Simone’s OncOpinion
Career development observations and advice for medical professionals from Dr. Joseph V. Simone.

Monday, April 10, 2017

​Changes in leadership are common at government agencies and the academic medical centers influenced by them. Having observed such changes recently, I have begun to ask myself what makes a good leader of these organizations and, better yet, what makes a great leader.

Leadership matters; it matters a lot. This is so whether the organization is a business, a practice, a hospital, an academic institution, or a government agency. Books on business success, including leadership, seem to be everywhere. Typical is the book, Winning, by Jack Welch, the former CEO of General Electric, which became a bestseller. While books on leadership of non-profit organizations, particularly those in health sciences and healthcare, are almost non-existent, leadership qualities are shared in both venues. So let's review what some gurus of management have had to say on the subject.

One of my favorite sources of business management wisdom is Peter Drucker. This legendary sage understood and clearly described the features of running successful businesses. He is famous for believing that integrity and high ethical standards are central to good business practice because it is the right thing to do, but also because it is good for the long-term health of an organization. Here is an excerpt from his work.

"What would I look for in picking a leader of an institution? First, I would look at what the candidates have done, what their strengths are—you can only perform with strength—and what have they done with it? Second, I would look at the institution and ask: 'What is the one immediate key challenge?' I would try to match the strength with the needs. Then I would look for integrity. A leader sets an example, especially a strong leader."

Drucker then quotes a famous and successful business leader whom he asked what he looked for in a leader. And the man responded, "I always ask myself, would I want one of my sons to work under that person? If [the leader] is successful…would I want my son to look like that?" Drucker then concludes, "This, I think, is the ultimate question."

He continues, "In human affairs, the distance between the leaders and the average is a constant. If leadership performance is high, the average will go up." And finally, "Effective leaders delegate, but they do not delegate the one thing that will set the standard. They do it."

Another well-known management expert, W. Edwards Deming, also held this last principle. Deming is best known for being the American consultant who revitalized Japanese industry after World

War II. "It is the responsibility of management to discover the barriers that prevent workers from taking pride in what they do. Rather than helping workers do their job correctly, most supervisors don't know the work they supervise. They have never done the job." Deming goes on to say that such supervisors often use numbers or quotas as the only basis for judgment, without understanding the nature of the work.

The greatest leader in American history was, in my view, Abraham Lincoln. This view was cemented in my opinion by a book that focused on his leadership and political skills and, of course, on aspects of his personal character that shaped the former (Lincoln: A Life of Purpose and Power). Lincoln's integrity, vision, and bedrock principles were combined with uncommon political skills acquired in his Illinois years and with a keen sense of public opinion. These enabled him to navigate skillfully the most difficult and treacherous times of our country. He devoured information from all sources and sent aides into the field to obtain first-hand information that helped him make astute strategic decisions. He was an uncommon leader who engaged some political enemies in his administration because he believed they were the best people for the jobs.

In my experience, it has been clear that the ill effects of poor leadership, at any level from CEO to department head to housekeeping, insidiously permeate an entire institution. This invariably leads to inefficiency at best, and at worst leads to falling dominoes of lost opportunity or catastrophe. Effective leadership is often subtle but direct, nuanced but clearly understood. What makes great leaders is not a secret. They not only have grace under pressure, which means both courage and character, but they remain focused on the important aspects of an issue in the midst of chaos. Great leaders repeatedly articulate a consistent, simple public vision by example, conviction, and actions. If the troops don't know what is expected of them, what direction is set or what the leader values most, that is the leader's fault.

However, this vision must be backed by public acts, not just words. There are many opportunities to demonstrate one's vision, both subtle and overt. Whom the leader hires, fires, and promotes sends the most effective signal, but smaller acts can indirectly express his or her values. Great leaders take satisfaction in the success of team members and try to hire people who are better than they are.

I end with two qualities that help distinguish a great leader from a good leader, especially in the not-for-profit world. First, though he remains confident in his final decisions, he must have humility in sufficient measure to mitigate arrogance and promote active listening to those holding other views. Second, he knows that at some time he will be asked to compromise basic principles. If his values cannot be sustained because of the environment, the great leader may choose to lose favor, be fired, or quit over a key principle. If the position or stature or pay means so much that the leader will not put his job on the line for a core value, he is no longer free and has taken a step onto a slippery slope. Great leaders have the mindset upon taking a position of holding core values and principles dear, no matter what the cost. 


Monday, March 27, 2017

I am not sure how I get there, but now and then I find myself facing a stone wall with a large gate. There is a woman sitting in a guardhouse the size of a telephone booth. I walk up to the gate and greet the woman. I start a conversation. Here is the first one.

JVS: I always thought the gate would be pearly, but it is just rusty iron.

Woman: The gate you refer to is further up the path, and it is not pearly; it is made of titanium—lightweight, shiny, and rustproof. This is the triage gate.

JVS: This gate is open so may I go on?

Woman: No, you may not. You are not dead yet and only the dead may go further.

JVS: I am here because I have some very important questions for St. Peter. He was known in his day as Simon Peter and I think we may be related; my father's name is Peter (from the Greek for stone) Simone. He must have passed through this gate almost 50 years ago.

Woman: Yes, he did. Nice man.

JVS: You saw him? Was he OK? Was he allowed past through the pearly— sorry—the titanium gates?

Woman: Everyone who passes through this gate is OK. And I can't say what happened to any of them after they pass through, but I wouldn't worry about him.

JVS: But I must ask these very important questions of St. Peter because he will be the last authority I see before "The Decision," and I do not know if he will let me through the titanium gate or point me to the sign, "All ye who enter here abandon all hope."

Woman: Maybe I can help you with your questions.

JVS: But these are detailed questions about the medical profession. I am a physician.

Woman: I know all about you, even about that incident in Kyoto.

JVS: Uh-oh.

Woman: My scanner identified your DNA as you walked up and my computer had your entire history in 6 milliseconds.

JVS: How can you "scan" my DNA; you didn't take a tissue sample. And I don't see a computer.

Woman: We have had non-invasive DNA scanners forever; they are entirely biological and small enough to be implanted in my eye. The computer is also biological and is in my brain. No cables to fool with and no stupid IT department required. Every staff member here has this equipment and we are all connected wirelessly.

JVS: That is astounding! You must have a gigantic memory.

Woman: You can't even imagine.

JVS: Well, OK. I guess I have no choice but to ask you the questions.

Woman: That's right, and you better get on with it. We need to finish before the evening rush.

JVS: Well, the first question is…wait a minute, do you know what I am going to say before I say it?

Woman: Yes, but go ahead; I enjoy the exercise.

JVS: I am worried about the state of the medical profession back home. We find ourselves in the middle of an econocentric society, one that often measures success by how much money and goods one accumulates. And we doctors end up focusing on financial issues and dealing with payers. I am ashamed to admit that, at times, money becomes a main focus of the practice overriding prudent medical judgment, sometimes consciously, sometimes not.

Woman: Your worries are justified. What have you done about it?

JVS: Me? Well, nothing. What can I do about it?

Woman: It is not my job to tell you what to do.

JVS: What about St. Peter? Can he tell me?

Woman: No. He answers to only one question—"Which way?" But there are others above who may respond to your questions and, as you know, we are all connected wirelessly. Who would you like me to ask and what is your question?

JVS: (Pause)

Woman: Well?

JVS: I'm thinking. OK, I would like to ask Sir William Osler the following question—Sir, you set very high standards for the practice of medicine. What can myself and my colleagues do to protect the noble values of our profession? I know we have lived in a different eras, but you must have dealt with this issue.

Woman: [After a pause, she speaks with a male voice.] Physicians in all eras have dealt with this issue. Doctors' behavior is subject to the bell curve of human nature, just like the population at large. A minority consists of idealists who are willing to forego personal gain and safety for the good of patients and the profession. At the other end is a minority essentially wedded to the business of medicine. For them, there is never enough income and, using self-serving rationale, they willingly sacrifice the good of patients and society for personal gain.

The remainder is the great middle that consists of individuals who have some features from both extremes, but lean more or less toward one extreme or the other. That is where hope lies, not with the idealistic saints, but with those on the "good" side of the great middle group. They are pragmatic but have mature, well-informed consciences that lean toward idealism and the option for the patient. And the group is large enough to be influential. They need to know they are not alone and they can make a difference. The better professional associations may be able to foster and support this group; but, unfortunately, membership organizations often pander to the lowest common denominator. They offer glitzy programs on or near the beach and pass out trinkets and shoulder bags, which some doctors collect. You and others of like mind have your work cut out for you.

JVS: Thank you, sir.

Woman: Satisfied? [In her own voice.]

JVS: Well, it was helpful, but somehow I expected something more specific.

Woman: You can ask someone else, but only one more; it's getting late.

JVS: Yes, the evening rush.

Woman: Well, we don't really have any evening since time does not exist here, but we try to use terms familiar to the souls coming through. Who would you like to question next?

JVS: I'm not sure; maybe William Carlos Williams. I admire him enormously both as a physician and a poet, but on the bell curve he may be too close to the border between the great middle and the idealists. He wrote about the practice of medicine:

"I have never had a money practice; it would have been impossible for me. But the actual calling on people, at all times and under all conditions, the coming to grips with the intimate conditions of their lives, when they were being born, when they were dying, watching them die, watching them get well when they were ill, has always absorbed me. I lost myself in the very properties of their minds: for the moment at least I actually became them, whoever they should be, so that when I detached myself from them at the end of a half-hour of intense concentration over some illness that was affecting them, it was as though I were re-awakening from a sleep. For the moment, I myself did not exist, nothing of myself affected me. As a consequence, I came back to myself, as from any other sleep, rested."

I think if I asked him that might be his answer. It is admirable, but so personal that it might be of little help to me.

Woman: How about Don Berwick?​

JVS: But Berwick is alive.

Woman: So? He does live in your era.

JVS: Yes, I guess Osler was right. Medicine has had, and still has, heroes like Berwick as well as its scoundrels. I guess we must look within ourselves and our profession, as it is today, to find and encourage those who have studied and work at sustaining the more noble values of our profession. We must look to them for leadership and support. This has been a valuable experience; it has given me a lot to think about and ideas for some actions I might pursue. I guess I will head back. Thanks for your help.

Woman: You are welcome.


Tuesday, February 28, 2017

What influences us to choose the specialty of oncology has always interested me. Today, there are many training programs and role models for medical students and house officers to emulate. But when I completed my internal medicine residency in 1963 and started a fellowship in pediatric hematology (that's another story), there were few formal training programs in oncology; ASCO did not exist; there were no subspecialty board certifications for hematology, medical oncology, or pediatric hematology/ oncology. At that time in the late 1950s and early 1960s, there were many locations where only radiation oncologists and surgeons gave chemotherapy.

The relatively few full-time medical oncologists often arrived at their professions via other medical activities. The migration from hematology was the most common, but others came from a variety of specialties and activities as diverse as endocrinology (studies of hormone-dependent cancers) and from World War II studies of toxic compounds like mustard gas. As with physicians today, the choice of subspecialty in the early 1960s was influenced by a mentor, a patient, a family member, personal traits, or by unique or serendipitous circumstance. In my own case, the example and mentoring of Donald Pinkel, MD, the first director of St. Jude Children's Research Hospital, made me a committed oncologist, scientifically as well as clinically.

Choosing medical or pediatric oncology was unusual and no easy matter in those days: medical and pediatric oncology were viewed with condescension by the pooh-bahs of academic medicine because they were "unscientific;" medical and pediatric oncology were mostly poor sister add-ons to hematology in medical schools (they thrived mainly at cancer institutes); the foundation of clinical trials was being laid with fits and starts; diagnostics for most cancer were primitive by today's standards; disfiguring and debasing gonzo surgery, including "super-radical" mastectomies and the fabled "hemicorpectomy," was common; and the prevalent radiation oncology equipment was the cobalt-60 machine.

But the most defining feature of that time was the treatment—it wasn't very good and the great majority of patients died relatively quickly. Because of the stress of dealing with so many dying children, it was not unusual for pediatric oncologists to change specialties; some of my own colleagues switched to radiology, dermatology, neonatology, and radiation oncology.

While the support of mentors, our personality type, and the other factors noted above often influence our career decisions, I believe the picture is more complex. I would guess that each of us could easily recall distant and seemingly unrelated personal experiences that instilled in us "life lessons" that helped us navigate this challenging field. Such recollections are seen, of course, through the fog of passing years. So with selective hindsight and a bit of puckish reconstruction, I have listed in roughly chronological order some of the character-shaping lessons that I believe helped me to choose in 1967 to become a full-time pediatric oncologist.

Family Culture

I attribute my father's influence for my values. But in this context his example of a deep mistrust of material possessions and of living within or below one's means served me well and later provided me the option of enabling me to take extended postresidency training and an academic career which, of course, I did. The lesson: Live below your means and keep your options open as long as possible.

High School Football

All the coaches were "old school" in the early 1950s. Pre-school summer practices were brutal: twice a day in full pads and uniform in the August heat and humidity with no drinking of water during practice (I did say old school), and punishing scrimmages to see who could "take it." We had snug-fitting leather helmets with no facemasks; I think all they protected was our ears from being torn off while blocking. We all talked about quitting, but few did. I wasn't a very good player and I rarely started, but I played well enough and the experience was invaluable. The lesson: I was capable of persevering under severely trying circumstances (handy insight for an oncologist).

Holding Retractors

Like many medical students, my choice of specialty changed several times before I made my final decision. I loved surgery…in theory. But after hours of holding retractors and doing all the other related chores (not very well), I decided that surgery wasn't for me. I didn't see myself getting enough satisfaction out of the operating room to make up for the rest of it. The lesson: The manual and technical aspects of medicine did not suit me as well as the intellectual. When I met the chief resident of the service, he said: "Do you want to be a cutting doctor or a thinking doctor?" He sifted me out with one question.

Homer

No, not the Greek poet. Homer was a 5-month-old African American baby under my care during the pediatric elective of my medicine residency. He was a beautiful, chubby, happy baby that was always glad to see me. He had pyloric stenosis that eventually was surgically fixed without incident. For reasons I can't explain, caring for Homer helped me realize how much I liked taking care of kids; I still think of him years later. The lesson: Patients had much to teach us about ourselves, including what direction to take in our medical development.

Serendipity

Three examples: I moonlighted to support myself and my upcoming new family. I took call in an industrial clinic and later worked the night shift as a hospital lab technician; that stirred my interest in hematology, which ultimately led to a career in oncology. One of the best available hematology fellowships happened to be only two blocks from my residency institution so I could go to an interview at no cost; it also happened to be in a pediatric department (Irving Schulman, MD, an eminent hematologist, was chairman), which ultimately turned me into a pediatrician. A colleague in the department (Charley Abildgaard, MD) was asked to look at a "hematology" job at a place I had never heard of then, the 4-year-old St. Jude Children's Research Hospital in Memphis. He was a Californian and suggested that it might be a better fit for me. I subsequently spent 24 great years at St. Jude. Each of these serendipitous events had a profound impact on the course of my career. The lesson: Planning is important, but chance can play a major role in a career; one should keep an open mind and not plan too rigidly.

The Chicago Cubs

Finally, I learned to read newspapers for pleasure from the sports pages of the Chicago Tribune. The Chicago Cubs' games were broadcast all summer; there was no TV and the radio announcers' dramatic renderings of the play made me a passionate fan. I suffered many years of the Cubs' legendary futility—they last won a World Series in 1908 and last played in one in 1945, when I was a 10-year-old. And even after leaving Chicago, I could not remain completely detached from their fortunes or switch allegiance to another club. Maybe it was because I was born a few blocks from Wrigley Field. Maybe, as someone once said, a sports allegiance passionately held at 8 years of age is ingrained for life, like it or not. In any case, being a Cub fan entails accepting many defeats while retaining unquenchable hope. The lesson: Being a fan of the Chicago Cubs was excellent preparation for a life in oncology.​

In summary, we all can point to major influences that led us to become oncologists, but I believe there are many seemingly minor factors as well. These "minor" factors may in the long run have been at least as important as the "major" factors, if not more so … and certainly are more interesting.


Wednesday, January 25, 2017

I don't know much about Olympic swimmers or professional quarterbacks, but with my unscientific observation, I would guess the average top-notch swimmer probably peaks in competitive ability at about 20 years of age, give or take 4 years or so. I also would guess the average competitive professional quarterback probably peaks at about 30 years of age, give or take 4 years or so. By that I mean they will not consistently perform substantially better after reaching that peak. Subsequently, they will perform at about the same level for a while and some time later, slowly or rapidly, progressively get worse.

Barring a serious injury, they may still perform satisfactorily, but not at their historically best level. There are exceptions, of course, but the variations are most likely to be when the decline occurs, not if it will occur. A decline is inevitable.

As I have aged, I often have wondered when physicians reach their peak of skill as a doctor. To be clear, I am speaking of physicians as practicing doctors who provide ongoing care for patients on a consistent basis. Of course, this is not easy to measure (maybe impossible) so my attempts to tease this out cannot be a straight line because we have no quantitative comparatives, such as swimmers' race times and gold medals or quarterbacks' touchdowns and interceptions, to use as a gauge.

This is basically a personal reflection of my 5-decade span as a physician and as one who has observed, trained, worked with, and judged many physicians. My focus is on physicians as practitioners of the art and science of medicine face-to-face with patients, not as a chair of medicine, leader of a practice group, laboratory scientist, or any other related professional activities that physicians may enter.

The first challenge in this exercise is what is meant by peak? Peak of what? Surgical or other technical skills, diagnostic skills, compassion, knowledge? Wrestling with these questions led to my approaching the issue from an oblique angle rather than head on.

When I view the evolution of physicians' abilities, I believe there are at least three overlapping phases. The first is experience. This is the basis for all the rest. The next is intellectual insight, which combines experience and knowledge acquired from experience and indirectly from publications, meetings, grand rounds, colleagues, and students. The third stage is humility, knowing the boundaries of one's ability and the common sense to act accordingly. Humility implies that one is open to becoming wise, to acquiring wisdom. This is the opposite of the know-it-all.

Each of these three qualities can be, and usually are, expanded over time and each reaches a peak, often independent of the other two. For example, an experienced and knowledgeable surgeon with long experience and excellent technical skills may remain infantile when it comes to humility and tends to inflate the accolades he receives to justify acting beyond his experience, knowledge, and skills. I can think of examples for radiation and medical oncologists as well.

If a physician lacks one of the three pillars described above—experience, intellectual curiosity with knowledge, and humility—it would be impossible to reach a high level of medical practice. The peak of one's ability would not be "competitive" and it would be difficult to imagine such a practice being even satisfactory. The degree to which one raises his/her skill level in all three of these qualities will collectively determine the peak of skillful medical practice.

For this purpose, one may encompass all these qualities into a single "measure" (really an attribute) of peak ability and skill: wisdom. Experience, intellectual curiosity, knowledge, sensitivity to patients and their needs, and a measured balance of good judgment and humility contribute to what we might call, "medical wisdom," which includes the application of all three qualities.

Let's digress for a bit about "wisdom." First, here is a short poem.

The Road to Wisdom

The road to wisdom? Well, it's plain

And simple to express:

Err

and err

and err again,

but less

and less

and less.

—Piet Hein (Danish poet)​

This reinforces the idea that wisdom comes from experience, learning, and the ability to accept that one has erred (or observed another who erred) and change one's practice, the latter being a sign of medical wisdom.

So back to the initial question: When do physicians reach their peak? It may vary a bit by specialty, but my guess is that most physicians are at their best and have reached their balanced peak in the span of their forties and fifties. They may reach their peak of technical skill, knowledge base, or intellectual curiosity earlier, but wisdom is like a fine red wine, it takes longer to develop. I have known physicians who remained at or near that peak in all three qualities well into their sixties, but more often there is a decline in stamina or enthusiasm, or distraction with other duties that causes slippage; slippage in one area may be mitigated if the pillar of wisdom stays strong and a humble mind stays open.

Of course, some of this speculation is autobiographical. In my own case, I thought I was the best pediatric hematologist-oncologist on earth in my 30s, a clear lack of humility. I believe I reached my peak as a physician in my early 40s and remained close to that level until about a decade later. I accrued administrative responsibility by then and eventually started to lose track of antibiotic doses and much of my imaging skill due to lack of use. The fellows and nurse practitioners knew more about many details than I did.

When I left St. Jude in my mid-50s for an administrative role at Memorial Sloan Kettering, I realized I could not and should not assume primary responsibility for patients because of this decline, but mostly because I was undertaking a full time administrative job and would not be readily available to patients and families. Happily, I found I could still think about and discuss clinical problems clearly (as in rounds and conferences) and retained what I believe was good judgment for quite a while; technical day-to-day bedside knowledge declined first and analytic wisdom faded last.

It is humbling to realize that, in my view, despite all my training and experience and study I was at my very best as a physician for only a decade or two. I like to think I was pretty good before and after that period, but who can say? Certainly not I. Humility is the only one of the three pillars that I believe has continued to grow in my case. A review like this is one reason why.


Tuesday, January 10, 2017

Most oncologists get phone calls from relatives or friends about someone who has been diagnosed with cancer. Trying to be helpful, they suggest the friend or relative contact "my cousin (or uncle or classmate), the oncologist" for advice. They call and typically, we are told a sketchy story with so little information that we cannot provide even superficial comments or advice. The call often ends with our saying, "she is in good hands," or "he lives very near to (I name a good cancer program) if he wants another opinion." On occasion, we get more detailed information and face the difficult task of offering counsel without destroying the patient's confidence in the attending physician.

Less often in my own experience, my relative or friend passes on a request that I speak with the patient or spouse of the patient. These patients almost always have widespread cancer unresponsive to therapy. If it is clear from the discussion that the patient seems to be in good hands and that critical decisions must be made among difficult choices, I always honor the request.

First, what the patient or spouse (with the patient listening) asks is whether there is any other treatment out there that could help. But there is an unspoken understanding that their question also concerns the imminence of death and what course they should take. This is hard to do on the phone, some would say foolhardy. But if it seems right from what I have learned and the rapport is appropriate, I tell them what I think. Sometimes this means recommending the patient get his affairs in order, arrange for management to relieve pain or other problems, consider hospice care, and spend as much time at home with family as possible. In effect, I often confirm what their doctors had said, that the patient would die in the not-too-distant future.

The art of telling someone they will die does not come naturally. It requires confidence and experience and wisdom. I cannot explain these qualities with sufficient clarity to help someone else do it. The approach is sui generis, adapted to the teller's and the recipient's character, knowledge, and personality. It never gets easier…in fact, it may become harder as one ages.

Having to relate this opinion, and having done it all too often in my first years as a pediatric oncologist, has led me to read a great deal about death and dying over the years and to this day.

Unavoidably, it causes me to think about my own mortality. Philosophers, theologians, psychologists, and novelists have written reams about death. Many try to rationalize death in some way. They and I are looking for solace or some mechanism for facing the death of a patient or relative or friend or oneself.

I have found some understanding and a dash of comfort from these sources, but I am most touched by the poets who can, in a few words, contain volumes about the human condition, death being an integral part. The poet's oblique and figurative approach to the subject sometimes makes much more sense than the direct and rational. Here are two poems on the subject by Billy Collins, of whom I am an avid fan; he is a former Poet Laureate of America.

My Number

Is Death miles away from this house,

reaching for a window in Cincinnati

or breathing down the neck of a lost hiker

in British Columbia?


Is he too busy making arrangements,

tampering with air brakes,

scattering cancer cells like seeds,

loosening the wooden beams of roller coasters

 

to bother with my hidden cottage

that visitors find so hard to find?

 

Or is he stepping from a black car

parked at the dark end of the lane,

shaking open the familiar cloak,

its hood raised like the head of a crow,

and removing the scythe from the trunk?

 

Did you have any trouble with the directions?

I will ask, as I start talking my way out of this.

Collins thinks about death and with a few strokes describes the human condition and the mystery, apparent randomness, and loneliness of death. He wrote another poem about death inspired by a quote by Juan Ramón Jiménez: "The worst thing about death must be the first night." He explores the mystery of death and the feebleness of our ability to imagine or describe it with our catalogue of words.

First Night

before I opened you, Jiménez,

it never occurred to me that day and night

would continue to circle each other in the ring of death,

 

but now you have me wondering

if there will also be a sun and a moon

and will the dead gather to watch them rise and set

 

then repair, each soul alone,

to some ghastly equivalent of bed.

Or will the first night be the only night,

 

a darkness for which we have no other name?

How feeble our vocabulary in the face of death,

how impossible to write it down.

 

This is where language would stop,

the horse we have ridden all our lives

nearing the edge of a dizzying cliff.

The word that was in the beginning

and the word that was made flesh—

those and all the other words will cease.

 

Even now, reading you on this trellised porch,

how can I describe a sun that will shine after death?

But it is enough to frighten me

 

into paying more attention to the world's day—moon,

to sunlight bright on water

or fragmented in a grove of trees,

 

and to look more closely here at these small leaves,

these sentinel thorns,

whose employment is to guard the rose.​

Finally, after puzzling over what is beyond death and the futility of words to describe that mystery, he returns in the last three stanzas to earth to focus on what he can appreciate that is here, the beauty and the mysteries that are closer to home. A good lesson for me, too.