Unmentorable

I am terrible at finding mentors. I accept this as it is primarily my failing. I am silently critical and judgmental of anyone I audition for the part. Not too intensely, but enough to tarnish the sheen which drew me to them in the first place.

I expect too much from a mentor. A mentor must have figured out all of life before I am willing to sit at his or her feet and await the flow of wisdom. I have never had harsh break ups with possible mentors, I simply never pursue the relationship past a certain point.

This is not to say I do not learn things from people. I study and examine decisions and approaches individuals have to life and career and pick and choose lessons from them all. I will learn anything from anyone who has something to offer

Yet, I can never quite slide into the role of mentee. I cannot quite let myself be vulnerable enough to to commit. That more complete learning relationship continues to elude me.

Invariably, I find something disappointing in any possible mentor. They may be highly successful in their field, but I always seem to find some flaw in their history or personality which leads me to slowly extricate myself from any burgeoning mentor-mentee relationship.

The reasons are numerous:

They have sacrificed more time with family than I am willing to.

Medicine fills them up enough, they don’t seem to have any other intellectual interests.

They aren’t philosophical or thoughtful enough.

They aren’t skeptical enough, too sincere and believing.

Despite all their success, they seem unfulfilled, not satisfied, sometimes even unhappy.

They are boring or uninteresting

There are many more.

Why Am I so Harsh?

Why do I do this? I don’t necessarily find myself yearning for a mentor, but I certainly think it would have been beneficial for me to find one at some point along the way. Yet, I cannot say I have ever had a long term and truly fulfilling mentor/mentee relationship.

I have come to an annoyingly Freudian conclusion: the mentor-mentee relationship is too close to a paternal relationship for me to ever be comfortable with it.

Unlike many young men with complicated paternal relationship, love and affection were never the issue.

My father is simply bad at functioning in the world on society’s terms. He has never been able to play the game. I have learned more about how to function in this world from his mistakes than I ever could from his example.

He struggles with his mental health and in typical boomer male fashion, avoided addressing it at all costs for most of my life. While loving, I also remember him being angry, impatient, and emotionally unreliable.

Additionally, I have inherited a certain amount of his difficulty with playing by the rules. Not the written rules, or the ethical rules, but the unwritten cultural rules which only exists to enforce group mediocrity.

And, I have found, it is the breaking of these rules which engender the harshest backlash because they are irrational, so the response to their transgression can only be similarly irrational.

Unfortunately, in practice, medicine is a life that punishes those who break from orthodoxy more fiercely than most.

I have come to terms with these things about my own father, but I cannot help but feel they are the root me being unable to be comfortable with a mentor. No mentor will ever be complete enough, reliable enough, wise enough for me to let my guard down.

I will always find some failing – moral, intellectual, spiritual, ethical which will sow doubt, and my walls will go up. Sadly, it has led to a rather lonely professional existence.

Mentors from the Page

As a poor substitute, I find myself turning to authors as mentors in situ. I can go to the arts and literature, the great stories to try and glean wisdom to apply. Occasionally, the inspirations have been specific to medicine, but more often they are general.

They are usually men, not surprisingly. Usually already dead, their story having reached its terminal moment, I can safely know the whole arc, analyze their decisions, inspect their psyches as best I can from the page.

They are Hemingways (who has been mentioned on this blog frequently), Edward Abbeys, Steinbecks, Anthony Bourdains. Their unconventional lives are a common thread. As noted above, I am drawn to the unconventional, unorthodox – not in my personal life, but in my intellectual life.

Deep down, I have always been a puzzle piece which doesn’t quite fit. Always a little uncomfortable in any given role or position. Always pushing moving, pushing, straining.

I may not have been well suited to a career in medicine because of this tendency. I am not saying poorly suited to being a doctor, but poorly suited to a medical career. All my sages tend to be tortured, horribly flawed, often kind of miserable shits, with some hole that can’t be filled. And, disproportionately men who have killed themselves.

Even in my imaginary world of mentors from the page, I seem to be able to learn only from their mistakes, from their character flaws, their weakness. Maybe this is because great art is inherently emotive, not intellectual. And only those who wrestle with great emotions can make art which makes you feel something meaningful.

Let me tell you something. Happiness is bullshit. It’s the great myth of the late 20th century. You think Picasso was happy? You think Hemingway was? Hendrix? They were miserable shits. No art worth a damn was ever created out of happiness. I can tell you that. Ambition, narcissism, sex, rage. Those are the engines that drive every great artist, every great man. A hole that can’t be filled. That’s why we’re all such miserable assholes.

Ed Harris, as Ben in Kodachrome (2017)

I have learned much from some of these names. Their grand pursuits, their art, all seemed to stem from a deep unhappiness. And so I increasingly shy away from the addictive pursuit of art, accomplishment, money, career. They all seem to lead to a generally miserable life, punctuated by acclaim and accomplishment – but certainly not happiness.

Is it all a sham as Ed Harris’ character says? Is happiness a myth of the late 20th century which has visited upon us the curses of consumerism, the opiate epidemic, multiple other converging mental health crises?

Are greatness and happiness antithetical? Is is impossible to have a family, to be generally content with life, and work in the pursuit of something larger and more meaningful than oneself?

Who knows? I guess all I can do is keep reading, because I am pretty sure I am never going to let anyone show me the way.

Featured Painting: Alcibiades being taught by Socrates, François-André Vincent, 1776. Musee Fabre.

America’s COVID Response is Old News

Our current media environment is simply overwhelming. Talking heads dissect and opinionate on every minute occurrence and off-handed comment ad nauseam. Enough true news simply does not exist to support the advertising driven media ecosystem which now saddles us.

The pandemic has only made this worse.

I suppose whenever you live within an environment or industry, it is always rather amusing when the news and social media discover what has been known for years within your circles. This is how I feel about much of the news surrounding the boots on the ground handling of the pandemic.

None of this is New


“America’s health care system is neither healthy, caring, nor a system.”

-Walter Cronkite

Hospitals overwork nurses, doctors, EMTs, clinical staff everywhere leading burn out and unsafe conditions? Who knew? COVID just shines a light.

Hospitals have making money hand over fist on procedures which, when postponed have apparently had little effect on the over health of the population(which begs the question of why we are doing them in the first place), This has destroyed hospital hospitals bottom lines. COVID shines a light.

America incentivizes hospitals not to care for the sick and ill, but to provide procedures aimed at making the lives of people with good insurance more comfortable. Is it so shocking this has led to hospital systems prioritizing such care over general health? COVID shines a light.

Health systems were caught flat footed protecting front line workers because prioritizing staff safety didn’t generate RVUs and billable procedures? COVID shines a light.

Health inequalities are rampant and appalling – both at point of care but as part of the baseline health of large portions of the population? People of color are suffering more disability and dying at higher rates than the general population? COVID shines a light.

The American Healthcare System Prioritizes Private Wealth over Public Health

Walter Cronkite knew what the problem was decades ago, and we haven’t done a damn thing to fundamentally alter the situation. COVID isn’t anything new, it is just happening all at once when we are all paying attention.

We do not have a meaningful public health system. We have a private disease treatment facilities. Our healthcare system works great for young, healthy, and wealthy individuals. Guess what? They rarely need healthcare.

Why can’t we effectively respond to a widespread, nationwide public health crisis? Because we do not have a comprehensive, nationwide public health infrastructure.

As long as we treat health as an individual problem, we will be unable to respond to any true public health problem.

Just Look at our track record:

Obesity Epidemic – only getting worse

Opiate Epidemic – people dying by the thousands

COVID 19 – check the counters on your favorite news platform.

Well…you get the idea.

Hospitals are not substitutes for Public Health Infrastructure

Hospitals treat individuals, they do not coordinate responses to widespread public health disasters, even if those disasters produce individual illness.

Yet, we keep trying to force a square peg through a round whole. We call it population health now, as if it is somehow different from public health. Hospitals and clinics will always fail to address these problems because they are the wrong tool for the job.

Healthcare services determine only about 20% of a person’s health status. That means, 80% of the outcome of any individual’s health is already decided when they show up at the hospital.

We need to actually protect the public’s health

It is unfair to our fellow citizens (particularly to the poor, people of color, and the mentally ill) to expect doctors and nurses to make up for a lifetime of abuse and neglect society has visited upon many people in our society.

Yes, bias (based on race, class, disability, mental illness, etc) in the provision of healthcare negatively affects the health of many people. However, it is time that society accepts responsibility for our fellow citizens and recognizes the patterns of our lives drive our health far more than anything that happens within the doors of a hospital.

My work reminds me of this reality daily. I have the power to do many things, yet more often than not, I am effectively powerless in the shadow of a life lived without access to healthy food, a good education, a safe environment, the list goes on.

Poor people will always have poorer health outcomes than rich people, because resources matter. Yet, we as a country can and should do better. And we need to stop looking at the end of the pipe for solutions.

The disaster COVID is wreaking on the health of Americans is no surprise, if you were paying attention.

A system is designed to get the outcome it gets. We have designed our system to produce these unequal, inconsistent, and often deadly results.

The outcomes the pandemic has brought to light have been happening every day, in every corner of this country, for decades.

The light was apparently just not bright enough.

Our Sacred Grief

With nonessential procedures and medical visits postponed, an eery quiet has descended on hospitals on the High Plains. The surge is not yet here, and the curve, thankfully, appears to be flattening.

It is, however, the quiet of an undisturbed bowstring. Taut and tense under pressure, yet ready to snap. Most of us have tried to lose our anxiety in work, yet work provides little respite from the anxieties of this moment.

I am awash in time aplenty to catastrophize and perseverate on my anxiety regarding our current pandemic. I am thankful not to be sick. I am thankful not to be doing battlefield triage on people’s grandmother and grandfathers.

Yet, the time means I am awash in stories of others’ grief. Of people losing children, parents, spouses, siblings. All tragic, some seemingly more so than others.

The stories of young parents and children lost strike me the hardest, of course. The distance all too small between them and I. There but for the grace of God.

I Know This Valley

While my own grief is not in the front of my mind anymore, I know it is not gone. It sits on a shelf in my soul, perfectly undegraded.

Occasionally, I pick it up in my mind, dust it off, and the pain of it comes rushing back. I reminder of love as well as pain. As I read stories of other’s grief and know of how much more grief is yet to come. I feel their pain reflected off my own preserved grief.

Even moreso, I feel the pain of their loneliness. I think of the thousands of people who, panicked and in fear, kissed their love ones good-bye in the ambulance or at the ER door. They watched gloved and masked helping hands carry them away, desperate to see them discharged safely from the hospital in few days.

Yet, too many will never hold them again, never see them again other than through a camera lens in an App. They will grieve at a distance, knowing that somewhere, their loved one’s bodies have been hermetically sealed and placed in refrigerated trucks, waiting to be taken somewhere else.

I know the pain of holding my daughter and watching her take her last breaths. Yet, no matter how painful that was, it was better than not holding her, not carrying her around the house she didn’t get to grow up in.

I am reminded of stories of how grief changes when the world is turned upside down. During WWI, Russian villagers would have a funeral for any young man called up to the front from their village before they even left.

As a teenager, this story simply seemed really sad and evidence of how likely death was in the Great War. Now, I also see it as an attempt to maintain something human in the midst of inhumanity.

Better to grieve together and be wrong than to never get closure.

I can only imaging the anguish of not being able to grieve next to all who also loved your beloved. So, this disease steals not only lives, but the opportunity to grieve together, to say good-bye in an embrace.

Why Do We Grieve?

When I was struggling with my grief, I did what I always do when I don’t feel prepared. I read about it. I am an intellectualizer to the core.

I read multiple books and grief and grieving. A question I had never asked myself, but which exists in the literature is a simple one:

Why Do Humans Grieve?

Grief extracts such an intense cost, personally and communally. Some literally die from it. What could be the evolutionary basis of such a thing?

I found a few posited answers to this question, none with good evidence. One was that grief shows the community or future mates the intensity of the bonds you form.

This didn’t really hold much water for me.

The one which resonated with me was that grief serves to bind a couple, family, or community closer together. Not only in sorrow, but in love for the who or what is lost. It is a sacred function of grief. When we grieve well, we grow richer in love for everything.

When you are sorrowful look again in your heart, and you shall see that in truth you are weeping for that which has been your delight

-Khalil Gibran

What strikes me is how, on a physical level, COVID will deny many of us the opportunity to participate this sacred aspect of grief. I literally cry thinking about it.

Yet, the lack of that connection in the moment also amplifies a need for community, for humanity on a much larger scale. A time will come when contagion no longer separates us from each other. We will hold hands and embrace again.

We must remember to take that opportunity and hold it with the weight and reverence it will have earned. All of the death and loss will give us a gift. A gift of communion in pain with more people than we have ever met. Our local, national, and international loss has the power to bind us together in sorrow and love, if we let it.

Every one of us will be touched by this event. We must not slide into comparison and recriminations as a people, but join together in a collective wail of wild grief and love for what we have lost, but also with whom we are will be so blessed to remain.

Grief is pain, yet it is also a gift, because it can only come from love. I hope we do not waste the gift this plague will bring us.

Photo: Grief, by Oskar Zwintscher, 1898.  Work created before 1925 and public domain in the U.S.

Beware, Narcissus!

By now we have all seen the images. Carousers on beaches, partiers in bars, etc. The exuberance and perceived invincibility of youth which the government and media boosted with poor messaging. Modern incarnations of narcissus, so in love with their own beauty and youth they can see no other truths.

Sure, on a population scale, statistics are near destiny. However, on an individual scale, statistics are a poor substitute for adequate personal protective equipment.

Trust me, I know something about being the 1 in thousands. So does my wife and our first daughter. We were young, healthy, with access to good medical care. Statistically, we were destined for a healthy and uneventful pregnancy and healthy child.

Here is the thing about statistics, someone is that 1 in 100, 1 in 1,000, 1 in 10,000. And all the statistics in the world will not stop you from being that one.

At 3 weeks old we had to sit and hold our baby while she took her first and last breaths without a machine to breath for her. Statistics didn’t help me sleep. Statistics didn’t comfort my wife. Statistics didn’t soak up our tears in the middle of night.

Some of us young, otherwise healthy people will die from this. And the more people who get sick at once, the more of us and others will die.

The other side of those statistics is this: we all know 100 people, including people who are compromised or elderly. At the rate we are going, we will ALL know multiple people who will die from this virus. It will touch us all, one way or another.

As someone who knows about grief, do what you can to limit how many people you will have grieve over the next year. You may not be able to spend time with the people you love in their last hours because of restrictive hospital quarantines.

Someone you know, and in all likelihood, someone you love, will die alone in a hospital bed in the next year.

Why do anything which means this will happen more than has to?

Because it is inconvenient? Because it will cost money? Because it is boring? Because it isn’t necessary?

Because I don’t want to sacrifice for something which may not directly benefit me?

The Individual will No Longer Be King

We are at a deflection point in our nation’s soul. For the last 60 years, the role of the individual has increased in our nation’s psyche. Society and the good of all have occupied a smaller and smaller place in our national priorities.

This must change. This will change. The only way for as many people as possible to emerge from this alive is for all of humanity, but in our case, Americans, to remember we are part of something greater than ourselves.

Our petty desires and whims pale in contrast the great struggle humanity is embarking on. This is terrifying, but also an opportunity. Our dependence on one another, the bonds which keep families and communities functioning will grow clearer than they have been in a long time.

We are part of a whole. A mass of humanity, connected now more than ever. We must find where those connections can be nurtured, strengthened, and where each of our own gifts will contribute most.

Specifically, this is a calling to my generation, often known as Millennials to stand up and make our contribution. We must show up, we must act. This is the beginning of a great test as a nation and a generation. It has been decades since humanity has been called to such an epic task.

For some of us, it will be 3D printing of needed parts, sewing of masks, running to the front lines in hospitals, caring for elderly or high risk neighbors, getting groceries.

For others, this will simply be staying home. We will contribute to breaking the chain of infection.

We must not underestimate the courage of staying of home.

The act of staying home is no simple feat. Staying home makes real the fear of the threat we face. It would be much easier to pretend no threat exists, because no fear could torture us.

By staying home we sacrifice the sweet delusion of the absence of fear. It is worthy sacrifice, as we cannot be courageous until we have first felt fear.

Courage is resistance of fear, mastery of fear – not absence of fear.

-Mark Twain

So, I call on all of us to act courageously, to allow ourselves to feel afraid. We can only begin to know the depths of our collective courage once we have touched that fear collectively.

We cannot continue to hide our fear behind paper tiger statistics. We will not have truly entered the fray until we have allowed ourselves to feel at risk. We must show up and give of ourselves.

This means giving not what one wishes to give, but what others need. We must give what is so desperately needed, not something easily dispensed.

History has given us a moment to rise to the occasion. It is terrifying. Yet, it is an opportunity for us all to be our best.

Beware Narcissus, my fellow Millennials, live your best life, feel afraid, act courageously, stay home.

Image: Narcissus, by Michaelangelo Da Caravaggio, circa 1597 – 1599. Galleria Nazionale d’Arte Antica.

The Tide Went Way Out

When a disaster comes to the High Plains, the sky holds the warning. It has always been this way. The sky dominates the land on the plains. Of course it where the warning first appears.

When wildfire rushes across the plains smoke clouding the sky announces its imminent arrival. When the “black blizzards” rolled across the plains in the Dust Bowl their towering clouds of dust blocked out the sun on the horizon. The sky lets you know ahead of time.

Except this time it doesn’t. The sky is serene and blue as far as the eye can see.

The pace in clinic and the Emergency Department is slow. I have only been on staff here for about a month, but I know this is slow even for here. Physicals have been cancelled, colonoscopies postponed, the usual minor urgent care visit in the ED have effectively ceased.

I think of stories from the islands of the Pacific during Tsunamis. First, the tide goes way out suddenly, then the wave builds in the distance and it just keeps coming. As I stand on the edge of town, looking West at the setting sun, I feel like I am watching the tide rapidly recede.

I have spent the last 48 hours running around the hospital checking for what supplies we have, asking pharmacy techs to order more vecuronium (on backorder), steroids, duo-nebs, and morphine, oh God, please make sure we have enough morphine. I verbally underline the need to stay stocked with morphine to the pharmacy tech.

I repeat Dr. Edward Trudeau’s mantra in my mind, “To cure sometimes, to relieve often, to comfort always.” In a preparation meeting, I remind my colleagues Rural America looks demographically a lot like Italy. Mostly older, and in our case, very chronically ill.

We unfortunately have even fewer doctors and hospital beds per capita than Italy. This will swamp us, I emphasize to my colleagues. And our typically release valve, “transfer to higher level of care,” is going to stop working pretty soon, because it will hit transfer centers before it hits us.

I am preparing to practice mass casualty, battlefield medicine. I fully anticipate we will run out of IV fluid, IV tubing, etc at some point. I insisted we order 3% saline so we can mix it with D5 or Sterile water to make more normal saline than we otherwise would be able to order.

I made our pharmacy tech other oral rehydration solutions, feeding bags, and NG tubes. Once we realize we are getting low on IV supplies, hydration will have to be done orally, with NG tubes if necessary for the weakest.

Just like everyone else, we have started rationing PPE. Hopefully the supply lines catch up by the time it really reaches us. We will probably have a 1-2 week lag compared to urban centers.

When I get home, I completely strip, all my clothes go into the wash – on sanitize. I shower more thoroughly than I ever have. Only then do I get to kiss and hold my wife and daughter.

Like everyone else is saying, please stay home for us and our families.

20% percent of Italian healthcare workers have contracted the virus, when one out of every five healthcare workers is out and cannot work, more people than need to will die.

This is what I dread is coming….I hope I am wrong….but I don’t think so.

The Wave is Building

We all take comfort in our founding myths and narratives. The physical and social isolation of the High Plains from the coasts and cities allows people to act as though the problems of those places exist in another world. This time has been no different. People have reacted slowly and still aren’t sure whether or not to take it seriously.

I have been trying to create a sense of urgency without panic. A narrow balance beam to walk. I don’t know if I am succeeding.

I can feel the shocks of the formative earthquake rippling through my body, even if the wave is still not visible. It is corporeal. The wave is building, rising. I survey the horizon, there is no high ground. No where to run to. We are it out here.

The state has already told us not to expect extra equipment any time soon. The strategic stockpile is already spoken for.

Already, we are accepting low acuity patient’s from the nearest large urban hospitals in an attempt to free up bed space for them. Our normal Critical Access bed cap of 25 has been lifted to 35 beds.

The wave is building.

We really normally only function with 5 acute inpatient beds which normally hold the lowest acuity patients who would ever be in the hospital. We have one ventilator, and it is transfer vent. No bipaps, our nursing home is physically attached to our hospital – a disaster in the waiting.

We won’t be keeping anyone alive on ventilators out here. To try and do so would utilize valuable resources in the hands of physicians and staff who are not well suited to maximize that person’s survival.

The role I anticipate we will play is three-fold. Surge capacity for low acuity cases who simply need oxygen, hydration, and nursing care. We will likely provide convalescent care for people who are weakened after serious illness and sent out here to take the load off of urban referral centers. And, finally, hospice and palliative care.

We will comfort the dying. Comfort always. At some point this will be the greatest gift we can offer.

Death will Walk with Us

In a moment between meetings, I sit dumbfounded in my chair in front my computer. The photo is an Italian military convoy hauling trucks full of bodies out of Bergamo. This is different.

The wave is building.

As a physician, we have all interacted with death before. This will be different. Italy is showing us this now. I learn the next day, we don’t even have a funeral home in town. Our options are 20 miles in either directions.

I ask our emergency preparedness director what the plan for moving bodies out of the hospital is. She tells me the mass casualty plan includes a plan for bodies to stored in the community center until refrigerated trucks or another location can be identified.

Well, that’s at least something, I think and take walk to the edge of town to watch the sun go down.

It seems fitting that the edge of town is also the edge of the cemetery. I estimate the space left in the cemetery, probably insufficient. I guess it doesn’t matter much anyway. People’s bodies who die in a pandemic are supposed to be cremated anyway.

This is rural medicine in the age of the pandemic. A family medicine doctor is running around helping to creatively order supplies for the entire hospital. I am urging administration to build a list of somewhat medically trained people in the community to use as an auxiliary nursing force.

Trying to think of anything and everything we can do to keep people out of the hospital – I plead with our leadership to start building a framework of phone trees and community health volunteers to check on the vulnerable and elderly.

We need to compile and update a list of recovered people in the community, because in 1 month, they will be like gold.

I worry about where the dead will go.

This is our life now and for the foreseeable future. Acceptance will be key to maximizing survival, not only of individuals, but of communities and our way of life. We must not stick our heads in the sand.

Comfort always.

Photo: The Great Wave Off Kanagawa, c. 1829-1833. in Metropolitan Museum of Art by Katsushika Hokusai.

The report of my death was an exaggeration


The report of my death was an exaggeration.

-Mark Twain

Yep, not dead. Not even internet-dead. Although, since I don’t have an Instagram account, I think I may have never been internet alive – technically.

I am still practicing medicine roaming the High Plains. I just stopped writing. Not even on purpose, at least if I had done that I could say I had made a decision. One day, I didn’t post anything, then another, then another, then suddenly it had been weeks.

Writing is hard, doing it consistently is even more difficult. More specifically to my situation, things have just been better. So, I have less to process and complain about on the blog. Or, I should say, my life has been better.

Having a kid who can breath on her own has turned out to be pretty awesome. It also means I am busier than I was and something has to take a bit of back seat, e.g. the blog. Moreover, we have decided to buy a house, so I had been working more to save up for a down payment.

I still kind of feel like buying a house is a big scam, but, I would really like to plant some fruit trees and grow more of my own food – much easier when you own a piece of land.

It also seems to make more sense when you have a small child. Having a kid doesn’t mean you need to buy a residence, but somehow it makes doing so seem a little more logical.

The Bitterness Subsides

On the other hand, medicine is a still an FOS crazy train barreling towards a bridge the Wile E Coyote of corporate healthcare waiting to blow up.

I am just more ambivalent about it all.

At one point, I felt a burden to make healthcare in America better. It drove me crazy to think how terrible it all was. How the incentives were all misaligned. The way we harmed people through overtesting, overtreatment, and overprescribing on a daily basis appalled me.

All the while treatments which could actually make a different in people’s live are not available to huge numbers of people because of our terrible health insurance nightmare.

Yet, anyone can score some oxy or sildenafil without much finagling at all, legally. And usually get some or all of it paid for.

I have come to accept my smallness in this shitstorm. I have also come to accept the sad fact that a lot of people would rather have the shitty system we have than risk a different system or especially risk changing their own lives to improve their own health – physical and mental.

Occasionally, I do something noble and decent as a physician. Usually, I am just moving people’s problems around and giving them pills to treat the physical symptoms of a broken, lonely, and self-destructive society.

We seem to prefer it that way. Better the suffering you know….

Settling Down, Kind of

So, with my life outside of medicine improving, and my expectations from medicine having decreased significantly, I have decided to settle down – kind of. As I said above, we are buying a house. I will continue to travel for work, but mostly to the same location.

I have signed a contract to work as a staff physicain with one Critical Access Hospital 80% of the time. I have worked with them off and on for the last year. It is a low volume place with a good set of local staff. It has very few resources, but a rather pleasant patient population.

We will not, however, be moving to this town. Once bitten, twice shy. We may end up splitting time for a while. We may even move there eventually if it all works out. I’ll spend 2 nights a week there and give it a shot.

You might ask, why travel out to the middle of nowhere when there are plenty of good suburban urgent care or PCP jobs available closer to home?

I will make more in this new gig that I would in the City practicing 5 days a week as a PCP. I will even possibly be able to access some loan repayment. And the volumes I’ll see would be laughably small in a City. I’ll get to see patient’s in the ED, Hospital, clinic and NH. So, other than delivering babies, will be able to keep my skills up for the most part.

Chief Complaint – R foot swollen, hurts.

But mostly, it is because of stories like this:

I was working at this location a few months back and this older man comes in to see me in clinic.

Chief Complaint – R foot swollen, hurts.

Walking in the room, I see my MA has exposed his right foot to the knee. It is swollen, red. It looks painful. The remains of a homemade bandage lie on the floor next to the foot covered in dried blood and pus.

So, Mr Banks, what happened here?

I cut the bottom of my foot on the screen door three days ago. The day or so has been swelling, getting red. Hurts like a sonofabitch now.

I bet, let me take a look.

I bend over and look at the bottom of his foot. There is a 4 inch gash at the base of his right small toe down to the tendon. Shockingly, his toe’s movement and function is fine. Red, swollen, cellulitic skin surrounds the wound and streaks up his leg. A golden crusty discharge of a staph infection frames the image.

I lean back and sit down. Well, Mr Banks, it is definitely infected. Unfortunately, even it weren’t infected it has been too long to close it with sutures, so we’ll have to let heal on its own. Given the how bad of an infection it is, I think we should have you in the hospital for a day or two on IV antibiotics…

Hold it, he interrupts. I am not going into the damn hospital. I’ll take some antibiotics, but I am not gonna be in the hospital.

I startle a bit. My normal experience is people trying to convince me they are sicker than they are and need more pills, treatments, nights in the hospital than I think will do them any good. I pause and look him in the eyes. Well, I say, let me think about we can do.

After a bit of creative restructuring, I pitch him this plan.

If you’re willing to come to the hospital twice a day for a couple of days for wound care and IV antibiotics as an outpatient we might be able to work something out.

I am not crazy doc, I’ll do what I need, I just don’t want to be in the hospital.

Ok. We’ll check a CBC and CRP daily and a Vanco level every 2 days, make sure the infection is improving, and then transition him to oral antibiotics.

I can handle that, doc.

I write the outpatient orders for the hospital nursing staff and set him up for clinic visits for the next two days. These will physically take place in the hospital outpatient ward, but will be billed as clinic visits.

In 30 minutes, I have set up an outpatient hospitalization for this man. Medicare has saved a huge amount of money. I will see no benefit. No financial incentive exists for this kind of care.

I was meeting the patient in the middle and get him the care he needed.

I know of no other setting where a clinic doc could arrange this kind of creative care without a huge outlay of time and energy.

This poor doctor would still probably fail in the end. Angry patients would then punish her for being late. She would sacrifice time at home with her family to more charting. Yet, it was possible for me to do this fairly quickly at a Critical Access Hospital.

Sure, it was a little more work, but not an absurd amount. Honestly, it was less work than a hospital H and P and medication reconciliation plus a discharge summary at the end.

This is why rural medicine pulls me back in. There is still a place for creativity and bending the possible on the High Plains. I am not sure for how much longer, the corporations are at the gates.

But, very little money grows in the Big Empty, so they may just stay at the gates for a while longer.

Photo Credit: Mark Twain, by AF Bradley, New York, 1907.

Special Shout out to Dr. Mo, his recent post lit the fire under my rump to write another post.

Mental Healthcare, Still Excising the Stone of Madness?

My phone rings.  I stop walking.  The sudden change in velocity causes the gravel under my feet to let out a slow grinding noise.

I often walk the gravel roads on the edge of town when things are slow, even at night.  Maybe especially at night.  Getting away from the few lights allows the full grandeur of the night sky of envelop me.

It is an expanse I rarely get to appreciate in the city where the smog and light pollution only let a few key stars shine through.

Of course, I am always within 20 minutes of the ED, but at my walking speed, that could be over a mile away.  I answer the phone.

“Hello?”

“Hey Doc, the police are bringing in a guy who has been acting strange and his mother called a safety check on him. So, they are bringing him in for evaluation.”

“I’ll be there shortly.”  I turn and head back to the hospital at a slightly faster pace than before.

The Rural Mental Health Crisis Team

I walk through the doors into the ED.  The standard mental health crisis is now assembled: Two small town police officers, an ED nurse, and myself.  God help this poor soul, because we probably won’t.  At least, not in any way which changes the trajectory of his illness.

“Hi,” Char, my nurse cohort for tonight begins. “So, this is Tim, his mom called the cops because he has been acting strange the last few days.  He is talking all the time, wouldn’t let his mom into his room in the house.  He has had a lot of problems with meth, so, y’know…”

I acknowledge Char’s statement, but also mentally try to put it on a back shelf.

One of the double edged swords of small town doctoring is everyone knowing everyone.  On the one hand, it is quite a bit easier to get a detailed and relevant social history on people.  On the other, people often have their story made up in their mind about who a person is and what is going on.

Could Tim be on meth? Sure.  Does the fact that he’s done meth before mean he is one meth now?  Not necessarily.  I have developed a technique of trying to mentally disprove the suggested theory while also proceeding as if it an equally likely possibility.  It seems to help me find balance in diagnosis.

If You Get Hurt on this Rotation, You Fail.

We did our emergency psych rotation in medical school in the ED of the county hospital, a level 4 trauma center in the middle of downtown.  It was the quintessential urban ED.  On orientation day, safety was the first and last thing addressed.

The attending psychiatrist, a tall, thin man who projected both bookishness and a tempered, pulled bowstring kind of hardness, listed some maxims:

  1. Do your first cursory exam from the door
  2. Never let a patient get between you and the door
  3. Try to project calmness
  4. If you feel unsafe, leave

He finished his talk with this warning: “If you get injured on this rotation, you will fail this rotation.”

Honestly, this was the scariest threat he could have made to a room full of medical students.

Whenever I find myself back in this situation, I stop at the door and do my initial exam.  I look Tim over.  He sitting in the bed, his hands flailing over his head in somewhat rhythmic circles.  If he’d had glow sticks, he would have fit right in at a rave.

“Tim, what’s going on?”

“Just keeping everything together.” He spat out in between his rave routine.

“Are you feeling okay?”

“Oh yeah, I feel great. I just got to keep everything moving.”

“Have you been doing any drugs?”

“Nope.”

“Do you know where you are?”

“Yes, the hospital.”

“Do you think anyone is out to get you?  Do feel in danger?”

“No, but people have been watching me, talking about me.”

“Who?”

“Everyone”

I review the chart.  His heart rate is quite elevated and his blood pressure his very high.  It could be meth, but he also seems to have some paranoia and something else going on.

Of course, true psychosis and meth intoxication are not mutually exclusive diagnoses.

“Give him 4mg of lorazepam IM, if he calms down, start an IV and give him and a liter of normal saline, he’s probably dehydrated and we’ll need some urine.”

Collateral History

I leave and call his mother.  She tells me he smokes marijuana still (of course, I think to myself, marijuana is just a vitamin these days). But, she continues, he hasn’t been acting like he used to when he was on meth.  He has been saying that he has been talking to his deceased father and repeatedly saying everything would be okay because they would be seeing him soon.  He has not been sleeping, eating, or drinking she goes on.

She runs through a disconnected description of the past few days.  She is clearly very shaken.

I return to the ED about a half hour after Char gave Tim his sedative.  He is out cold.  Rousable enough to avoid intubation, but way more sedate than someone psychotic on methamphetamine would be after that much lorazepam.  His vital signs have normalized.

His story is starting to sound more and more like true psychosis, possibly a manic episode.

“Okay, Char, I don’t think this is meth, we should get mental health here.”

“They won’t come til we have a U Tox which shows no meth.”

“Of course, well let’s get that urine then.”

We Count the Hours…..

What is understood between us is how long this is going to take.  The closest emergent mental health evaluator is 90 minutes away.  So, even if we immediately had a magical urine sample at that very moment, we would be 2 hours from someone actually evaluating him (which has to happen before we even discuss placement).

2 hours later, we finally have a urine sample.  We call the mental health evaluator.  She agrees to come.  I go out for another walk.

After Julie, the mental health person has evaluated him, we talk.

“He is psychotic and needs placement?  Right?”  I prod her.

“Oh yeah.  He definitely needs placement.  I have already placed him on a mental health hold. I am going to go start making calls looking for placement.”

“I love you already, Julie.”  She smiles back.

This is music to my ears.  I hate placing people on holds.  It is a huge legal move to restrict their rights and comes with a lot of paperwork.  I love it when someone else does it.  And placing them on a hold pales in comparison to the work of finding a mental health facility to take him, which she is already starting.

Seriously, I love Julie right now.

I stand up and turn to Katie, the nurse who has replaced Char.  This has already gone on so long shift change has already come and went for the nurses.  I am here for 48 hours, so no such luck for me.

“Call me when you have paperwork for me to sign, I am going to go to sleep.  He can have more ativan if he gets agitated again, I wrote for it already.”  I think about ordering him an antipsychotic, but since he is compliant enough on the ativan, I would rather the psychiatrist get to see him in his full psychotic glory rather than already partially treated.

I trudge off to the sleep room.

A New Day Dawns

I wake up to the phone ringing again.

“Hello,” my voice comes out a froggy moan.

“Hey Doc.”  It is Char again, shift change has already happened again.  He has now been here for 18 hours. “Need you to come out and sign Tim’s transfer paperwork, we have placement and transport is on their way.”

“Okay, I’ll be right there.”

I scribble the legal necessities on the paper work and finish my half typed note from the night before.  Honestly, I am pretty pleased at how relatively seamless this was.  It took a long time.  I feel like it went well.

Cynicism Creeps Back In

However, my cheerfulness quickly fades as I am honest with myself about the situation.  Sure, we did what we were “supposed” to do.  Theoretically, the ramshackle network of mental health on the High Plains worked.

If I am honest with myself, all it succeeded at was passing the buck.

I know from experience how this will play out in the end.  He’ll get stabilized on medications in an inpatient setting, then he will be sent back to the High Plains to the care of his elderly mother, where the closest psychiatrist is 2 hours away.  Even then, the psychiatrist is only available 2 days a week.

No one will have the power or will to make sure he stays on his medications.  One day, he’ll stop them, because self-medicating with marijuana feels better than antipsychotics, and eventually the cycle will repeat.

Who knows if he or anyone else will get hurt next time.

Dividing the Care of the Person

This is how we make ourselves feel better so our souls don’t rip in half.  We break down the tasks involved in caring for human beings into such small parts so we can all feel like we’ve “done a good job,”  All the while, for the person, nothing really changes.

This is our “system” of mental health in this country.  A revolving door of failure.

Sadly, I shouldn’t even complain.  I was thrilled to find out such services even existed. In large parts of rural America, the same patient would have been placed in the local jail.  In many towns, the jail is the only secure location in town for these people until placement can be found.  At least Tim avoided that fate.

I played my part in this farce brilliantly.  We efficiently and effectively “placed” Tim.  Who could find fault with my actions?

Of course, it is not my fault we have such a failure of a mental health system and my participation does not mean I own all of its sins.   Nonetheless, it is just one more of the millions of tiny cuts physicians endure to our souls while working in our healthcare system.

The history of mental healthcare is filled with terrible and inhumane practices. Will we look back on today the same way?  We might not be lobotomizing people anymore or cutting into their heads looking for the “stone of madness,”  but we should not delude ourselves.

Repeatedly sending ill people into a world their brains cannot process to self-medicate with drugs and endure repetitive trauma through physical and sexual abuse at the hands of each other is not a more humane choice.

At least the old quacks cutting the stone were actually trying to cure something.

Featured Image: Cutting the Stone, Hieronymus Bosch, 1494 or later.

What is Adulthood?

The tumultuous diversity of America is great gift.  Our dynamism as a country surely depends on the constant exposure to new ideas and ways of thinking.  On the other hand, it comes at a cost, too.  Community cohesion seems to be the cost we are paying for this wonderful engine of our country.

One of the binding forces of community is ritual.  Traditional cultures have rituals for all major life events.  These rituals bind us to one another and help us feel rooted in our people and place in the world.  One such ritual I often feel is missing in our culture is that of passage of into adulthood.

I think many of us reach adulthood at different times in our lives.  Clearly 12 years old is no longer the time for recognizing our transition into adulthood.  Yet, I think clarity would be helpful.  Those of us in Medicine often seem to have a prolonged entrance into adulthood due to the many years of schooling and training.

When did I become an adult?  At 18?  When I graduated college, or medical school, or residency?  Maybe, for us Millennials, the transition to adulthood happens when you have to start paying off your student loans?  I had a long slide into adulthood, slowly gaining more and more responsibility.

A little ritual to mark a moment might have provided some clarity.

Is responsibility what marks our transition to adulthood?  I am not so sure.  I always had a fairly large amount of responsibility, often more than my peers.  Yet, it did not make me feel more “adult.”

Growing up, adults are the ones who have the answers.  They teach us the rules of life.  They provide structure and certainty to young, expanding minds.  I know more thing than I ever have, but often feel like I have fewer and fewer answers to the questions which matter.

I still don’t really feel like an “adult.” I certainly don’t feel like I can offer anyone else any certainty.

Feeling Old

Yet, I do know what it means to feel old now.  Unlike adulthood, I learned what feeling old feels like within a matter of 2 months.  After the first, burning, searing weeks of grief gave way to a smoldering, tired blanket of grief.  Our first daughter dying made me feel old.  All of the sudden, I was world-weary and inexplicably brain-and-soul-tired.

It seemed as though the world had gone gray, and taken me with it.  Everything took more energy than it had before.  Then, the hospital-pharmaceutical complex came and demanded I keep performing my RVU tricks.  Any hope I had had of finding some comfort and solace in work and my supposedly noble profession was dashed.

I have hurt more deeply than I knew possible.  Yet, life keeps going.  Now, I visit my grief at times.  Sure, sometimes I feel guilty I can not feel it for a few days to even a week at a time.  Sometimes, when I feel guilty about having joy and pleasure in life again, I got back to the day we had to say good bye.  I remember holding her as she stopped breathing.  Soon, I am softly crying, and I know I haven’t stopped feeling her loss.

The grief of losing my daughter was by far more painful of the two wounds I sustained at that time.   No one should have to lose a child, but people do.  Sadly, it is more common than many realize.  A path exists, there are books, and people want to be supportive (even if they are often bad at it).   Maybe because of this, I have found the process of coping with her loss and healing from it to be simpler, if not easier, than coping with my disillusionment with Medicine.

You Can’t Turn Back The Clock

The repeated grief of coming face to face with my disillusionment with a calling I had had actually grown to believe in seems to be never ending.   The Hospital-Pharmaceutical Complex seems to take joy in reminding me of its callousness and love of profiteering.  It never fails to slip comfortably under the already low bar where my expectations are.

While I have come more to terms with the reality of modern doctoring, it still makes me sad.  Sure, sometimes I am angry, too.  But really, it is mostly sadness.  I don’t have the energy to be angry at a giant faceless industry.  That sadness seem to be the well which feeds my feeling of elderliness.

Before, I felt like I was participating the arena of Medicine.  I was an eager young pupil, ready for action. Now, I view the going-ons of all the little hospitals as an old man on a bench dispassionately watches a cat stalk a squirrel in a park.  It is a drama, but a small and distant one, separate from the man’s life.

Sure, it will be sad for the squirrel, but the world is simply this way.

Welcome to Adulthood

Maybe, I wonder, this is what adulthood is.  It is not rituals, nor accomplishments, nor financial responsibilities.  It is the world teaching you it is not a place of endless possibilities, at least no longer for you.  Is adulthood the place and time where we realize life can be just as cruel as it is wonderful?

Do we become adults when we transition from an excitement about how the world could be to a acceptance of how it is?  No longer the young revolutionaries, we become harnessed bureaucrats and accept our fate?

Maybe then, I was lucky to make it to 32 before I became an adult.  I had a long and wonderful childhood, full of joy and discovery.

On my better days, I hope to return there.

Maybe that hope means my transition to adulthood isn’t so foregone, after all…

 

Is This Path Sustainable?

I suffer the curse of rumination.  I ruminate, overthink, and ruminate some more  Strangely, I don’t tend to worry all that much, but I think on things, repeatedly, and often.  My ruminations have a tendency to make the simple complex, the joyful a morass of conflicted emotions.

A recent drive home across the Big Empty was fertile grounds for such rumination.  I had completed a 78 hour shift on the High Plains.  It was an easy shift.  I saw 10 clinic patients, 5 ED patients, one of which I admitted to the hospital.  None of it was particularly complex nor emergent.

For that amount of work, I made roughly 1/2 the salary that most outpatient family docs make in a month.  That is right, for 15 patients, I made about over a 1/3 of my income for the month.  You would think I would have been driving back home thinking about how I lucky I am to have found such a gig in modern medicine.

Instead, I became what my wife terms “thinky.”  I couldn’t help but feel somewhat guilty.  Imposter syndrome quickly followed the guilt.  Is someone going to figure this out and get rid of this?  What will I do then?

This clearly is not sustainable for the country…Is it sustainable for me?

The Stories We Tell Ourselves

Obviously, from a financial standpoint, I did not generate enough income from my physician fees to justify what I was paid (not to mention what the company I contract with got paid). I generally justify what I get paid with this knowledge:

The hospital pays me to keep the ED open, not to generate revenue. 

It is true, of course.  And a true free marketeer would simply say, “If someone will pay you to do it, it is the market’s will.”   A lot of people don’t want to do what I do, so my willingness to do it is worth a high price.

It may just be that simple.

Nonetheless, I often still feel like a profiteer.  My services are expensive. I can’t help but wondering why someone hasn’t figured out how to avoid using me.

Of course, this is not my problem to solve.  Plenty of people are paid quite well to manage these little hospitals, and if they can’t figure out a better solution, why does it bother me?

I keep speeding along open highway…

I stare at the prickly poppies in the ditch as they race past fenceposts along the green and tawny plains.  I can feel my brain chewing its cud.  The anxiety behind the above question is, of course, what will I do if they do figure out something better?

It is a real, yet remote anxiety, I turn down work every month.  There is too much need on the High Plains to fill.

How is there still so much work available that I am constantly turning down shifts?

Of course, I know the answer.  The High Plains are not for everyone.  It is tough country.  There are no beaches nor ski resorts to attract and retain doctors like resort towns have.

Moreover, hospitals tend to ask more and more of their staff until they quit.  Succession planning is not in the vocabulary.  Rural hospitals live from crisis to crisis. Part of this is the natural result of having shallow benches.

If a town only has 3 docs, all it takes is for one one to get sick, retire, quit, get in trouble with the medical board and you are suddenly asking your docs to take every other day call.   The call schedule for the rural Emergency Departments is like Jonathon Edward’s God:

The God that holds you over the pit of hell, much as one holds a spider or some loathsome insect over the fire, abhors you, and is dreadfully provoked;

-Jonathon Edwards, Sinners in the Hand of an Angry God

The Rural ED Call Schedule takes but a faintest provocation to throw the lives of its participants into absolute chaos.  It only knows how to ask for more.  Living, day in, day out, under the guillotine a rural ED call schedule is knowing your kids’ games, family dinners, trips with friends all hang in a delicate balance.

They could all be lost at a moment’s notice.

It is not for the faint of heart.  It is also a stress which the non-clinician cannot know.  Managers of rural hospitals ignore the psychological effects of living under that cloud at their peril.  Unfortunately, most do and turnover is constant.

As long as a cost-based reimbursement continues to be a policy of Medicare, I will have more work than I know what to do with.

Cost-Based Reimbursement, the Lynchpin

I have mentioned cost-based reimbursement before.  It is absolutely the only reason Critical Access Hospitals are able to use me and not go broke.

The basic tenet of Cost-Based Reimbursement(CBR) is that for a given hospital stay in a Critical Access Hospital, Medicare will pay 101% of the “cost” of providing services to that patient.  Who gets to decide what is included in that cost?  The hospital.

So, because my fees can be included in the cost of providing an inpatient stay, they can be written into the CBR formula.  Of course, if I am in the ED seeing a bunch of patient’s, this cannot be included in an inpatient cost report.

So, hospitals have to report how much time a physician spent on an admission, rounding, other inpatient tasks.  Then, they can roll that percentage of my fee into their cost report and get reimbursed for it.

In short, without cost-based reimbursement, I would likely be out of a job.

Though I am technically a “business” as a 1099 sole proprietor, my entire income hangs on government spending at its root. This is the reality of most of healthcare in this country.  Sure, some people have private health insurance, but public healthcare spending is what keeps the lights on around this county’s hospitals.

We would do well not to forget that.

So, is it Sustainable?

I decided to write this post for one reason, to break my rumination cycle.  Sometimes, putting thoughts down on the blog helps release them.  The reason a cycle keeps going because I have no definitive answer.

Clearly our current healthcare system is unsustainable.  Cost-based reimbursement may be as well.  However, I am hardly alone in making a very good living off the healthcare system without necessarily adding that much value.

On the other hand, rural locums is common in plenty of other countries with systems less screwed up than ours (New Zealand, Australia, UK, and Canada).  So, this might be plenty sustainable.  Like every thing else in healthcare, we all know it can’t keep going like this forever, but it might go like this long enough for me to finish my medical career.

I guess this is gig will be sustainable until it isn’t.

Featured Image:  Path in the Forest.  Spruce Forest.  Ivan Shishkin, 1880.

Can Physicians Resist? Or Only Vote with Our Feet?

The Culture of Medicine values orthodoxy.  The requirements for getting into medical school are extremely rigid and in no way value aspects of an applicant not easily testable or quantifiable.

Indeed, the various hoops, tests, and checked boxes of getting into medical school seem more designed to weed out renegade, innovative, creative types than to assure a high caliber of applicant.

They select for the correct quality of applicants, not the high quality of applicants.

Medical school admission seems primarily designed to identify individuals who are adept at learning the rules of the game and then driven to win the game.  Anyone who questions the game is summarily excluded.

As a cadre, physicians are poorly equipped to resist the Hospital-Pharmaceutical Complex.

We are acculturated to shrink our purview to the smallest area possible. This makes it easier to control all of its aspects, which soothes our control-oriented personalities (also selected for in the admissions process).  However, it also dilutes our influence and robs us of seats at the decision-making tables.

Yet, many, if not the majority, of us are extremely dissatisfied at the state of American Medicine. I have written plenty about this.  If we are so dissatisfied, why aren’t physicians across the country rising up and demanding change?

We don’t know how to Resist

Physicians spent their high school and college years languishing in libraries and study halls.  We didn’t go to trainings in direct action.  In residency there are no rotations in “managing organizational change.”

We are so focused on getting the “right” answer, we have rarely had the opportunity to demand those asking the questions defend their choice of question.  Give physicians a set of rules to a game, and we fight tooth and nail to prove we can be best.

Ask a group of physicians whether or not the game is just, worth playing, or if the rules should be changed and we just stare blankly back at you. Those questions have no winners, it does not compute.

For sure, we are raising our voices at higher rates than we ever have in the past.  Yet, the machine keeps jugging along.

Debt, Competition, and Greed

Maybe it is as simple as too many of us are debt-indentured.  The vast majority of us start with $200k+ in debt in our early thirties and then add a mortgage and often some other consumer purchases as well.

Are so many of us permanently debt-indentured to the point where all we feel we can do is just keep our heads down, pay off our debt, and get out?

I slammed my head against the wall for 12 months in my first job. I tried incrementalism from the inside.  It was terrible, and when tragedy hit, I didn’t have the stomach for it anymore.

No one ever articulated what we were working towards. What change were we really trying to make?

Of course, I learned no one was trying to make change.  They were just trying to make as much money as possible, for the system, and then for themselves.

My partners just agitated for more money for less work with a better schedule without the EMR. Their passion had withered to greed and self-interest, cloaked in the name of patient care.

Effectively, they were still applying to medical school.  They were just just trying to win the game.

They didn’t care that the game was corrupt and the purpose of the game was completely divorced from its original purpose.

Or, has this always been medicine?  Has medicine always been a dichotomous beast of greed in the name of helping others?  Test, cut, prescribe until we are wealthy enough retire to a golf course community?

Have those who couldn’t hold their noses any longer always just left?

Is that our only option, to vote with our feet?

Is There Another Way?

At least in rural medicine, it seems as though all physicians can do is vote with their feet.  It seems so dissatisfying to have that left as our only option.  Also, as the problems of the healthcare industry are truly national in scope, there are few places left to run.

No real competition for physicians exists because the industry leaders have all embraced the same models which perpetuate burnout. As we are squeezed more and more to “produce,” our time and energy doesn’t allow for resistance and fighting for change.

Normally, it is the young and energetic who push for change.  The newest generation of doctors emerges into a field where all their excess energy must be tapped towards getting out from under a debt load. One reasonably measured in fractions of a million dollars.

We debt-laden young physicians have nothing left at the end of the day to offer the fight for change.  As such, our voices are largely silent in the national arenas, except of course on the impotent platforms of social media echochambers.

Instead, healthcare “industry groups” and our National Academies usurp the right to speak for us.

Our supposed representatives mostly seem hell bent on protecting or increasing reimbursements for their loudest members, not on making doctoring a fulfilling vocation again.

Surviving the healthcare industry has sadly become our goal.

I certainly hope something or someone comes along as a realistic option to fight for change, but my hope is mostly vestigial.  It is a mere remnant of an idealism and passion which seem a bygone memory.  Pretty soon, the only place left for our feet to go will be out of medicine entirely.

Honestly, I don’t think I am smart enough, connected enough, nor strong enough to find this other road.  I would love for someone to show it to me, though.  I would love to follow someone on that journey.

I do not believe I have the strength or skills to lead anyone in hacking a path out of the wilderness we are in.  Besides, I have proven myself to be more than content with wandering.

After all, the wilderness is a fine place, we could use more of it.