, and be willing to recognize that you are sometimes wrong, and then you have to correct course. A lot of what happened---except for the criminal British incompetence---was because of people not being willing to back down and conceding a point in the face of overwhelming evidence. Rather reminiscent of the way we do science in most fields.

The story that Hajari tells was carefully omitted from my history textbooks in school, or at least the details were whitewashed. Of course everyone knew about the partition; the machinations that led to it were kept pretty obscure in the textbooks I had to read. If instead of making us memorize the names, special characteristics, and dates of creation of various temples, had the school history books just told this story, my history lessons in school would have been much more useful. In many ways, this book reminded me of the classic Lies my Teacher Told me: Everything your American History Textbook Got Wrong:

The only thing that disappointed me about Nisid Hajari is his enthusiastic support for that plagiarist, Fareed Zakaria. South Asians love to plagiarize, and so Zakaria's plagiarism in itself is not surprising or remarkable. But I am very uncomfortable with Hajari's association with Zakaria.

Saturday, July 4, 2015

Dialysis: The attitude of nurses

I'm convinced that at least this one nurse in my dialysis center has only contempt for me. I used to encounter the attitude in India that anyone with an illness was considered to be to blame for having that illness---probably the result of some vaguely formulated karmic theory that Indians find so attractive. I sometimes (very rarely) get the same impression in Germany too. There is one nurse in my dialysis center who is assigned to the night shift quite rarely, but when she is there and is assigned to connecting me up, my night is sure to be hell.

First, she gets all the parameter settings wrong; when I correct her, she says I don't trust her. Damn right! You are getting all the numbers wrong. If the heparin stop time is not set correctly, I can be sitting there for one hour waiting for the bleeding to stop, after the needles are removed. It matters whether the parameters are exactly right. The biggest problem I have with this nurse is that she consistently leaves air bubbles in the heparin feed line, which leads to non-stop alarms all night. After this happened three times with her, I have become firm with her about removing those air bubbles. Every time she mutters about my not having any faith in her.

So I've managed to piss this lady off; I can understand that. After all, I am essentially questioning her competence by checking everything she does.  It doesn't matter that she *is* incompetent.

But the thing I don't understand is that she takes out her frustration with me by taking revenge: she slams the door shut loudly every time she comes in to check during the night whether everything is in order, waking me up each time. Why would she do that? I can understand that she's pissed off with me because I keep correcting her mistakes, but what's the logic of waking me up throughout the night and ruining my next day? I guess it must be satisfying for her to "get back" at me.  But it speaks to an attitude of contempt for the patient.

There was an interesting case recently in the US of a patient accidentally recording what their doctors said while he was getting a procedure under anaesthesia. You can read all about it here:

It's very hard for me to understand why medical  personnel ever think it's OK look down on their patients and to treat them like they are worth nothing.

Friday, April 10, 2015

The high drama of self-cannulation

I've been inserting my own dialysis needles into my shunt for more than two years now. One would think I'm an expert by now. But each time it's a challenge. You have to push the needle past the skin into the shunt, but not too far in, or else you will go right through the lower wall of the shunt and into the muscle below it. At a certain point after insertion, you have to change angle so you can move along the inside of the shunt, and not hit the wall at the other end. All this is one smooth movement. In and turn.

I have had a nearly 100% success rate so far over the last two years. The first six months were hell, bloodbath after bloodbath, but I got good at it and could get it in nearly pain-free (unless I hit a nerve, but I gradually learned to avoid the bad spots).

But on Monday this week I made a huge blunder. I pushed the needle in just a little too hard, and it ended up deeply embedded into the muscle underneath. It doesn't hurt, but you hear a distinctive pop, which is the sound of the needle exiting the shunt from the other side deep inside.

At this point I lost my nerve; do I pull out the needle, and if so, how will I know that I'm out? Could I end up pulling it out entirely if I pulled too hard, and have a bloodbath on my hands? The nurse was standing by luckily, and he took over. It turns out you hear a distinctive pop when the needle exits the muscle on retraction. So the nurse expertly pulled it out just enough to get the needle correctly positioned and all was well...till the next morning. Now that a hole had opened up in the shunt, blood leaked out slowly all night into the tissue underneath, with the result that I developed a huge swelling around the shunt, so much so that I could not even see my shunt any more (at least not the part where I had done my mis-insertion). The visual impression of my shunt half disappearing really freaked me out.  It's the one thing that's keeping me alive and seeing it "gone" amid the swelling somehow really shocked me.

So much so that I didn't really have the nerve to insert my needles again on Wednesday, I had the nurse insert it. There wasn't much space left on my shunt to insert the needles, so the nurse stuck it into a fresh spot that had never been needled before, high up on my shunt. Very very painful! The skin on the upper part of the shunt was fresh and never punctured, so it had no hardened skin.  To make matters worse, I think the nurse inadvertently hit a nerve and so I was in pain all night. Amazingly, I managed to go to sleep, but I dreamt of being tortured by someone or the other.

Today's Friday, my last dialysis for the week happens tonight. Am I going to go back to inserting my own needles? We will see how much nerve I can muster. I must say, I feel like a total failure---so much for being a third degree black belt in Iaido! A needle insertion is very much like classical Japanese sword technique: you go in straight, with the sharp end of the needle, and you have to make a quick change of angle to make a sharp clean cut with the edge of the needle to enter the shunt. If you do this just right, there is not a trace of blood. I should be really, really good at this, I've been practising this movement for decades! I guess the problem is that there is so little room for error, it's happening at millimeter precision.

Dialysis is usually OK for me, I can live with it and it doesn't intrude into my life much any more, now that I do it overnight. But these incidents really mess up my life.

Saturday, January 3, 2015

Review of Assholes: A Theory, by Aaron James

According to the author, the definition of an asshole, who is almost always male, is (emphasis mine):

A person is an asshole when, and only when, he systematically allows himself to enjoy special advantages in interpersonal relations out of an entrenched sense of entitlement that immunizes him against complaints of other people.

An Asshole (capitalization mine) is to be distinguished from a Jerk; the latter only systematically allows himself to enjoy special advantages in interpersonal relations.

The Asshole refuses to recognize you as a moral equal. This is a key reason that Assholitude arises in the first place. The recipient ends up fighting for moral recognition, and this is where the frustration on part of the recipient comes from. There's the humilation of knowing that you are considered inferior; and that there's nothing you can do to change that.

The opposite of an Asshole---presumably something to aspire to---is the Fully Cooperative Person (capitalization mine). These are people who "see themselves as equals, as having grounds for special treatment only in special circumstances that others will equally enjoy at the appropriate times.''

An example is a person's birthday; we expect (well, most people expect) special celebrations of their existence on that day, but they will equally well celebrate their friends' existence some other day. For the Asshole, every day is his birthday.

The author offers classification of different types of asshole. There is a delicate balance between deciding that someone is an asshole and deciding that he doesn't really rise to the level of assholitude (one really does need to enrich the English vocabulary to discuss this subject; the author doesn't use this ugly word, however).

The classification: I won't spell out the details. After all, you should read the book. I do provide some example asshole sub-types from the book, so you can compare your knowledge of these people with the label to get some idea.

1. Boorish asshole: Rush Limbaugh and Michael Moore
2. Smug asshole: Richard Dawkins, Gustave Flaubert, Bernhard-Henri Levy

    Flaubert: "Woman is a vulgar animal from whom man has created an excessively beautiful ideal".

    This subtype also has a French translation due to the French public intellectual being overrepresented in the list: le smug asshole.

3. The asshole boss: Naomi Campbell and General Patton

4. The royal royal asshole: Henry VIII

5. The presidential asshole: Hugo Chavez, Mahmoud Ahmedinajad, Dick Cheney, Silvio Berlusconi

6. The corporate asshole: some guy I've never heard of

7. The reckless asshole: Cheney and his Iraq-war cohort

8. The self-aggrandizing asshole: Cheney

One odd thing about the above list is that it's not using attributes consistently. I would have expected better from a professional philosopher :). The corporate/presdential/royal royal asshole has in common the fact that their position changes them into assholes. The smug and other categories of asshole seem to point to internal causes. I was left a bit dissatisfied by this. Perhaps it would have been better to have a typology with several layers: external causes vs internal, and then drill down, perhaps cross-classifying across sub-categories (Cheney ends up everywhere; perhaps the generalized universal one-size-fits-all asshole type applies). We need a type-theoretic treatment of assholes, with a full feature specification.  Maybe HPSG practitioners can help. The author does provide further classifications in a subsequent chapter, but I think the classification criteria can be improved.

The author continues by discussing why it is that it is mostly men that are assholes. He basically argues that it is largely culturally determined; there are female assholes (Ann Coulter is mentioned). This of course raises the question: to what extent is the asshole to blame for their behavior, if most of it is the result of a conditioning process? I didn't quite get his conclusion, but I think he's saying that the asshole bears some moral responsibility and can therefore be blamed for his behavior.

The author then moves on to asshole management; on his home page, he has a 13-step list (not mentioned in the book as such), but basically it's an amalgam of Stoic principles and small steps one can take to minimize one's own unhappiness. The bottom line is you are not going to change the asshole's behavior, so focus on other issues you can control (e.g., vigilant avoidance, only working with the asshole on your own terms, etc.).  Ideal asshole management needs years of training, it seems, a bit like doing aikido.

The author also talks about things like asshole capitalism, the erosion of social structure as a consequence of the way the political system is set out. He believes that Italy is a prime example of asshole capitalism, and that the US is getting there. His basic theory is that asshole capitalism arises if there are incentives to achieving "unbounded personal enrichment", undermanagement in that there is no system in place for damping the tendency to be an asshole (e.g., in Japan there is a shaming culture). He also lists destabilization (gradual degradation), but this seems more like a consequence of the first two to me.

Some reflections on the implications of this book:

One possibly upsetting consequence of reading this book is the realization that, at some point or another in our lives (especially if you are male), we have acted like an asshole. The author provides us with this lifeline: someone can act like an asshole---in a particular situation or over a particular day or week---without really, ultimately, being an asshole. Wow, that's a relief! Because I feel much better about myself now. I've acted like an asshole (um, more than once). I'm sure you have; actually, I can't think of many male academics I know that haven't acted like assholes at one time or another (and I can think of a few females academics who did). By the way, if, while reading this, you didn't realize that you've acted like an asshole in the past but you think pretty much everyone around is one, you probably are the asshole we are discussing here. The author notes this point: "if you would be willing to call yourself an asshole, this indicates that you are not in fact one." The corollary of this statement is the one that's more interesting for me (I'm not one to focus on the positive, I always look at the negative side ;). The author also astutely observes that you may either feel (a) shame, or (b) a thrill of joy, at discovering that you are, in your opinion, an asshole (under the above self-test). (a) is OK, (b) not so much. You can also be a half-assed asshole, not a full-fledged one; but even that is bad enough.

Ultimately, in my opinion, thinking about assholitude is a bit like talking about alcoholism; a significant proportion of the population is already part of the problem, and a major part of the problem is the inability to recognize that one has a problem through the way one is.

Another thing that the author doesn't mention but which I think is true is that each one of us has an inner asshole waiting to leap out. The same thing happens with racism. The distinguished liberal professor who would never say an unkind word about a particular minority, and steadfastly votes left of center, will happily express contempt for some sub-class or the other if you just open the way for their inner feelings to express themselves. You can always get the most enlightened and open person to eventually say something that counts as racist.  In India, I used to study in a left-wing university, where equality for all was what mattered, and my fellow students were super-conscious of projecting egalitarianism. Even the formal courses on western philosophy were all about studying (and memorizing) Marxist-Leninist pronouncements. But even this group would find some regional group to mock. Surprisingly, these Khaki kurta-clad intellectuals would mock Punjabis the most in front of me; this is surprising because I am Punjabi---why would they mock this group to my face? Biharis were another common target. They saw no irony in the disconnect between their egalitarian concerns and their mocking of regional groups.

 So how can one mitigate the influence of one's inner asshole? Remind yourself periodically that your interlocutors are your moral equals, that courtesy and respect do not need to be abandoned when bringing up your opinions.

This book is hugely relevant for academics. The most dramatic manifestation of academic assholeness is in the reviewing process. Reviewers can be unnecessarily harsh when they critique a paper. And yet, I actually sympathize with such an asshole reviewer; I too have felt the rage when reading an incompetently done piece of work. My solution to that has been to write my asshole-version of the review, and let it sit for a day or two. I got it out of my system, I feel happy as I am know I am right and the authors are obviously, each one of them, a piece of shit.  Then I rewrite the review. I first start with the positive achievements, and rephrase all my criticisms into a milder form. When I do this, I always find that some of my criticisms were the product of rage, and they do fall by the wayside. I do sometimes fail to do this, but the cases are diminishing with increasing age and experience. Another way to mitigate the assholitude that comes naturally to us during the reviewing process is to sign your review. That will definitely motivate you clean up your act. Academics don't just sit back and take the criticism. If the "enemy" knows who you are, and this opens up the possibility of blowback, your tone will automatically improve. My harshest reviewers have almost always been anonymous.

The book also made me think about my life in Berlin/Germany: how commuters will elbow you out of their way to get into the train first, how people walk right through you as if you were not even there, and how they just walk past you without acknowledging you if you hold the door open for them. Anyone inside a car automatically acquires a sense of special entitlement too. How everyone plays music ever more loudly on their headphones with every passing year. How people will park all their bags on the seat around them in the train and roll their eyes if you want them to move their stuff so you can sit. How people will smoke in no-smoking areas (and folks have been beaten up and hospitalized in Berlin for asking such people not to smoke in these areas).

Compared to Japan, or even Paris or the midwest in the US, the contrast is dramatic, and I could not help thinking that somehow German society has managed to foster the culture of assholism. But thankfully we have not succumbed to asshole capitalism (at least not to the extent that the US or Italy has). It would be very interesting to study where this culture of self-entitlement came from. Why didn't Germany evolve into a *relatively* polite society like their immediate neighbor France, or the extremely polite Japanese? It's a fascinating question. However, on the positive side, one thing I took away from this book is to follow Epictetus and just accept things as they are and not fume about all the daily injustices one experiences. Let it go, as the song goes.

Thursday, January 1, 2015

One year of night dialysis

I'm now in my fourth year of hemodialysis, and 31 years from my first dialyses and transplant back in New Delhi. For one year, 2011-12, I did dialysis in a center in Berlin, but I couldn't handle it---dialysis patients in Germany are by far the most inconsiderate of all, compared to dialysis I have done in Australia, Copenhagen, Japan (Kyoto and Tokyo), Spain (Barcelona), USA. France comes a close second to inconsiderateness. They will watch TV with the volume on their headphones set to maximum, talk loudly to neighbors even if others are sleeping, shout out loud and do all manner of objectionable things.

So, after training for nine months, I switched to home dialysis. I tried it for a year, but that didn't work out either. I documented my experiences here:

Eventually, my doctors got sick of my complaints about the so-called technical support and (diplomatically) kicked me out of the dialysis center by recommending I do night dialysis in a different center. So here I am, one year later, on night dialysis. I have to say I have converged; this is as optimal as I think dialysis will ever get for me. My days are relatively free. I have trained myself to meditate myself to sleep once I am hooked up to the machine, and to not move my shunt arm during the night (it is amazing what you can train your mind to do if you only try). One year later, I am nearly off all my blood pressure medication, and for the first time in my life I am nearly medication free. This is the most normal I have ever been in my 32 years since my kidneys failed.
So I am happy to say that I am now pretty satisfied with my dialysis situation. Night dialysis works for me.

The downsides: There are some disadvantages, however, that I have to learn to live with.

1. Come rain or snow, I have to go to dialysis in the evening, around 8:15PM, when I am dog-tired, and take a one hour trip to the center. And I get done at 5:15AM, which means that I take the train home at 6:00AM and am home by 6:30. Taking the early morning train in Berlin is fraught with danger: there is vomit, there are seriously deranged people about, there are people looking for a fight after a night out drinking. You see the margins of society in full display, and it is not a pretty sight. Statistically, I am pretty sure that one day something bad will happen to me on one of these trains. 

2. I feel much fitter; I can do 165 pushups (in five reps of 30-40 each) and am steadily building up to my goal of 250. But I can't build muscle because it's a losing battle with dialysis; most of the protein gets sucked away by the machine. I have lost 5 kilos since I started dialysis, mostly muscle I had built up during my transplant days. I had built that muscle up with weight training, something I cannot do any more because my shunt arm is not allowed to lift anything more than 10 kgs. So I train with 6 kg weights, and that has almost no effect on muscle size (although my stamina has gone up). I've lost significant muscle mass on my legs. (Have to work on this in 2015, need to find more time to build pure muscular power.)

3. I am still at the mercy of the expertise level of the nurses, and the formal rigor they bring to the table. And the same type of chaos I experienced earlier in patient management continues.  Whether I have a good night or not depends to a great extent on the nurse in charge. If they tape my needles even slightly wrong (hitting the wall of the shunt) I am going to get alarms all night. If they don't remove the air bubbles from the heparin pump, the machine will detect the bubbles eventually and set off alarms, waking me up. I mentioned all this to the doctor, and asked them to set up a checklist to ensure that every detail is checked (this is how they do it in Tokyo: one nurse comes and works through a checklist with the nurse in charge to make sure everything was done right). But I was told that we don't do checklists; the results are there for us to see and for me to experience in all their fullness.

4. Nobody is tracking the slow deterioration of my shunt, except of course for me. I have had two ultrasounds so far on my shunt, and the evidence is clear: the blood flow is decreasing. This means I will soon need a procedure for widening up the shunt. However, no one but me is keeping track of the reduction in blood flow volume.  There just isn't any record of what the results of the first ultrasound were, and no comparison with the second ultrasound; if I didn't have the volumes memorized we would not know that volume went down over the last year.  That has been my experience in Germany. When my shunt was built, it was a major operation with general anesthesia. The last thing I heard before they made me inhale the gas to knock me out was "Where's the patient's checklist?" "We can't find it, it's not in the folder." "OK, we'll do it without." The anesthesiologist (or was it the surgeon? don't remember) also used a ball point pen to make a cross on the arm on which the shunt was to be built. The broader point is that a dialysis patient has to be his own doctor; if you don't get informed and track your own life, you are going to pay a price.

What to do about the fact that chance plays such a big role in one's career/life trajectory?

 Adam Ruben writes about Pure, Stupid Luck: how luck governs success in academia:

Although he's absolutely right, I feel that this article's point is beside the point for an academic for whom the dice didn't give all sixes, or indeed for anyone. First, luck plays a role in everything (not just academia). That is something outside your control, so you'd better learn to accept what you can't influence. Second, bad luck comes in different variants. A terminal illness that gives you weeks to live is catastrophic. Not becoming the world's leading scientist is...well, if you consider that bad luck, then ask yourself why you do science. If it is for the fame, then you're better off in the film industry. Scientists who are able to publish in top journals with ease are not just lucky; more often then not, the editor in chief works down the hall from them in their own department, or they have worked on building such a vast network of friends that usually get friendly reviews. Or indeed they are just that good. The unethical aspect of publishing (using your colleagues' influence to get published) is unethical and not something you should emulate. The ethical way to proceed to is to try to become just that good. That's a constructive thing you can do to thwart the inevitable buffeting chance will subject you to. You will get as far as you will get---even there chance plays a role---but that is a much more constructive thing to do than to say it's pure, stupid luck.  Why does one become a scientist? For many the answer eventually becomes: for the power, for the fame. But that should not be your answer. The answer should be: to do the science.

I have been thinking about this question---the role of luck---in response to a question from a student. She was worried about her future in science. The question for me is: what can the individual do? One answer comes from So Good They Can't Ignore You. The basic thesis of this book is that you need to develop unique skills. That's something largely under your control and will have unexpected (positive) consequences for your life. It may not make you the world's leading authority in whatever, but as I said, that should not be your goal in the first place.

The final point emerges in this amazing book, Worldly Philosopher. This is a biography of a Berliner who went on to become an economist: Albert O. Hirschman. Although the story of AO's escape from Nazi Germany and the aftermath itself is an amazing one, one basic insight I got from this book was that nothing goes as planned or hoped for, but you have to try to turn that to your advantage. You have to try to make a virtue out of the unexpected outcome. A related idea is that you should try to turn a disadvantage---a bad outcome from said dice roll---to your advantage. There is often a way if you think about possible ways to leverage your bad luck. I think these are much more useful observations than Adam Ruben's.