Cold and Dark Return to the High Plains

moon over the snow

I walk the outskirts of town, the cold and dark are everywhere.  The darkness has returned to the High Plains.   From daylight’s savings until the return of sunlight becomes perceptible again in January are the low parts my year.  I don’t mind the cold, but I miss the light.

The cold can be clarifying tonic on the High Plains.  It is not suffused with the dampness of Eastern cold.  It is a freeze-drying cold.  Bracing is the word for it.  The darkness can be disorienting, but the cold wakes you up – keeps you focused on the fact you are still alive.

Moonlit Night on the Dniepr – Arkhip Kuindzhi – 1880, Tretyakov Gallery, Moscow. Public Domain.

Tonight is cold and brightly dark, punctuated by the shine of a waning moon, though still nearly full.  It has been a tough past few days on call on the High Plains.  The darkness and the holidays bring out dysfunction and mental illness.  Without a clearly lit path, people quickly wander back into their own darkness.

A razor-thin slice shy of freedom

For the second time in 12 hours, I am reapproximating the flesh on the left forearm of a man in chains – offenders as the guards say.  The same man. Two cheeked fragments of a razorblade did the work, the second one not found in time.  I had known he was serious about wanting to die.  While stitching up the wound when it was only 4 inches long, he had calmly made small talk.

Disinterestedly watching me sew his numbed arm, “I guess it is harder than on the movies.  In them it is one smooth slice and they die quick.”

I pulled my running vicryl suture, the fatty subcutaneous tissue tightening. He didn’t flinch – a good anesthetic field.

“The body is designed not to die,” I replied. “The body wants to survive.  I might not be able to get your tattoo back to what it was before.”

I ligate an small oozing vein, luckily for his blood volume, he didn’t know the vital vasculature is quite a bit deeper.

“That’s okay.  It’s just their to cover the name of a girl who isn’t my girlfriend no more.  I don’t suppose you can tell me this, but what’d I do wrong?  Where’d I miss?” He asked.

“You’re right, I can’t tell you that.”

That was the first time. After stitching his arm back together I thought about the safest place for him.  Prisoners don’t have a lot of options.  A locked unit for prisoners in the county hospital 2 hours away?

The prison guards assured me he would be watched and would have access to telepsychiatry within several days.  All the options sucked, this one seemed as good as any other. I discharged him back to their care with signed orders for follow up. I even asked them how they were going to keep him from ripping it back open – they had had an answer.

just looking for some peace

Within 12 hours, he was back.  The wound twice as long, but only minimally deeper.  Still no muscle or large vessel damage.  Killing yourself with a half-inch long piece of broken safety razor is not for the faint of heart.

Shit, I think.  I should have found harder for a different solution.  Clearly that didn’t work.  Was I cavalier with his safety?

Me: “So, how did you get another razor blade?”

Offender/Patient(O/P): “I had another one hidden.”

Me: “Where was that?”

O/P: “Well, I can’t tell you that, its privileged information.”

He sprouted a mischievous grin.

“Was it somewhere sensitive?” I pushed.

“No.” He seemed ashamed of the implication. “I had it cheeked.”

shit, he had a back up plan…

A different facility would not have been any safer – he really wanted to kill himself.  Who tries to kill himself and holds something back, just in case he fails?  Someone who knows life is worse than death.

Me: “Well, why do you want to die?”

O/P: “I just want some peace. I’m tired of my shit getting fucked with, of me getting fucked with.  I am not affiliated, so everyone fucks with me.  I just want to be left alone to do my time.”

(Affiliated, if you are not familiar, means not in one of the prison gangs)

Me: “How much time do you have left?”

O/P: “Well, I am up for parole soon, but I don’t have much hope for getting out.  My latest possible release date is 2024.”

Me: “What would it take for you be able to want to live that long?”

O/P:  “Just to be alone, in peace, doing my time.”

Me: “Like solitary?”

O/P: “Yes.”

I place the last 3-0 prolene horizontal mattress suture – for strength, just in case he has another back plan.  Well-approximated, I muse.

the lonely moon

Sitting on the hill, I take in the pale moonlight glancing off the water tower.  It sands in front of the red warning lights of the wind turbines on the distance ridge, which are blinking in unison.

The guards placed O/P into a prison van and took him to the state penitentiary’s system infirmary.  He would be kept shackled the entire time, to prevent a similar incident.  Likely shackled to a bed, with minimal to no freedom of movement. Additionally, the guards assure me he will have urgent access to mental health resources.

I don’t know what this man did to be in prison.  The prison nearby holds serious offenders.  He likely needs to be in prison to protect the rest of us.  Whatever he did was probably enough to sacrifice his right to freedom.

I can’t help see the irony in his desperate attempt at finding peace.  Trying to free himself from his current version of hell, he lost the last of his freedom.

I take in the peace of the night.  The moonlight reflects off the recent shallow snowfall.  My breath freezes in the air and slowly drifts off, without any perturbation. I think about Johnny Cash’s classic – Folsom Prison Blues.

Well I know I had it coming, I know I can’t be free
But those people keep a movin’
And that’s what tortures me

Shit is fucked up, I think to myself.  I start to slide into my cerebral self-flagellation.  Am I supporting the prison-industrial complex?  Am I profiting from it?  Who am I kidding?  Continuing to breathe in this world necessitates a tarnished soul.

I watch the bank of red lights blink.

O/P seems to have accepted his sentence of time.  I cannot and do not want to pretend he is a gentle man or a kind man.   True compassion doesn’t require a made- up story to make the person worthy of it.  He probably needs to be where he is.

Nonetheless, I do wish him some peace and hopefully it does not require his death.

 

 

 

 

My First Death Cafe

It takes the whole of life to learn how to live, and – what will perhaps make you wonder more – it takes the whole of life to learn how to die.

-Seneca

growing closer to loss

Until my wife and I both welcomed our daughter and ushered her out of this world within the span of a month, I had had little personal experience with death or loss.

Roadside Grave, Kinney Rim, WY. Author’s Own Work.

I grew up far from extended family.  I had no close relationships with older adults such as grandparents, and so their deaths did not affect me very strongly.  As such, I had not really observed much death or loss until residency.

Nonetheless, in residency I frequently led end-of-life care and goals of care discussions.  I was good at them, able to connect with families and patients, elicit their values, and move care in the appropriate direction.

I found the discussions gratifying.  It always felt like important work – real doctoring.

In clinic, I felt many of my patients were lost or stuck in regards to their physical and mental health and often life in general.  I did not have an inherent understanding of how people ended up in these states of life-limbo.  Over time, I came to feel that it was related to loss and our relationship to it.

As I did not have much personal experience with loss, I took to reading about it.  In particular, The Illness Narratives gave me a framework about how to understand the nature of repetitive loss and eventual death as a clinician.  This clinical research was a helpful backstop when faced with confronting death in my own family.  At least I had a framework.

death becomes him

Moreover, because of my clinical background in loss and death, the behavior and lack of acumen of my partners shocked me.  Compassionate and attentive clinicians with their patients, they were emotional ogres when it came to a fellow clinician.  I have since learned this is unfortunately fairly common in medical culture.

Our wider culture’s inability to engage with death shocked me less, but was still striking.  When grieving, even well-meaning people mostly just want you to feel better.  Your grief is disquieting and the assumption is that if they say something to make you feel better, everything will be ok.

Announcement:  When someone is grieving, everything is not okay.   Yet, that is natural.  That person’s world has been unmade, and they are relearning how to live in it.  It is supposed to be difficult and sad – that’s normal.  As a bystander, this is what you need to know.

My experience led me to seek out venues of personal healing, but also how to engage with the wider world about death.  We need to be better at this.  Our culture cannot afford – both materially and spiritually – to continue to view death as as optional – something to avoid. This is how I stumbled upon Death Cafes.

Death Cafes are simply groups of people who want to talk about dying, death, and life – to demystify the experience.  The movement started in 2011 in Britain and has spread around the world.

my first death cafe

So, I found a Death Cafe in my area and decided to go, not entirely knowing what to expect.  My wife agreed to come with me, though she was a little reticent.  Of course, we showed up late, sliding into the circle surreptitiously.

The circle was bigger than expected, 20-30 people.  A few were veterans, a few more had come only for the second time, and many more were first timers like us.  It was heartening to see it so well attended.  People were from their early 20s to their 80s.  The group was overwhelmingly female.

We went around the circle introducing ourselves and our reason for attending.  One man had simply been sitting in the area of the bookstore the group reserved and decided to stay.  Others were wrestling with their own grief, their own mortality, or simply had a desire to have a discussion about death openly and freely.

GINA

After introductions, one young woman erupted with emotion.  She had suddenly lost her father to cancer about 18 months prior.  They had been extremely close, he had been her rudder in the world.

Her grief and anger and a sense of injustice continued to possess her.   She was trying to learn how to evolve.  Her family were unequipped to have these discussions, so she was looking elsewhere.

She came to a room full of strangers, looking for answers.  It was a courageous act, to engage with her emotions and death openly and honestly.  It was plain to see she was struggling.  The group did not recoil.  Collectively, everyone leaned in, nodded, and listened.

As someone who has been through a great grief recently, it is hard to overstate how rare this experience is in modern America – to have strangers engage in your grief with you, without discomfort.  It is otherworldly, almost magical, especially in contrast to everyday life.  Even 10 years ago, this space did not exist.

the flow of conversation

The rest of the conversation flowed in an easy back and forth, remarkably civil and deep given the current public discourse in this country.

We touched on differences in how men and women deal with death and emotions, how you go about buying urns before you die, the fear of death and dying, and impermanence in general.  We came back to Gina’s grief once or twice.

In the end, we went back around the circle and people where able to express one or two thoughts they had not had the chance to express during the open discussion.  Overwhelmingly, people were simply thankful for everyone showing up, sharing, and being open.

My wife and I left feeling remarkable uplifted, even more alive.  It had been intense, Death Cafes are generally held monthly, and I am not sure we could handle them more frequently.  Nonetheless, the experience had been life affirming, not morbid in the least.

everything gets a return

The great Stoic philosophers had a phrase for this: Memento Mori.  Seneca and others recommended a daily practice or remembering and accepting death as a way to remind ourselves of our wondrously short lives and that nothing is guaranteed.

They argued the practice increased happiness because to helped us live our lives more fully.  I have not adopted the daily practice, but if it is anything like what experienced after my first Death Cafe, I think they were on to something.

Our culture is out of touch with Death.  We close it up, hide it, shaming public expressions of grief.  The daily practice of remembering and accepting death is a big ask in our current culture.

However, an open space to confront death in community may be a good place start.  This is what Death Cafes provide, a welcoming community of people on different stages of the journey towards knowing and accepting to death.  The experience was remarkably life affirming – I know we’ll be back.

Questions?  Thoughts?  Please comment below.

When Winning Prevents Success

One of the great lessons I took from my experience in my first job was to spend more time with a potential team before signing on a contract.  Things are often not as they seem.  My partners sold me a specific image of the practice.

They were, they said, a tight group of doctors who were passionate about providing rural healthcare in all settings: clinic, nursing home, emergency department, and hospital.  This was the perfect description of what I wanted to do, I thought.

I left my first medical staff meeting thinking, “What the hell is going on here?”

The vitriol, anger, and greed I heard in that meeting shocked me.   I had never heard people talk more aggressively about money.  Anytime someone floated a proposed change to staffing, coverage, or practice the meeting devolved into a squabble over potential effects on earnings.

I had thought that my partners were passionate about providing healthcare to this rural community.  Instead, they were passionate about making as much as possible while providing healthcare to this community.  Now, I am sure they would disagree with my assessment – greed seems perennially justifiable.

I have thought a lot about how we said the same words and yet meant completely different things.  I have boiled it down to the difference between these two words: winning and success. 

Why Winning and Success are not synonyms

While winning and succeeding seem similar aims, their underlying requirements vary in one significant way: comparison.  We must have a yardstick to assess a win and success.  The difference is which yardstick we use.

When framing accomplishment in terms of winning and losing, the yardstick becomes the performance of another competitor.  When we talk about success, the yardstick can be any number of measurements.  Success can stand on its own, a win necessitates another’s loss.  A near limitless number of participants can share in success, it does not demand a vanquished competitor.

Success is a far more inclusive goal than winning. 

what does this have to do with medicine?

Physicians’ ranks are subject to intense selection bias.  The process of getting into medical school is rigorous and very specific.  As such, people who get into medical school have tendency to be highly organized, driven, and ambitious.

Being ambitious does not require being competitive.  However, in American culture, it is almost always synonymous.  We arrange our culture into a series of competitions.  As such, medical students have a strong tendency towards competitiveness, or winning.

What happens when everyone in a room has organized their lives around the pursuit of winning?  They need to win.  For many, their entire personal identity is wrapped up in the idea of “being a winner.”

In a world organized around competition, if you aren’t a winner, you are, by definition, a loser. Therefore, someone else has to lose to keep a winner’s personal identity intact.

The winner’s ego demands the sacrifice of others to maintain its self-perception.

If excellent leadership is present, these tendencies can be harnessed to provide a cohesive team culture focused on conquering some external competitor.  Unfortunately, that takes truly excellent leadership, which is rare by definition.

culture changes slowly

Something I did not appreciate until I arrived in the “real” world of medical practice, was how change in medical culture lags our culture at large.  Due to the hierarchical nature of training programs, the long delay between joining the profession and being in a position to affect change, new voices take a long time to be heard in medicine.

Historically, medical training was egosyntonic with physicians’ tendencies towards winning and autonomy.  However, over the last 10-20 years, medical schools recognized the negative effects of this tendency and set out to try and train more collaborative doctors.  They found a generation ready-made for this in millennials.

millennials and physician work

Millennials grew up with group projects, team-based learning, and the much-maligned “participation trophies.”  In medical school, team-based care seemed logical and necessary.  Many of us we unaware that what our professors told us was still NOT the norm in medical practice.

Many older physicians view the millennial physician as lazy and entitled, not interesting in working, etc.  What many miss is that millennials are looking for something to work towards, preferably in a team.

We don’t want to win, we want to succeed.  Millennial success doesn’t look like working hard just to have a bigger pile of money, house, or fancier car than our neighbor.  We’ll keep our time, thank you very much, if all you have to offer is money.

Many health systems are fundamentally failing to address this change physician priority.  Millennial physicians are putting an onus on the health system to provide a strategically sound and meaningful vision with which we can align. Yet, the organizations repeatedly fail.  It would be so much easier to buy our complicity – it has worked up until now.

I believe millennial physicians are willing to work as hard as physicians ever worked, but for a reason – not for a paycheck.

I think my supervising partner’s eyes almost fell out of her head when after a mere 8 months in my practice I looked at her and said: “In residency, I was working 25% more hours for 1/6th the amount of money, and I was happier.”  It simply, yet profoundly, did not compute.

evolve or die

Going forward, understanding what younger physicians are looking for will be the key to the success of health systems.  I may be wrong, maybe enough physicians are willing to sell their time so health systems can get into bidding wars and pad upper management’s compensation.

When confronted with the reality of modern medicine, I bailed. I have no interest in working 80 hours a week to support a system in which the care of patients is actually just a means to an end.  Caring for the patient becomes the intermediary goal, the task done to generate revenue.

Well, I should clarify, we document our care of the patient to make money.

The pursuit of winning in the economic morass of the American Hospital-Pharmaceutical complex is getting in the way of our collective success.  As long as we care more about beating our competitor than building the best healthcare system, success will remain out of reach.

Palliative Care Consult: Dad

Patient advocate – new father

My daughter’s neonatologist and I stood close facing each other, cramped at the foot of my daughter’s isolette in the NICU.  She was only 2 days old and on a ventilator.  He had just finished updating me on her bilirubin and other labs, as well as her imaging.   I honestly didn’t care.

Most physician parents would have wanted to know all the data, all the lab values, etc.  I had complete confidence in a level 3 NICU to replete potassium, manage a ventilator, and correct neonatal jaundice.  All routine things in a NICU.

I was steeling myself for a more difficult conversation, one I had had dozens of time before.  But before, the conversation was about a patient, someone behind the emotionally safe distance of the doctor-patient relationship. This time, the end-of-life discussion was for my own daughter.

I felt I could broach this subject with our neonatologist early.  He had told my wife and me that our perfect, beautiful, newborn daughter was in fact not healthy.  He had done it in a straightforward and kind way.

After the first two or three questions from my wife he stopped her and said, “Those are good questions.  We will answer them as we can, but right now, you need to go fall in love with your daughter.” So we went to her bedside and did just that.

So, I stood in front the neonatologist, both a father and a physician.  I started to speak.

Jebediah’s Story

As a clinician, you never know when you are going to stumble across a gift that a patient has given you.  Sometimes they are obvious, even physical.  Other times the gift is knowledge and insight you would never have gained if not for the intimacy of caring for them.

Jeb gave me and my wife one such gift, and in a round about way, our daughter as well.   Jeb was a very sick toddler who was frequently in and out of the pediatric hospital I trained in.  He had been born very early, a twin.  His brother, Alex, had fared better than him.  Alex had developmental delay, but otherwise a fairly healthy 2 year old.

Jeb was a very cute kid.  His language skills were not well developed for his age.  His only verbal communication was limited to blowing raspberries in various tones that correlated to his mood.

As residents, we would walk into the rooms gowned in protective clothing.  Once into Jeb’s room, we would turn to see Jeb standing in the hospital crib, nasal canula secured to his nose, belly protruding outwards, blowing raspberries to get our attention.  Heart=melted, every time.

Jeb had bronchopulmonary dysplasia (poorly developed lungs as a result of his premature birth), he was chronically oxygen.  Additionally, he had Hirshsprung’s Disease (improper nerve development in the colon), this could lead to bouts of constipation and bloating so severe that it would compromise his lung function.

Jeb’s illness put an extreme burden on his mother.  She was a single parent who lived about 90 minutes from the hospital in a small town.  Any slight cold or virus would send Jeb into the hospital.  His mother did all she could for him.  His health was so fragile that she lived her life around him and his illnesses.

During one of his hospitalizations, Alex was with him.  Alex had a small tricycle that he was riding around in the hospital room. He rode it up to all the hospital staff, stopped, smiled and waved.  He occasionally even spit out a few words. His mom never took her eyes or attention off of Jeb.

In that moment, I saw all the sacrifices this mother was making for Jeb.  Time, money, energy, sleep.  Also, I could see she was sacrificing Alex’s share to Jeb.

Alex was still in need of extra support and therapy, yet compared to his brother, was the picture of health. Even if a mother’s love is infinite, nothing else in this world is.  At some point, she had to take from Alex to give to Jeb.

Jeb was so sick.  His lungs weren’t going to “heal,” this is the way they were.  The airways would get bigger, but he would never have healthy lungs.  His colon would never develop the nerve endings that it lacked.  I left the hospital that day a little devastated.

I couldn’t get over the image of Alex, who needed so much, being ignored because his brother needed so much more.  The collateral damage Jeb’s health was causing seemed obvious.  I even talked to his pulmonogist at one point, whose statement, “Jeb is a very sick, complicated case,” seemed to say it all.

Jeb wasn’t going to get better, we were just “managing” his illnesses.  All the doctors knew, Jeb would probably at some point die of the complications of his birth. Indeed, about a year later, he did succumb to complications of a respiratory infection.

This does not mean Jeb’s life did not have purpose and was not worth living. On the contrary, Jeb clearly brought a great deal of joy to those around him.  However, that joy came at a very real human cost, to both his mother and brother.  Like so many other parts of life, there is no such thing as a free lunch.

Jeb’s gift

That night, I staggered into the house, emotionally punch-drunk from the existential quandaries I had dissected during my shift.  I laid down next to my wife in our bed and told her Jeb’s story.

We laid on our backs staring at the dark ceiling.  I asked my wife, “What if we have a baby like Jeb?  Are we going to hook our child up to machines and oxygen, knowing what we know?  Is any life for our child worth any sacrifice? Both our child’s and ours?”

We discussed this at length.  My wife cried and hugged me.  In the end, she said, “No, if we have a child like Jeb, we will love him or her sooo much, and let him or her go.  That is no life for our baby.”  We hugged again, rolled over, and drifted off to an unnerved sleep.

Neither of us had any inkling that 3 years later we would be sitting next our daughter’s bedside in NICU and thanking Jeb for that conversation.  We continue to be so grateful for the gift he gave us.

back in the nicu

Back the foot of our daughter’s isolette, I started the conversation with our neonatologist.

I began, “I know we still don’t know much.  But, you don’t have to do what we do for a very long to see a lot of therapeutic creep.  More than anything, I am worried about her ending up on long term ventilation, with a G-tube, never being able to live without a machine.”

Continuing, “Again, I know we are waiting for more information from tests and imaging to see if we get more answers.  I also know a significant chance exists that we will have to make a decision without a discrete answer.  As an experienced physician you get a feeling, a gut feeling, about how things are going to turn out.  That might be the best information we get.  I just ask you to tell us when you have that feeling, because we are ready to have the conversation.”

His response was measured, but honest, “I am not there yet, but I am glad you are bringing this up.  Certainly, the possibility of tubes and long term ventilation are real.  I want to know I agree with you.  Just because we can do something, doesn’t mean we should.  I will let you know when we have to have that conversation.”

being your daughter’s palliative care doctor

That was my first, but not last, instance of feeling like I was my daughter’s palliative care consult.  I spent a good bit of our time in the NICU having similar discussions with nurses and, eventually, the hospice team.  Frequently, I felt like I was in between two worlds.

I was translating our values and emotional state into medical speak, because I knew that was the best way to advocate for my daughter.  Code-switching back and forth between the human and medical seems to be beyond many clinicians.

It took a great deal of effort to be both a physician and father in those days. Yet, it was a rare ability and gift I was able to offer my daughter.  I want to give a shout out to my counselor for teaching me to view it that way, instead of the burden I had felt it to be.

In the end, when we said we wanted to take our daughter home to pass, it was a groundbreaking request for that hospital.  It had never been done. Nonetheless, our neonatologist and the hospice team were amazing.

By Zerbey, CC BY-SA 3.0, Photo by Chris Horry at Arnold Palmer Hospital in Orlando, Florida, November 2002. Source Wikimedia Commons

My wife and I decided that we didn’t want 100% of our daughter’s life to have been lived in a windowless NICU.  At one point, I said that if we could at least get her into the parking lot, where she could feel the sun, I would have been satisfied.

Yet, we were able to take her on a 45 minute drive through the mountains to our home.  Our neonatologist came on his own time, the one who extubated and pronounced her.

We sat in the dappled shade under the pines, holding our daughter for the first time without the ET tube or ventilator to worry us.  He told that us that some of the nurses had asked him if we were doing the right thing.

He had apparently told them, “This is the ONLY right thing.”

Just Swooping in to Save the Day

a weekend a month keeps the doc in town

Retaining doctors, physician assistants, nurses, and nurse practitioners in rural areas is often very challenging.  Once a provider leaves, it often takes longer than average to replace him or her.  Unfortunately, this happens frequently.  I should know, I was one such provider.

Providers often cite the burden of covering the Emergency Department as a reason for leaving.  That was the inspiration for the company behind what I currently do.  It is cheaper to pay a temporary physician to cover occasionally so that the local MDs get a break, don’t burn out, and don’t leave than hire one full time doc or replace a burned-out one.

This often places me in an interesting situation.  Often times, I find patients and local providers very thankful for my presence.  I receive far more gratitude currently than I ever received from my patients and partners when I was a staff doctor.

I earn some of that gratitude.  Keeping local docs who have roots in their communities practicing is a worthwhile goal.  If helping cover a shortage on the odd weekend or holiday supports the local docs, I am glad to do it.

the prodigal parent returns

On the other hand, I often feel myself the deadbeat dad who shows up with ice cream and a trip to the amusement park on a birthday, only to disappear for another year.  The guilt I feel can be a little intense sometimes.  My wife thinks I should give myself a break.

Having been the local doc, I know how it can be.

The appreciation for being there day(and night) in and day out is often scant and irregular. Patients often take Steady Eddy, MD for granted.  The doc who is present whenever needed rarely gets a significant show of appreciation until their retirement party.

Why is this?  Humans seem to appreciate assistance in a moment of increased anxiety, dread, or pain more than the relationship, maintenance, and prevention that a long term physician provides.

This is an understandable human response.  These events brand our emotional hides much more strongly than functional and reliable relationships do, even if the latter is better for us. Though understandable, it is a BAD way to build a health system.

pounds and pounds of cure

I became a primary care doctor because I believe in prevention over cure.  I believe in helping people to live well, not just continue to exist.  Sadly, that is not the way our health system rewards doctors.  Apparently, because an ounce of prevention is worth a pound of cure our system pays doctors an ounce for preventing and a pound for curing.

By extension, I believe most people in the healthcare system have come to value expensive, painful, high risk cures over consistent preventative behavior.  This seems likely to doom our system to failure by any objective measure of a health system.  For a time, I tried to swim upstream, but the current was too strong.

The ED is a place for life-saving and band-aids.  I see so many wounded and broken people in the Emergency Department.  Most ED docs are not trained in primary care, despite the fact that huge amounts of what we do in the ED is actually primary care.  In the ED, we patch people up and send them back to their PCP, if have one.

On the other hand, just because I am in the ED, doesn’t mean I stop being a family doc.  I know what these people need.

They need an anchor of consistency and rationality in their lives.  They need a consistent relationship with someone who will compassionately hold them to account when their behavior slips.  Whatever I have to offer in the ED is rarely what they really need.

Again, the guy who temporarily patches the broken dam gets paid better and celebrated more than the guy keeping the dam from breaking in the first place.  Now I swim with the flow, patching holes as I go, and feel a little dirty about it.

Embracing insignificance

One of the greatest aspects of the High Plains is the size of the sky and the lack of city lights.  Standing under the full immensity of the universe during a call night, I often revel in my own insignificance.

Life is a great tapestry. The individual is only an insignificant thread in an immense and miraculous pattern. – Albert Einstein

Looking up at the stars, I cannot forget that I, too, am a pawn in this system.  I have no influence over our medical system, other than voting with my feet.  This seems unsatisfactory, as one is only able to vote for realities that already exist.   We are unable to create a new or better reality through “voting with our feet.”

As I labor on in our flawed system, I cannot help but wonder:

When the deeds of my doctoring are counted, how will they tally?

Does the good I do outweigh the system’s inadequacies?

Should I make this much money, given that I am propping up such a flawed system?

“Whatever you do will be insignificant, but it is very important that you do it.” – Mahatma Ghandi

If, even despite our cosmic insignificance, value exists in doing the work, then maybe results of the system are not my responsibility.  Perhaps simply showing up and trying to be a positive influence in the cascading stream is enough.

A stone in a mountain stream does not stop the stream, rarely even significantly redirecting the flow.  However, I have found many a beautiful, shimmering trout in the pools surrounding those large stones.  The stone did not built a system designed to provide me with a trout to eat, but is essential to the process nonetheless.

Am I such a stone, simply slowing down the crashing cascade enough to allow local doctors enough breathing room to survive, and hopefully thrive?  If so, is that good enough?  I don’t know, but at least its something.

 

A Crisis of Faith at the Crossroads of Sanctity and Commerce

 No other vocation—not even the sacred ministration of religion itself—requires a more constant exercise of the higher faculties of the human mind, or a more earnest devotion of the purer and nobler attributes of the human soul. …  Never suffer yourselves to be betrayed into anything that can degrade your [humanity] or cast the slightest stain upon the bright escutcheon of your honorable profession. - Doctoral Address of Gov. J. Proctor Knott, KY School of Medicine to class of 1890.
Oh, these sweet, noble lies

Those who train future physicians love graduations for the opportunity to repeat exaltations about our sacred calling.  Of course, in the middle of a 36-hour call shift, a speech like this can be a lifeline of validation.  That speech echoing in your head reminds of the purpose of sacrifice.

Yet, the phrase “Healing is an art, medicine is a profession, health care is a business”* continues to be re-quoted. These articles usually discuss the “reality” of healthcare being a business.  They comment on how doctors are increasingly seeking out business training in order to succeed in private practice or leadership settings.

Source: Wikimedia Commons

On the one hand, training programs still hammer the importance of self-sacrifice, humility, and service into young physicians.  Then, they graduate residency directly into a “business system” which, by definition, is trying to get as much profit out of our “sacred art” for the lowest cost.

Sometimes, it feels that training groomed us for exploitation.

 

Externality (n) - a side effect or consequence of an industrial or commercial activity that affects other parties without this being reflected in the cost of the goods or services involved.
doctor and patient outcomes: externalities of the “business of medicine”

As much as “value based payment” is in the news, it is far from mainstream and even farther from delivering its promise.   The healthcare system makes money from providing a large volume of services, not healing or treating.

In the business of providing a high volume medical services, the outcomes of patients only matter if they sue.  The satisfaction of physicians only matter if they leave.  Otherwise, they remain externalities.

Healthcare companies prefer greedy physicians, greed is a value they understand and can exploit to their benefit.  The noble and principled physicians are a nuisance – disruptive.  Those values have no value in the marketplace of American Medicine.

If you can’t bill Medicare for it, it doesn’t exist.

We graduate residency totally unprepared to compete in the arena of business, we don’t even know the rules.  As such, we are also unprepared to protect our own humanity from it, let alone our sacred art.  The current generation of graduating physicians are inheriting a system that has collected a century worth of stains.

Christ Driving the Money Changers from the temple. Source: Wikimedia Commons

The old Catholic hospital saying is, “No margin, no mission.”  It seems now that the margin has become the mission.  Medicine has lost its way at the crossroads of the sacred and the commercial.

The healthcare machine has replaced our once bright escutcheon, bearing the symbols of healing and humanity, with the Madison Avenue designed brands of healthcare delivery.

The moneychangers now own the temple.

“It is easy, when you are young, to believe that what you desire is no less than what you deserve, to assume that if you want something badly enough, it is your God-given right to have it.... I thought climbing the Devils Thumb would fix all that was wrong with my life. In the end, of course, it changed almost nothing. But I came to appreciate that mountains make poor receptacles for dreams. - Jon Krakauer, Into the wild
is medicine too, a poor receptacle for dreams?

I had thought medicine would provide a meaningful, useful vocation in life.  My teachers taught me I should guard my humanity and the sacredness of my profession.

How can you guard these things when the majority have already sold them before you step foot into practice?  Has being a physician become just trading pieces of your soul until you have enough money to FIRE?  Is that the best medicine has to offer?

If  losing my daughter and my first job taught me one thing, it is no one deserves anything.  It seems I have to fight for the kind of medicine I envision, no organization will provide it for me.  Is that the lesson?

Maybe my noble profession is not the direct laying of hands on the sick, but struggling for a new world.  Is a future where the layers of hands and the sick are once again on the same side possible?

[* Dr. John E. Prescott, chief academic officer, Association of American Medical Colleges, quoted in The New York Times, Sept. 6, 2011]

Direct Primary Care, Healthcare Costs, and Financial Independence

Disclosure:  I currently do not have any financial interest in any direct primary care businesses and have no plans to do so.  This may change in the upcoming years.  I simply find the model interesting and provocative as a healthcare consumer and a physician.

healthcare costs, the great unknown

I was reading TPP’s financial interview #13 and found another mention of how healthcare costs are a great unknown in planning for retirement/financial independence.  We all know healthcare in this country is too expensive and is getting more so.  Physicians should know more than most.

What has struck me is how limited the conversation tends to be: Healthcare costs are hard to predict and are the big question mark in retirement financial planning.  End of discussion.  I have not read any discussions on creative ways to mitigate this other than funding a Health Savings Account (HSA) to the hilt.

direct primary care could play a role

Direct Primary Care (DPC) is an emerging model of delivering primary care on a monthly prescription basis.  For a discreet set of primary care services a patient pays a monthly subscription fee (usually <$100), which covers all of those services.  Some additional services may be provided at cost or at a discount.  This varies practice to practice.

Most importantly, however, is the fact that DPC practices have a much smaller patient to physician ratio.  Usually 600:1, compared to 1,200-2,000:1 in traditional practices.  This means more time with the physician.  PCPs can save A LOT of money if they have the time to think through problems.

A well-trained internist should be able to handle the vast majority of nephrology, cardiology, and endocrinology without a referral – if they have enough time.  Anything task physicians do less frequently requires more time. Our current system incentives PCPs to refer as much as possible, because it saves the physician’s time, not the patient’s healthcare dollar.

Essentially, for those covered services, you are able to have a predictable monthly fixed cost for the length of the contract (likely to increase with inflation, etc).  To me, this seems preferable to the morass of opacities that is current health insurance and hospital billing.

Isn’t it appealing to avoid dealing with insurance companies for 80% of your healthcare?

DPC vs Concierge medicine

Many have critiqued DPC as “concierge medicine.”  This is unfair. Most specifically, concierge doctors tend to charge a monthly fee on top of what they bill insurance for increased access to the physician.  DPC charges the fee in lieu of charging insurance, getting rid of the middle man and increasing efficiency.

From a policy perspective, the one critique of DPC I feel has merit is DPC practitioners have “healthier” patients.  DPC proponents argue they have data showing their patients are just as chronically ill as the average primary care practice.  This may be true, but DPC patients are inherently more engaged in their healthcare.

Simply by taking the time to find an alternative model to obtaining primary care and putting some monthly income towards it, patients prove they value healthcare more than average.  Engagement in one’s healthcare is eminently more important in health outcomes than number of diagnoses.

brass tacks – DPC does not do everything traditional health insurance does
  1.  DPC does not fully replace insurance: Since DPC only covers primary care, you still should have some sort of health insurance.  Usually, this means purchasing a  catastrophic or high deductible policy.  On the other hand, health insurance is actually insurance (something paid for and hoped goes unused) and not coverage (something paid for and used as much as possible).
  2. DPC would not help a family afford expensive medications: For any diagnosis requiring a large number of branded medications, or even one or two monoclonal antibodies, DPC might not be sufficient.
  3. HSAs cannot fund DPC payments, though this might change.  If it does change, DPC would become a much more appealing option for higher earners.
  4. DPC practices are still emerging, they are not available in all locations.
  5. Obstetrics, for young families this is the most likely large healthcare expenditure.  Most DPC practices are unlikely to provide that service.
the pursuit of the perfect is the enemy of the good

Is DPC going to solve all of our systemic and personal healthcare issues?  Of course not.  At this point, any innovative model that saves cost and increases quality is worth discussing.

Especially for relatively healthy early retiree families, I think it is worth looking at in more detail.  Even for individuals with several common chronic problems DPC might be preferable to traditional primary care models.

Though I have yet to do the math, A less expensive high-deductible health insurance plan, coupled with a well-funded HSA (preferably holding at least your maximum deductible amount) and a DPC subscription could be a great “diversified healthcare portfolio.”

Why have I not purchased a DPC subscription?  Through my wife’s job I currently have access to very good and very reasonably priced insurance.  However, if this were to change, I would very likely be looking for a DPC practice in my area.  Also, see #5 above.

If anyone has looked at this in more detail or has strong opinions on the matter, I would be very interested to hear from them.

The Ups and Downs of the 1099 Life.

Living la vida locum (tenens)

If you haven’t read much of my blog yet, in 2017 my wife and I had a daughter whom we took home on hospice after she was born unable to breathe or eat without mechanical assistance.  My partners and the health system that employed me were not particularly supportive of me carving out time to process and heal.

To create more space to heal, I ended up moving to my current gig as an itinerant critical access doctor.    I fill in when small, rural hospitals are short for 12-120 hours of continuous call coverage, depending on average volumes of the facilities.

Technically, I am a short-term locum tenens doctor or maybe more like a full-time moonlighter.  It also means that I am now 1099 independent contractor.

Either way, I have experienced some ups and downs with this lifestyle over the last 6 months.  I wanted to explore some of these, with a bent towards the financial.

positives of 1099 locums work
  1. I have complete veto power over my schedule. I can’t create work where work doesn’t exist.  However, if I don’t want to work somewhere or at a given time, I just don’t.  Back in June, I realized that if I wanted make faster progress on my loans, I would to work a bit more.  I didn’t have to find a moonlighting gig or start a side hustle, I just signed up for more shifts.
  2. The hourly wage is generally higher for the workload.  I was making more money in my previous job, but I was working my ass off in the process.  Per patient seen, I get paid much better now.
  3. I only take care of patients. No inbox coverage, no prior authorizations, no utilization reviews, no meetings, just pure patient care.
  4. Variety of work environments.  If I get tired of working somewhere or need a break from a given site’s particular brand of dysfunction, I just don’t schedule any work there for a month or two. Think of it as a burnout release valve.
  5. I work fewer calendar days.  I really only work 10-12 days/month.  Conversely, they are 24 hour days.
  6. I am now a business.  I get to deduct all sorts of things from my taxes.  Because my wife and I won’t make >$315,000, that includes the 199a 20% of qualified business income deduction.  So, w00t.
negatives of 1099 locums work
  1. My income is not guaranteed.  So far, I am still having to turn down work.  Rural America has more work than there are people to do it.  However, the possibility exists that it will just suddenly dry up.
  2. I get no benefits.  I carry my own disability insurance, life insurance, and have to fund my own SEP-IRA.  No 401k match for me.  Luckily, my wife likes having a regular job so health insurance comes through her job. But that is another big question mark.
  3. Limited opportunities for collegiality, unable to participate in system improvement. I have to just deal with whatever system is in place where I go.  The only bad feedback I have received was when I dared to have an opinion on a facility’s processes.
  4. I can’t build a team/workflow.  Because I am just a place-holder, opportunities to integrate and develop a team are limited.
  5. I work nights, travel, and am on call for long periods of time in a row.  It can be lonely and my wife doesn’t love it, but being around me is way more pleasant now, so I think it is a wash for her.  Also, no vacation time.
  6. I am now a business.  I have to keep  record all my expenses and track my income more closely.  My taxes got a lot more complicated and I suddenly care about tax policy in a way that I didn’t have to before.
the upshot: working as a 1099 isn’t that different from production-based reimbursement

In my first job out of residency, my contract would have eventually paid me 100% on production.  This an “eat what you kill” model for reimbursement.  Certainly not all compensation models are 100% production, but it is hardly rare.

Now that I have been an independent contractor and been a production-based employee, I don’t my financial stressors to be that different.

Before, I was basically a doctor paid on commission. The organization ONLY paid me to provide patient care. I had to track my RVUs closely, which are way more complicated to track than how many hours I work.

On the other hand, when I was employee, I constantly heard about the financial health of the organization and the organization expected me to give a shit.

The way the organization designed the system, the only power I had to help them financially was to see more patients.  I didn’t have the power to hire or fire staff, invest in training programs for staff, recruit new staff, or even choose to spend a half-day on system improvement.

Now, as a 1099, I pay a little more attention to my finances and workloads, but all of it directly affects me and I have complete control over it.

Hospitals only pay me to provide patient care and my responsibilities end there.  No one tries to sneak more duties onto my plate without carving out time or adding compensation.  Finally, an honest relationship between a physician and a healthcare institution.

honesty is a good policy

In the end, this is my favorite thing about locum tenens work.  The relationship between the physician and the institution is as honest as it gets. Seeing patients is the only way physicians produce income.  So, in an accountant’s mindset, that is the only time worth compensating us for.  It is immaterial that we could be adding value to the system in a myriad of ways.

Locum tenens work is the only situation I have found (at least for a family doc) where I get to work so honestly. I show up from X hour to X hour and receive Y in compensation, I take care of whatever patient care needs arise during that time as best as I am able and everyone leaves happy afterwards.

Honesty and transparency are worth a great deal in Medicine.  They are becoming harder and harder to come by (have you ever read a healthcare bill?).  If this is the only way to find a little of both and still practice medicine, life could be worse.

Bad Financial Decisions I Don’t Regret

financially deleterious decisions in hindsight

Many physician and non-physician finance bloggers share their financial stories and their mistakes.  Xravzn’s story of trials, tribulations, and the financial decisions he had to overcome was particularly inspiring for me.

Financially, the first two bad decisions dwarf the rest:

  1. I went to possibly the most expensive medical school in the country (this might end up being about $500k by the time I pay it all off)
  2. I did not choose a particularly high paying specialty (Family Medicine averages 180-250k/year)
  3. Buying a house within a couple of months of starting my first job, having already figured out that we weren’t going to stay there for more than a few years.
  4. Taking a three month trip through Paris, Spain, Morocco, England, and Iceland in between residency and starting my first job (probably about $20,000).
  5. Going on a 4 week trip to Odessa, Ukraine and Bulgaria with my now wife, brother, and mother in my 4th year of medical school ($4,000 of student loan debt funded that adventure)

Could I have made some smarter moves with investments, decreased costs, etc.  Sure, but none of them compare to the first two on the list.  They are rounding errors in comparison.  Do I regret these decisions?  I am not sure.

#1 – Expensive Medical School

I certainly wish I had less student debt, but I met my wife where I went to medical school, which was her hometown and where we now live.  My wife gave brith to our daughter, whose loss has brought us even closer together.  I never thought I could love someone so much, so the debt doesn’t seem that important when you phrase it that way.

#2 – Low-Paying family medicine

As far as my specialty goes, I have mixed feelings.  Would it be nice to be able to pay off my loans faster, yes.  On the other hand, rural family medicine docs are in such demand that job security is not really a concern for me.

Indeed, my current position allows me to turn traditional family medicine (low acuity emergency department, inpatient medicine, as well as clinic) into shift work.

I get paid by the hour – 24 hours a day, often when I am sleeping overnight.  this means I can make 1/2 of a normal family medicine doctor’s months salary in 5 days of straight call in some of the locations.  I might see an average 7-12 patients (ED, Clinic, and IP combined) per day at these particular sites.  Unlike a busy ED doc, I am usually seeing only 1 patient at a time.

I have complete veto power over my schedule.  I often work a total of about 10 days/month currently.  It is a pretty chill lifestyle.  This is made possible by my low paying specialty which is in short supply.  If time is the currency of life, this job pays pretty well.  So, I consider it a wash.

#3 – buying a house

I do actually regret this one.  On the other hand, I am not sure I had many other great options.  We moved to an area dependent on tourism.  Many of the rental properties had been bought up to use as short-term rentals.  Long term leases were difficult to come by.

We ended up buying a house on 5 acres that bordered public land.  It was pretty sweet.  By urban standards, it was very affordably priced and well within our price range.  We moved after 13 months.  Luckily, it appreciated about 5-10% in that time, so we only lost about 10% of our down payment plus the $6,000 we had to pay rent and a mortgage.

Looking at it a different way, my wife and I realized that we don’t like spending a lot of time and energy on our house.  Cleaning a large house was a pain in the ass and neither of us enjoyed it.  Finding out that you don’t want to own a large piece of property early in life is probably worth a lot of money and headache in the long run.  So, I even found a silver lining here.

#4 and 5: Travel with people you love

These trips were worth every goddamned, interest-bearing penny.

Have you eaten grapes and brie with a warm baguette under the shade of the chestnut trees next to the canal St Martin on a warm, summer Paris afternoon? Have you done it while polishing off a bottle of wine with the woman who will be mother of your children? WORTH IT

Rila Monastery – Bulgaria

What about taking an overnight Soviet-era train with your soon to be wife, mother, and brother from the beaches of the Black Sea to an ancient Orthodox monastery nestled among the spring acid-green of a Balkan beech forest?  Retiring to the old monks quarters after watching the Alpenglo fade from the Peaks? WORTH IT.

Waterfall in Iceland

Or, hiking back from a glacier-fed waterfall, eating roasted Icelandic lamb, and washing it down with a cool, crisp beer? WORTH IT

Or, remembering sitting next to a spring in the shade of a walnut orchard at 6,000 ft in the mountains of North Africa.  Relaxing there with your wife of 13 months while being served a three course meal of salad, mint tea, tagine, and fresh fruit that was packed over a mountain pass on a mule by your grouchy but affable Berber muleteer. WORTH IT.

Standing on the summit of the highest mountain in North Africa and the Arab world with her two days later? WORTH.  IT.

There are times in one’s life when you realize the window for a certain type of adventure is fading quickly.  Is it worth letting the window close because that money could get you a 7-8% ROI?  Life is complicated, messy, and that’s what makes it great.  I refuse to give that up in the pursuit of financial stability and gain.

Why I Haven’t Refinanced my Student Loans, Yet.

vagaries of living with student loans

Student loans suck, I hate mine, with a passion – my wife thinks I am obsessed. Though I hate how expensive debt is, mostly I hate how it steals a certain amount of liberty from your life. Refinancing helps you save money in the long run, but it can also trap you in a job or situation that is really bad for you and your family – I should know.

Fleet Street Debtors Prison

If I had refinanced prior to my daughter dying and my partners being shitheads and had a 4000-5000/month student loan payment, I would have felt MUCH more pressure to try and stick it out.  Moving would have seemed much more risky.  At least financially, that gig was damn good.  I may have ended up losing my whole career or even my marriage for the sake of saving some interest payments over the course of several years.

I want to reiterate that I hate my student loans. In fact, after leaving that job, we sold a house, moved, and started renting.  We took what we got out of the down payment from the sale and paid down loans, 12-15% of my loan burden in one fell sweep.  That is how much I hate student loans.

why i still haven’t refinanced

That all being said, I wanted to touch on a couple of aspects of the whole student loan refinancing debate that I think are under-appreciated in some of the other discussions and with which I have personal experience:

  1. Income Driven Repayment has more options than I usually see discussed
  2. Not all physicians are anesthesiologists, radiologists, and private practice emergency medicine docs making $300-500k a year.
  3. Capitalization sucks – going off of an Income Driven Repayment plan causes all that accumulated interest to capitalize.
  4. Life is really freaking unpredictable and the federal student loan servicers are much more flexible than a traditional lending organization.
medical school and residency

Almost all of us ended up on income driven repayment (IDR) during residency.  My biggest financial mistake to date was going to one of the most expensive out-of-state medical schools.  I didn’t have to, my home state has one of the cheapest, and I got in.  I just thought it would be a better career move, and plenty of people agreed with me at the time.

As a first year attending, reading the White Coat Investor was like being visited by the Dickensian Ghost of Financial Decisions Past.

Anyway, I had and have A LOT of student loans.  When I graduated medical school, I signed up for Pay As You Earn (PAYE) rather than Income Based Repayment (IBR), which allows for a lower monthly payment.  There is another REPAYE, which is even lower (point 1).  Over the course of three years of residency, I accumulated about $65,000 in interest. True, only about 33,000 of that could capitalize under PAYE terms, that is till a lot new interest earning debt.

first year attending

If had gone off of PAYE at the time I started my first job, I would have had a $4000/month payment and $33,000 of newly capitalized debt (point 3).  Instead, I stayed on PAYE, my payment was about $1500 and that interest DID NOT capitalized.

My student loan burden (capital + interest) is about $150,000 less than when I graduated.  I am earning in the $200-250k range as a family doc (point 2) and not $500k/year.  Because of that, I still qualify for PAYE, and I still have about $35,000 in interest that has not capitalized.

Obviously, I payed much more than minimum.  I am not saying that paying the minimum is a good idea.  What I am saying, is that even though I was still paying $5-10k/month in student loan payments, I had the flexibility to pay less if something unexpected happened.  That flexibility is worth something.

Now, someone who likes math more than I do could probably make a educated guess on where the benefit/cost break even point is on refinancing versus interest capitalizing.  I still have never done that. I probably should.

But, Mousie, thou art no thy lane [you aren’t alone]
In proving foresight may be vain:
The best laid schemes o’ mice an’ men
Gang aft a-gley, [often go awry]
An’ lea’e us nought but grief an’ pain,
For promised joy.

Robert Burns, To a Mouse, on Turning Her Up in Her Nest With the Plough, November, 1785

LIFE IS UNPREDICTABLE (point 4)

The flexibility of IDR was priceless when I had to walk away from my job for the health of myself and my family.  Being able to only pay $1200/month for a couple of months on my loans was a huge relief.

As it was, arranging and paying for multistate move, paying rent and a mortgage for 3 months simultaneously, getting licensed in a new state, and arranging my current traveling doctor gig was stressful enough.

If I had been juggling a $5000/month payment, I might have folded.   Inertia and fear might have kept me miserable in my old job.  It could have cost me my life.  Physician suicide is not a rare thing these days.  How do you put a dollar sign on that?