Tag: Health

Cone-Eyes

JulianLeave a comment

The goal of medicine should be optimal health. You can achieve optimal health through all sorts of pathways.

Tomorrow, they will slice into my eye (graphic representation). I’ve been eagerly awaiting this day for years.

Fifteen years ago, I learned I have keratoconus, a degenerative eye disease that prompted my sister to nickname me “cone-eyes.”

I first wore glasses at ~12, contacts at ~15. Hated both. The etiology is unclear: maybe the growth plates that jammed in my cheeks as a child; maybe eye-rubbing caused the mis-shape; maybe the mis-shape caused the eye-rubbing. By the end of one’s twenties, the cone generally stabilizes.

Most people avoid elective medical interventions. As my mother likes to say: “You only get one body.” That logic explains why most people stop at the first reasonable doctor, take the standard recommendation, and live with whatever they’ve been handed.

I know at least three ways to play this game better. You can hire the world’s best, every time (expensive, not always available). You can take what’s offered, set low expectations, and hope (cheap, sometimes works). Or you can attack the doctors until you find one who doesn’t buckle. 

I do the third.

For my eyes, one optometrist wanted me to harden my corneas. Standard of care. I declined for my case. Another doctor, in southwestern Spain, wanted to harden them and then install hard plastic lenses. Closer.

Now, in Paris, I’ve found the Center for Keratoconus and the Cornea. The practice literally says “keratoconus” in its name. This specific surgeon looks at eyes like mine all day, every day. 700 of these surgeries; 0 major complications. Of the ~2 million performed worldwide, the number who have gone blind doesn’t appear in the literature. I believe it’s either 0 or close to it.

The risks:

  • The lens rotates (a second procedure is then needed to re-seat it).
  • If my vision deteriorates, I will need to replace the lenses. (The lenses won’t cause this deterioration: it’s just a natural occurrence for some people as they age.) 
  • A punch to the eye becomes a much bigger problem.
  • Worse night vision.
  • Infection (very unlikely with proper care).

The benefits:

  • Perfect vision, no glasses.
  • Perfect peripheral vision. Today, to look at something off the edge of my vision, I turn my whole head. The edges of my glasses cap my field. After tomorrow, just my eyes move.
  • Better at sports.
  • A weirder benefit: I’m less anxious without glasses. Legally blind without them, but calmer. I don’t know why. After tomorrow, I won’t have to choose.

I already spend most of my life attempting not to be eye-gouged. After tomorrow, that preference intensifies. In exchange, the head-swivel stops.

Today, walking through the park, I removed my glasses and looked at them. Despite the humorous engraving on the side[1], I’ve never liked them. I hope tomorrow evening to jump up and down on them in glee.

I feel nervous. That’s why the surgeon gave me xanax. That, and he’ll be operating on my eyes while I’m still using them. 

Will it go well? We’ll see, I hope. 

[1] It reads “HURRR DURRR !!!”

Win the Hand, Lose the Tournament

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“You already want. Want at the right level.”

Somehow, moving 6,205 lbs in 45 minutes is easier than moving 0 lbs.

My life was forever changed when I encountered this idea in Aristotle’s Nicomachean Ethics: 

  • Virtue is formed through habitual, repeated actions.

In college, I focused on habit formation. Routine is simple – and for me, can be easy: “Every day” is often easier than five days per week. Habit is a valuable default. 

But sometimes, excellence requires non-habit. Sometimes, wanting to win can make you lose.

Know When to Fold ‘Em 

The hunger that makes you a cutthroat poker player can also lose you tournaments. 

In many poker tournament situations, the winning move is to fold. There are plenty of spots where one has the guaranteed best hand yet the proper move is folding! (E.g. pocket aces with a short stack on a tournament bubble when multiple other players are all-in.) 

The fastest way to lose a fortune at poker is over-bluffing. 

Give up on this hand. Find a better spot.

Know When to Walk Away

The strategy that makes you a skilled weightlifter also exacerbates your injuries. 

Ten years ago, I bulged a disc in my spine. 

Three weeks ago, I re-activated the same injury. I paused deadlifts and squats, only returning to them 3 days ago. My sciatica flared up again. I stopped.

In the long term, one day without lifting doesn’t matter. One week wouldn’t matter. A re-injury could bench me for life. 

Wanting to lift weights makes you a good weightlifter. But wanting to lift weights can also make you a permanently-bad weightlifter.

Know When to Run

For the next 6 weeks, any lifts involving my back would be “rolling the dice”. Contrary to popular opinion, I don’t like gambling: I like situations where gambling leads to an edge. 

This isn’t one. Today, I’m taking a rest day from the gym.

Count Your Money When the Dealin’s Done

The game isn’t one poker hand. The game is long-term winning. 

The game isn’t today’s weightlifting. The game is long-term health. 

These intellectual reframes – “it’s not about this hand” and “it’s not about lifting today” – can have cascading effects. They relax your mind. They create new patience. 

Today I will take a rest day. And each second when I’m not lifting weights, I will remind myself I’m getting stronger.

Consistency, Consistency, Consstncy

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“Every Day” means Every Day! means ¿Every Day? 

I have a motto: Seven days a week means seven days a week. (Except when it means five.) 

I have three categories of “Every day”: 

1. Religious Commitments 

If lightning struck me and I awoke in the emergency room, I would still write every day. 

The commitment is inflexible. The details are wishy-washy. Sometimes “day” stretches into the early morning hours of the next day. Sometimes “writing” means a scribbled sentence onto a post-it note reading “I don’t want to write today.” When I was writing two pages per day for my first book, many days started with writing “I don’t want to write today… I don’t want to write today…” until I got in the groove and shifted to the topic. Most days, I pen and publish a brief essay. 

When I injured my back, I performed a prenatal core workout as my daily 5 minute abs. 

This “every day” works because the requirement is rigid but the goal very easy. 

2. When 7 = 6 

    I lift weights every day. 

    (Except for ~2 days per week.) 

    I tell myself I lift weights every day. Sometimes this approach is honest: Over the last two months, some weeks, I lifted 7/7 days. 

    The issue: Weightlifting relies on unpredictable activities. How well will I sleep? How recovered will I be? Sometimes, I need a rest day to prevent injury. 

    7 days per week therefore becomes 6. But if I aimed for 6, 6 becomes 5… and 5 becomes 4…  and very soon I’m watching cartoons with Dorito dust on my chest

    This “every day” works because the requirement is flexible but the goal very intense. 

    3. The Failure of Flossing 

    Jeff Foxworthy’s dentist asks, “Have you been flossing every day?” 

    “Not every day…” Jeff admits. “The last time I flossed… You did it!” 

    Most people don’t floss. I don’t brush my teeth in the morning. (I only brush at night.) 

    Turns out I brush in the morning every day the way most people floss every day. 

    Default to Yes

    I experience a large mental cost oscillating about action. 

    Writing 5 days per week is somehow more difficult than 7. If I give myself an out, I consider and negotiate. Instead, I commit and know my category. 

    Seven days a week means seven days a week.

    (Except for the contexts where it should mean five.)

    (Or zero.)

    (Or negative one.) 

    Do Fewer

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    You win by making the right move. You make the right move by waiting for it.

    Before my jaw surgery in 2018, I made too many moves.

    I underwent a sleep study at a facility that allowed me to sleep on my stomach. Obstructive sleep apnea is positional. Bad medical care.

    A dentist prescribed an oral appliance and lied to me about its potential side effects. I wore it. The side effects were bad. 

    A surgeon told me I’d need to fix my deviated septum, so I might as well do it now. Unnecessary surgery. I’d later have maxillomandibular advancement, which would necessitate a septum fix at that point anyway. I had mis-sequenced, again due to bad advice from doctors.

    Six doctors mis-diagnosed or mis-treated me before I found the world’s expert in obstructive sleep apnea. Not himself a surgeon, he sent me to the only surgeon he liked. I had the surgery. It went wonderfully. 

    One quality move would have saved me ten years and six bad doctors, one bad surgery, and one damaging oral appliance.

    I had an insufficient respect for quality.

    A friend has spent the last decade on a large legal case about a contract violation. Ten years, about ten moves. He says most of his days are spent staring at a wall thinking. The hardest part hasn’t been any single move. It’s been the waiting between them — the part where you’re not doing anything visible. 

    It’s easy to get antsy. But the right move at the wrong time is the wrong move. And the wrong move, just to do something is even worse. 

    That’s not laziness. That’s respect for quality.

    Recently, two optometrists told me I should get corneal crosslinking. The pattern-matching said I needed it. Something didn’t smell right. 

    So I went to the actual experts — the ones who’ve seen thousands of patients who look like me over the past thirty years and done seven hundred-plus surgeries on people with my eyes. 

    At the end of this month, I’m flying to France to install permanent contacts. The pattern-matchers were wrong. The real experts were right. The move they suggested would have been unnecessary.

    Refusing a move is also a move. Sometimes it’s the best move.

    When I started freelancing, I asked everyone for client referrals. I had to. I didn’t know who would say yes, what worked, what my rate was, or who my buyer was. This was the explore phase. More information was better.

    By my third set of clients, the machine started carrying itself. My hourly rate was higher than many lawyers’. Inbound exceeded what I wanted.

    The shift on calls was exponential. I had good pre-call materials. I had good post-call follow-ups. The call itself was mostly listening and repeating back what the client had said.

    One call, I was sitting at a kitchen table on mute, pulling funny faces while my then-partner pointed at the phone whisper-yelling, “Pay attention! Focus!” The client stopped talking. I unmuted. I said five words. I re-muted. The client said, “Wow, you really get it!” Then-partner was floored.

    I would tell early-Julian to keep investing in the process. And not to abandon it when he got tired of it — to keep investing, just in a new way. The work shifts from doing more to doing fewer, better. Respect the elegance. 

    Flailing is not testing.

    When I hired my contractor, I went for volume — got fifteen quotes, narrowed them down. The cost of each one coming by was low — just some of my time — so I figured why not. But I wasn’t systematic. A bit more research upfront — learning how the process works, what the categories of contractor are, what the right questions to ask are — would have produced a faster result with fewer visits. 

    Getting a lot of information systematically is a research strategy. Getting a lot of information randomly is flailing. The two feel similar from inside. They aren’t.

    Closing on this apartment took eight months. The required topics ranged from negotiation to financing to weird legal processes to printing documents at 11 PM in rural France. About ten major moves in total.

    Once the incentives were aligned — me, my broker, the seller’s broker — the rest clicked pretty smoothly. The eight months were spent making the right moves slowly, not many moves quickly. And about half of the key moves were me saying no to other people’s requests. At least two of those would have ruined the deal. 

    It’s not about doing less. It’s about doing fewer, where each one is more elegant. Build the system that reduces the steps. Invest in infrastructure. Make the right move when the right move presents itself.

    If “fewer” ever becomes zero, that’s a different problem. This approach won’t fix that one. But it does need fixing.

    Life is full of games. Games require moves. Don’t do less. Do fewer. 

    The Surgeon Who Quoted Standard Practice

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    You win the game by assembling the right team. In medicine, the right team thinks. 

    Before my sleep apnea surgery, I interviewed surgeons the way you interview contractors. Notebook in my pocket, questions prepared, specific concerns about specific structures, specific tradeoffs, and speculation about areas outside of the medical literature. 

    After ten years of complaining about sleep to at least a half-dozen doctors, I finally met a surgeon who lit up when I pulled out the notebook. We were in a teaching hospital; his students were in the room. He went question-by-question with me. He enjoyed the questions the way an expert juggler enjoys a bowling ball being thrown at his head. I pushed him hard. He juggled the chainsaws. We became friends.

    The second surgeon, at a different and widely respected teaching hospital, wore a very nice lab coat and said things like “the standard practice in this scenario is…” She said it several times. When I pressed on specifics, she returned to standard practice. She was pleasant. She was credentialed. She was a pattern-matcher. She wanted me to use a CPAP for the rest of my life. 

    Doctors are often pattern-matchers. You go in with symptoms, they recognize the pattern, they prescribe the standard response. Most of the time this works, because most symptoms are common. The pattern holds.

    The problem is that pattern-matching is indistinguishable from competence until you’re the edge case. And then it’s catastrophically different.

    A real scientist notices when the pattern doesn’t fit. A pattern-matcher doesn’t notice, because noticing would require understanding the mechanics rather than seeing the pattern. The failure is perceptual, not moral. The pattern-matcher isn’t lying and usually isn’t careless — they don’t understand the mechanics of the machine, so they follow the owner’s manual. 

    This is why “they didn’t intend to be malicious” is such a weak defense of anyone in a professional role. Nobody intends malice. Bullies don’t intend malice — they perceive attacks where there aren’t any. Cruel people don’t intend cruelty — they mis-observe what cruelty is (often by thinking they’re acting righteously). The failure of perception is the failure. 

    Optimism is a specific, dangerous version of this. The optimist sees only what’s going right. If their own work is the problem, they can’t see it — and they can’t hear it when other people raise it, because the pattern in their head is: my work is fine. 

    I don’t want a doctor. I want a scientist who practices medicine. Even better: a philosopher who uses science to practice medicine.

    A test: can you break your surgeon in conversation? If they can be broken – if your uneducated mind can throw questions that cause them to buckle – are you really going to trust them cutting into your unconscious body? If a surgeon can’t handle intensity well, do you really trust them with your surgery? 

    After my first six doctors mis-diagnosed or mis-treated my sleep issue, I now attack the ideas of every doctor who consults on my case. If they can’t hack it, I want a different doctor. I didn’t even go to medical school, and you can’t handle me? 

    I may irk some competent doctors who are unwilling to tolerate my approach. I accept this rate of false negatives, since I am happy to travel the country to find a doctor. If I had limited options, I would behave differently. 

    It’s lonely to keep searching for a new doctor over and over again. For one recent medical topic, I’m on six consults and counting. 

    When it’s not a big deal, I don’t fight this hard. But when it is, I’ll keep attacking your ideas, methodology, and approach until I dismiss you or I trust you. 

    Most people fall into the first category. The second category is how I befriended my surgeon. 

    Game on.

    Treadmills (Feb 28 2026) 

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    Criticism is best spoken directly to the creators. 

    Tonight I experienced excellent performance art. Insightful observations, beautifully executed. What follows is my letter to its creators: 

    My Dearest Pony Cam, 

    Thank you for a guffaw-provoking show. I enjoyed it from the Chef’s Table this evening. Both my partner (a trick-or-treating ghost) and I (the diner in the blue hat) will speak very highly of your show to our friends and family. 

    After leaving and discussing the show with another group of patrons (they recognized me as I was passing their dinner table two blocks away), I have one observation/suggestion for you to think about. 

    I see merit in the show’s ending (the explicit Ok Go reference, alongside the dance performance of that video). I think that the dance would benefit from a clearer host-to-audience emotional framing before it happens. 

    • Is it cheeky self-aware appreciation of the lineage of treadmill performance art (“That’s the best we can do with treadmills. And here’s the second best…”? 
    • Is it self-effacing (“We know when you return to work on Monday you’ll need some way to tell your colleagues what you saw. You’ll say, “Four people performing on treadmills.” They’ll say, “Oh, like the OKGO music video?” And you’ll say “Yes, exactly like that.” [Cue dance])? 

    The dance performance felt like an unframed homage. And, after such a beautifully constructed show, it felt like watching an innovative troupe ending with a cover. (Imagine Pink Floyd just ending a concert with a cover (but not making it clear why)). Even just a “We really want to acknowledge our roots” would change the experience, giving that dance meaning rather than only spectacle and (for some people) nostalgia. 

    Depending on what you’re trying to achieve with the treadmill section, I could imagine a few different framings. I’d love to chat more about your goal here and brainstorm ideas.

    Happy to chat about it more, as well as any other aspects of my experience of the show. (And to misuse the idiom, feel free to tell me to go fuck spiders 🙂 Hope this observation is helpful! 

    Thanks for a great night!

    Julian 

    [My phone number] 

    Elbows and Existence (Feb 20 2026)

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    An infinite array of options; I’ll be aye. 

    My elbow tenses.

    At 32 years old, my first repetitive stress injury. 

    Second, after a pickleball shoulder. 

    But this elbow is also a pickleball injury. 

    Squeezing paddle, sure. 

    But also the orientation of my elbow as I laid on my back, my computer on my chest for too many hours: the hunched-over curl of a crone despite my then-13 years old. 

    I hunched today as I did then. 

    Now I pay. 

    It’s odd to grow old. To scrape off one’s vigor and exchange passion for comfort. To realize my mind may be and continue to be heading farther away from me, not nearer. 

    To replace exuberance with action. 

    Having finished most of the big explore, to replace it with exploit. 

    Enjoying everyday enough to select it among the infinite. 

    To have experienced enough to know. 

    How many have made pilgrimage to Seoul for the finals of your favorite childhood sport? 

    Ran shirtless in Indonesia? 

    Meditated in Thailand? 

    How many have eaten pasta two blocks from the Vatican? 

    Kayaked the arctic ocean? 

    Swam the Great Barrier Reef?

    Negotiated for tee shirts in Mumbai? 

    I don’t feel like a life unlived. 

    I feel like the foundation; the fundamentals of everyday existence: 

    That those thusfar empties are slowly seeping solid. 

    I don’t need to see the thousand buddhas again. 

    I’ve seen them, snapped selfies with silly smirks, stumbled upon the graveyard, and biked home. 

    Share these with a future wife and children, sure. 

    Invite my extended family to duck and cheese at my Paris pied-à-terre. 

    Learn what makes my new brothers laugh. 

    When the door has opened, why keep knocking? 

    Step-by-Step Instructions (Feb 15 2026) 

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    In which Our Hero reflects on unusual timelines. 

    People often ask me how I formed such an excellent relationship. (No one has asked me. But let’s assume.) 

    Here’s my process, in case it helps: 

    1. Date her friend 
    2. Have a threesome with her and another one of her friends (not the one you were dating) 
    3. Let 10+ years pass 
    4. An AI matchmaker pairs you
    5. Schedule a 3-day-long camping trip as your first date 
    6. Extend date to 10 days long, ending only when one of you comes down with Covid 
    7. Wait 2 weeks <cough, cough> 
    8. As a second date, she moves into your van, and the two of you drive across the country together
    9. Attempt to purchase a house together in Puerto Rico within the first 6 months
    10. Backpack though Europe together
    11. Break up 
    12. Attend clown school together in France
    13. Get back together 
    14. Put down a deposit to buy an apartment 
    15. Buy life insurance on each other 
    16. Within one month:
      • Make embryos
      • Get engaged 
      • Buy apartment 

    We’ve got all the right steps, just not in the normal timeline. Maybe next we have kids before getting pregnant. 

    To Each Their Own (Valentine’s Day Poem) (Feb 14 2026)

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    In which Our Hero & Partner pen a poem. 

    She is to fear as I am excitement. 

    Our poor calibration; our tragic flaws. 

    Whether biology or culture, 

    faith or fate, 

    such is, we agree, a soulmate. 

    Is this framework unique to us,

    or is it self-evident? 

    Dislike of other comes from framework projection. 

    Sometimes mine’s better,

    sometimes yours. 

    Neither own all, 

    nor control wrongly; 

    Calibration is key. 

    Before you try to hyperoptimize a process, 

    be sure you’re optimizing for what you actually want 

    and not a correlate. 

    Hate Mail (Feb 11 2026)

    Julian2 Comments

    In which it’s nice to be seen 🙂 

    My first piece of hate mail arrived in the form of a google document from my partner’s former grad school weightlifting friend. It articulated all the terrible traits that he observed during the long weekend we stayed with him. It included such gems as, “There were multiple occurrences of him saying something to the effect of ‘this happened because of some thing you did Nikki’ or ‘whose fault is this?’ And because he was saying it in a silly way it is expected to be a joke.” 

    I read this criticism to a clown school friend of mine, who asked, “Oh, so you were doing bits?” 

    “Yes,” I replied. “One was blaming Nikki for absolutely absurd things that were clearly not her fault, like the weather.” 

    “That’s a pretty good bit.” 

    “I agree.” 

    —

    Then, two months ago, I received a second piece of hate mail. This one came as a series of text messages from a fellow clown student. She derided my blog, my relating to other humans, and my analytic approach. I hadn’t spoken with her in ~a month (I had broken my foot and stepped away from clown school), and before that, I recall only neutral-to-positive experiences. Apropos of nothing, she sent me this diatribe. 

    I have since shared that letter with a few friends. To a person, they describe it as “unhinged” (or various synonyms). 

    In her hate mail, she made a few good points. My writing was likely alienating to some clown students. Clown school is a beautiful place and a precious gift. 

    She also took some shots. Specifically, she said I “wasn’t funny yet” (the newsletter was called “Am I Funny Yet?”) and she described my blog as “very public and mediocre”. 

    After I received that letter from her, I of course didn’t reply. I also of course didn’t alter my writing or publishing schedule. The article I published that day prompted a second screed from her the next day. She – in whatever reality she was experiencing – thought my intervening post had been about her (it had not). 

    This second screed brought me great joy. 

    “Ah,” I thought. “How wonderful it is that she reads my blog every day!” 

    —

    I like to live my life in public. I adore New York partly for that reason: meeting strangers and living in an environment where big, bold people are appreciated. I take my shirt off in public. I do so even though I’ve grown breasts. 

    I also think it’s funny to call a blog about someone’s daily struggles “mediocre”. It’s not polished. It’s not complete. It’s not intended to be either of those. It’s a documentation of my attempts to do new and challenging things; a collection of my thoughts and observations and learnings and experiences. I’ve never been accused of waiting for perfection (and my partner, at least, thinks my life is better for it). That’s one of the clowning lessons: fail more, and befriend your flops. 

    To quote my partner: “Being mediocre is the first step towards being kinda sorta good at something”. 

    At present, I have 21 Substack subscribers and 168 subscribers. 

    I’ve never looked at my stats before. I haven’t cared. I still don’t. But it’s nice to know that her estimate is also true numerically. 

    So yeah, with my hundred of fans and my abnormal life, I’m proud to be: 

    Very Public & Mediocre.