Rural Medicine: Reaching the Limits

The world of Critical Access Medicine is unknown to most physicians.  Lots of reasons exist to explain this.  Most physicians come from rather privileged backgrounds – read urban/suburban/well-educated.  Outside of vacation, their exposure to Rural America is very limited.  They simply do not know what is out here.

Medical training largely does nothing to address this lack of familiarity.  In general, medical training concentrates physicians in large cities right at the time time they are beginning to have families and start careers.  This makes moving somewhere else after training even less likely.

The culture of large teaching centers glorifies the specialist and high-tech, high intensity medicine. Physicians who teach in these centers often denigrate “community practice” as somehow behind or inferior.  Moreover, physicians who practice in urban areas often cite the lack of resources as an impediment to good care.

I have met physicians who have all or some of these biases against rural medicine.  The lack of resources, however, is absolutely a real issue.  I run into it on a regular basis.  I understand other physician’s frustration.

Multiple times on my last shift, I ran headlong into barriers to providing care.

Making Do

On a recent shift, a woman came in with the complaint of weakness and slurred speech.  Upon seeing her, I immediately called a stoke alert.  I do not work in any hospitals with a neurologist, let alone a “stroke team.”  Some have telemedicine robots so a stroke neurologist can evaluate a patient remotely.

This hospital does not even have the robot.

In most Critical Access Hospitals, lab and X-ray are not in house until you call them.  So, we worked on getting things started: drawing blood, placing IVs, etc.  I did an NIH stroke scale, 11.  The score met diagnostic criteria to consider tPA, if her other factors didn’t disqualify her.

Finally,  tech X-ray tech arrives.

“I need a stat CT of her head.” I initially received only a blank, sheepish stare in response.

She looked at me, at the patient, and back to me.  The X-ray tech leaned towards me and asked under her breath, “How how much does she weigh?”

The bed scale registered an astounding 472 lbs.

I turned to the X-ray tech, “That is above your scanner limit, isn’t it?”  She nodded up and down.  I knew the next closest CT scanner was 30 miles away, the hospital is slightly bigger (they have surgery capability and visiting specialists).

“Call Otherton and see what their CT scanner can hold.” The X-ray tech ran off to call and ask.  The one room ED was milling with people –  family, EMTs, nurses.  None of them doing much at that point, save for the lone nurse struggling to get an IV in the patient’s difficult habitus.  This was the most exciting thing to happen in this down for weeks.

After a few minutes, she returned.  “Their limit is lower than hours.”

“Of Course it is.” At this point, I had already accepted this is not going to go my, nor the patient’s.  I grabbed the phone to call the nearest stroke center, almost 3 hours away.

The long distance consult/transfer conversation follows a script.  Patient’s name, brief past medical history, brief story of what has happened.  In the case of a stroke, special attention to presenting physical findings and last known normal is the expected.  Then, I get to the meat of my call:

“So, the real struggle right now is she is well over the weight limit for our CT scanner and the next closest CT scanner is 30 minutes away and apparently has a lower weight limit than ours.”

Then, I heard something I have never heard from another physician on the consult line.  The stroke neurologist offered a simple line.

“I’m sorry.” This was quickly followed by, “Yeah, let’s just get here as fast as we can.  She is already out of the tPA window, we’ll finish her evaluation here.”

We sent her by ground ambulance as quickly as possible.

We Don’t Have That

The next day, an ambulance arrived with a 40s male, actively seizing for 20-30 minutes after the police arrested him.  No IV’s were placed in the field, he is completely unresponsive.  We quickly placed an IV and began the rounds of diazepam.  Finally, after three rounds, his seizure activity stopped.  He was still unresponsive.  GCS of 7, even after watching for any post-ictal improvement.

I have learned at this point it is more effective to ask for certain items rural EDs keep in bundles rather than what you would, ideally, prefer.  So, I didn’t as for my preferred induction agent, paralytic, etc.  I just asked them to bring their RSI kit, video laryngoscope (if they have one) and regular laryngscope.

“While we are getting ready to intubate, can someone get some IV keppra ready.”

“We don’t have that.” I am told.

“Fosphenytoin?”

“Umm, I don’t think so.”

“What other IV anti-epileptic medications do you have other than benzodiazepines?”

“I don’t know, maybe ketamine?”

Practicing medicine in a Critical Access setting is not a smorgasbord.  It is an 8th grade cafeteria line.

You can have whatever you want as long as it is Salisbury steak.

I proceed to intubate.  Afterwards, he was thankfully easy to bag and maintained end tidal CO2 and Oxygen levels in desirable ranges.  I asked if we have a ventilator.  An eager EMT piped up.

“Oh yeah, it is right over there.”  He pointed to a machine sitting on a crash cart with a big red sticker on it, “Out of Service.”

“Oh, I guess not.” He sheepishly admitted.

“Okay, bag him, make sure not to hyperventilate.”

Luckily, we have already called the local Medevac crew for critical care transport. They arrived and hooked patient onto their ventilator.  Carefully, they moved him with all his the sedation drips and IV fluids to their stretcher and flew him off to somewhere with an ICU.

Somewhere with a functioning ventilator and some damn Keppra.

I looked around that the remaining EMTs and nurses.

“Well, that could have gone worse.”

Why Do This Job?

I have talked to a fair number of EM residency trained ED docs and I often get the response of, “Oh, practicing out there would terrify me.”

I have no MD back up, no specialist support other than what can be obtained over the phone.  The EDs are often minimally staffed and under-provisioned.  On the other hand, my shifts are rarely so eventful as this.  Usually, it is Urgent Care level work ups. Often times it is downright boring – 24 hours without a patient sometimes.

But, that is the thing with an ED, anything can show up, even if it usually doesn’t.

I think a lot of quaternary care center trained physicians bristle at the resource limitation.  “I just wouldn’t feel like I am doing a good job.” is another statement I have heard.

I actually understand these concerns, no one likes to feel like they are providing less than the best care.  My response is simple.  The patients I see can’t call 911 and get dropped off at a Level 1 trauma center.  They are 2.5 hours from a level II, 30 minutes from a level III, minimum.

You can only take care of patients where they are.  Patients in Rural America need medical care just like patient in Urban America, but that isn’t where they are.  It’s called Critical Access for a reason.  Doing what is possible when you must is often more meaningful to the patient as doing everything because you can.

Time is of the essence in so much of what we do.  Waiting 20 minutes for a BLS ambulance to arrive and then driving another 30-45 minutes to the next closest Emergency Department could have meant serious brain damage for the man that man.

Could I offer him everything?  Of course not.  But I offered him a hell of lot better than 30 minutes of seizing in ambulance.

The famed bank robber Willy Sutton once answered the question, “Why do you rob banks?” with a simple, “Because that’s where the money is.”

I suppose, in the end, my answer is just as simple.

Why do I do this job?  Because it’s where the patients are.

Featured Image: The British Army in the United Kingdom 1939-45 Soldiers from 24th Battalion, Hampshire Regiment scale an obstacle during ‘toughening up’ training in wintry conditions at Wateringbury in Kent, 20 January 1942.

 

 

What is Being Present Worth to You?

…Memories of presence…the intensity of interacting with another human being that animates being there for, and with, that person.

Arthur Kleinman, The Lancet, Vol 389 June 24, 2017 Pg 2466.

“Doc”

“What do you have?” I ask the paramedic with the clipboard standing in front of me. The ED is rather busy. I am trying to arrange transfer of a man with an intra-abdominal abscess and one with neutropenic fevers. The prospect of more work does not excite.

Hank, an older paramedic who really enjoys the “medicine” part of his job, launches into his presentation.

“Rex Mayfair is a mid-forties man with a history of metastatic prostate cancer, Stage IV presents with urinary retention since this morning. This happens occasional for him and he comes in and we place a foley and have him follow up later. I already bladder scanned him, 570ml, and our scanner has been underestimating lately. Can I place the foley? He’s hurting.”

“Any fevers, weakness, blood in his urine?”

“A little bit of blood earlier, none now. Otherwise no changes from his baseline. He is not currently undergoing treatment for cancer, but is not on hospice. Can I place the foley?”

“Sure, go ahead. I’ll be in a bit.” I am relieved he has such a simple complaint. Something straightforward. Shouldn’t slow us down too much.

I return to organizing antibiotics and transfers for my other two patients.

Cancer Just Sucks

Eventually, after I tie up some loose strings, I make my way to Rex’s room. By the time I get into his room, Hank has already placed the foley, 1000ml out, and Rex is feeling better. My participation is really only procedural – a physician needs to physically see every ED patient.

I have a confession to make, I hate cancer. I hate how all consuming it is. As someone who initially trained in family medicine, cancer makes me feel as though I have already failed. The time for prevention was long ago. Now we sit at the mercy of the tumors.

Bad cancer makes me feel helpless. Doctor’s hate feeling helpless. Rex had bad cancer, and he was young.

Walking into the room, seeing Rex’s young, gaunt face makes me want wrap this up as quickly as possible. I only need to make sure there is no reason to suspect this is something other than swelling related to the cancer and I can rush him on his way. This should be quick…

To be Present or…not

“Hi, Rex, I am Dr. HighPlains, are you feeling any better after the foley?”

“Oh yeah,” Rex says in a defeated sigh. “It is better now.”

He just looks so damn tired and weak. I inhale deeply, but shallow enough so Rex didn’t notice. I sit down in a chair, recline slightly, and prepare to be here for a while.

After a few perfunctory ED questions, I asked Rex how things were going otherwise.

“It sucks, y’know, it just sucks.” He admitted.

“I can only imaging how much it sucks.” My patterned doctor-speech.

“I hurt all the time, cancer is in my bones. My hips and back, they ache all the time and then trigger muscle spasms.”

Without probing, he tells me how his urologist diagnosed him after 8 months of treatment for prostatitis. He describes how he was on hospice for a bit, but didn’t want to have a catheter permanently yet, so now he is not on hospice, but not pursuing curative treatment.

I simply nod in silence. His eyes are sunken and tired, but whenever he looks up, mine are there to greet his and hold his gaze as long as he desires it. He pauses frequently, but never seems done.

He continues, again without probing. He decided not have chemo because he has a form of muscular dystrophy. His oncologists told him the chemo would render him bed-bound from weakness.

“I would’ve had no quality of life…it just sucks, y’know.” He trails off into silence.

“Yes, it does.”

You Don’t Have to Ask a Dying Man

What do you say to make someone who is dying feel better?

It is a trick question, of course. Not because there is nothing to make them feel better, rather the thing involves no speaking. The answer, it turns out, is simple: you listen.

You listen. Even when it makes your own heart break, you listen. You listen through the descriptions of pain which makes you wilt. You don’t have to ask a dying man anything.

If you listen, he will tell you everything he wants you to know.

Rex isn’t done. He tells me about the facebook groups he’s found, which have been helpful to fight the isolation of living in the middle of nowhere with end-stage cancer.

He describes how much he used to enjoy driving the bus which took local elderly to events in the city and hearing their stories.

He misses that.

He tells me again about the pain. He tells me how his doctor prescribed him oxycodone for the pain, but he doesn’t like taking it. It makes his sleepy.

He has two little girls. When he took the oxycodone he just slept all day. His voice trails off, but I hear the implication.

He would rather be awake in pain with his daughters than sleep away whatever time he had left with them.

“It just sucks y’know, I’m only my forties, not an old man. Shouldn’t have to have a tube up there….it just sucks….” He bows his head, the brim of his baseball cap hiding those eyes, deep-set in his sallow, bony cheeks.

At that moment, it was a good thing I was listening, I couldn’t have said anything if I’d tried. I was speechless. My mind whorled in appreciation for the beauty of his simple statement.

“I have two little girls, I just slept all the time.”

This man, who has all the right in the world to numb himself from the pain of his situation had decided being present with his family was worth the pain.

Maybe when someone tells you the name of the thing which will probably kill you, time becomes palpably more dear. I don’t know.

What would I suffer through to give my daughter better memories of her father? What would I suffer through to have those memories and make more for as long as I could?

Few of us face a choice so stark, but in some way or another, we all face Rex’s choice. We can choose to be present in our lives and in pain, or choose to chase numbness.

I sat in a room with courage that day. I sat in a room with a man who chose to live his life rather than run from death.

Occasionally, if we let ourselves, we can awed by those we see through our practices But, we have to let ourselves sit in acceptance and receive the gift. I could have easily kept moving and had Rex on his way.

Instead, I sat down, and I am richer for it.

Featured Image: The Artist’s Father in His Sick Bed, Lovis Corinth, 1888.

Lockjaw Still Lives Underground

“Alright doc, I have a 6 year old who fell in her back yard in the dirt and cut her right palm.” Bill, the ED paramedic gave me his report.

“Do you think it’ll need stitches?”

“Probably”

“Grab a suture tray, 1% lidocaine with epi, and 5-0 prolene. I’ll numb it up, wash it out, and we’ll get her home.”

I walked into the room, introduced myself and took a look at the wound. 4-5 stitches would likely do the job. It was a clean, straight cut – the easy kind to close.

“This should be quick'” I think to myself.

I love lacerations, they are the closest thing to actually fixing something I get to do in my practice. Someone comes in with an injury, they leave put back together. It usually isn’t terribly hard, but it is a discrete problem with a discrete solution.

It is a nice break from the parade of our health system’s failures I usually see.

Isn’t there always a catch?

I numbed the wound and irrigated it. It was straight, clean, and pink in her hand. About 2 inches long. I quickly placed 5 simple, interrupted sutures and it came back together nicely.

I told Bill the kind of dressing to place on it, inverted my gloves, and threw them in the trash.

Offhandedly, I asked her mother, “And she’s had all her vaccinations?”

“No, we don’t vaccinate.” Her mother responded, as if it were an integral part of her moral compass.

“Goddamnit.” I think to myself. “This was supposed to be a simple lac.”

I turn around, sit down on the stool and look seriously at the mother.

I start in calmly but firmly, “Tetanus is a soil microbe. It is everywhere. There is real risk she has been exposed because of where she cut her hand open in the dirt. Now we cleaned it out as best we could, it is very unlikely she would contract tetanus, but if she did it would be a life threatening illness. What would you like to do?”

I had to breath slowly and calmly through the silence until she answered. “We didn’t have to be here having this conversation,” I think to myself. “She chose this.” I fumed internally.

Love, Fear, and Distant Demons

I saw her expression change from defiance to honest concern. I had seen that face before. My annoyance softened, I know most parents who don’t vaccinate honestly think they are doing what is safest for their children. They love their children like I love mine, they want to keep them safe.

The world is a big, scary place, full of things capable bringing harm to our children and our families. We assess these emotionally. The more fear they generate in us, the more threatening they appear. In the end, as human beings, we worry most about the dangers we feel to be closest to our families.

The face she made was the face I have seen other parents make when a danger once felt to be theoretical becomes real. I saw that face when I had told an expectant mother she was not Rubella immune (because her mother had decided she didn’t need any vaccinations).

I explained if she were to get rubella it could cause damage to her unborn child.

The knowledge that she could not undue her mother’s decision until after the pregnancy only made the fear more real. I looked into the mother’s face of the child with the laceration now and saw that same look.

It is the look of previously dismissed dangers made manifest. Of looking at a real and present threat, not weighing theoreticals and philosophical “freedoms.” It is the look of talking about the possible illness and death of your child.

It is a look I didn’t have to see that day.

Cursing Our Impotence in the Face of Death

Soldier Dying from Tetanus – Charles Bell (1808)

When I think about vaccine preventable illness, it is hard to communicate the despair and sadness doctors and nurses feel about them.

I think of a 5 month old baby I once cared for as a resident in the PICU. I think of watching his tiny body convulse in status epilepticus. He was unvaccinated and had streptococcus pneumoniae meningitis.

His mother just hadn’t gotten around to vaccinating him, she had no moral objections. Things just got in the way. To this day, I am not sure which is worse, but the “why” didn’t matter to him.

As we loaded him with ativan, then keppra, then phenobarbitol his seizures eventually abated. I remember the PICU attending looking at us during rounds and saying softly under his breath, “This will not be a good outcome, he will not have a good outcome.”

He, like all of us, were looking for ways to distance ourselves from tragedy. Using the language of peer-review and metrics he isolated himself from the picture he saw in his head of this child’s future.

He had been previously healthy, on a path to a normal life. That future was now gone. He would have permanent brain damage – probably a crippling seizure disorder for the rest of his life. He would become one of the “chronic kids.” Who are in and out of PICUs their entire lives.

He survived that hospital stay, but his life was forever altered. It is so painful to watch these things because society places its hopes and dreams in children. As adults we glory in their blanks slates, their possibilities.

We put on them the hope of correcting the failures of current generations. It is a lot to bear, being a child, being the symbol of hope and the future for a whole society.

As physicians and nurses, we watch this suffering and know it was not random chance, something simple could have prevented it. We seethe with rage, because accepting and living through the sadness would be too much to bear. It is easier to be angry, to blame.

We are furious someone has taken that future, has destroyed a receptacle for our dreams. Yet, anger gets us nowhere. Sure, we feel righteous, but it changes nothing. Its only real purpose is to insulate us from feeling the true depth of tragedy.

Our rage is for us, not for the child who lies attached to a ventilator. My anger certainly did that boy no good.

A Pound of Cure

Back in the ED, the mother and I discuss options. Being a struggling, rural hospital, we don’t have tetanus toxoid on hand. The nurse manager tells me they can have it by tomorrow, otherwise they will have to go to the City to a facility that can administer it. Either today or tomorrow.

We do have vaccinations. Hesitantly, the child’s mother agrees to a vaccination. She balks at the compound vaccine that also protects against pertussis.

“Do you have just the Td? Without the pertussis part?” She asks.

I mentally roll my eyes. Apparently, only tetanus now seems real. She is willing to have her child inoculated with the human blood product of the toxoid, but is only willing to have the minimum amount of “vaccine.”

I don’t go into long explanations about deaths from whooping cough, how it is not eradicated, how it is a real disease. I have already had too much magical thinking for one day.

We give her daughter the Td, and make arrangements for her to go to the City to get the tetanus toxoid. It seems like such a farce. So, much unnecessary effort and risk for something that could be so simply prevented.

I watch them walk out of the ED, it is hard to let the anger go with them.

It Feels Personal

As people who regularly battle death and provide comfort and care for the suffering, the rejection of vaccines feels like a personal affront. So much suffering and premature death occur in this world over which we have no power.

The idea of choosing to increase the risk, of adding more suffering unnecessarily, cuts us to the quick. We know these old disease, the previously forgotten harbingers of death. As physicians and nurses, we see the rare case that sneaks through modern defenses. They are still real to us.

We keep their secrets, we still study the demons who live underground. We know in other countries they still kill people by the thousands. Those monsters are still real to us, they keep us up at night.

We go home and kiss our children and thank God there is at least one threat in this big, dangerous world from which we can easily protect them.

This is why we respond with so much anger and vitriol sometimes. It is because vaccine preventable disease hurts us so deeply. We bear witness to so much suffering, because this is out job.

But to have suffering added to our plate, to have it piled on unnecessarily – this can be too much to bear.

Deep down, I know people love their children and are trying to protect them as best they know how. I only wish I knew how to make them feel the fear of those long-forgotten demons who still live underground.

If they were to live with the fear we know, I don’t think we would even be having these conversations.

A Shift as Death’s Attendant

“When was the last dose of epinephrine?” I ask the Tara, the recorder.

Her blood is everywhere. My gloved fingers are tacky with it.  I see it dripping off the edge of the bed, smeared across the floor, oozing from the open fracture of her right leg.

Her foot, connected to her leg only by skin and tendon, was still in a shoe. This struck me as an obscenity.

I watch blood pulse back forth in the tube draining her chest with the same rhythm as the chest compressions.

Tara’s reply makes its way through the commotion, “3 minutes ago.”

I turn to the team.  “Get ready to give another dose of epinephrine. Pete, take over chest compressions at the rhythm check.”

“Still in asystole.”

“Resume compressions, give the epinephrine.”  My voice has so little emotion. It seems to simply echo the recordings of the ACLS trainings I just completed the week before. Good timing, I think to myself.

On the Banks of the Styx

This is the second time in 48 hours I have stood at the foot of the bed, directing our modern dance with death. 

36 hours ago, it was all for show. We surmised he was dead well before his family found him. But EMS started CPR in the field, so we continued it. We invited the family in, to see us try and bring him back to life. We showed them all we could do.

We added artificial adrenaline to his veins. Then, when the lab-made adrenaline did nothing, we gave him our own – in the form of chest compressions, bagged breaths, and sweat-beaded brows. We danced with him, this newly dead man. We danced for his family.

We danced so they would know the drama and pain of the moment when we had done all we could.

He gave his body to those he left behind. He allowed us his body as salve to the grief of those who would miss him.

Dance of Death, replica of 15th century fresco; National Gallery of Slovenia

He sacrificed his body to lighten the burden of guilt of those he left. He didn’t make that choice, we and his family made it for him. I don’t know if he would have wanted it, but I found the gesture noble.

Now, 36 hours later, I am back in the same position. But this woman, she came in alive. Now, she was dead.

Only by standing at the threshold do you see how thin the veil really is.

Despite the intubation, the fluid, the pressors, the chest tube, her heart had stopped.

A code can actually have a lot of down time, especially once chest compressions have been going on for 20+ minutes.  I take a moment to let my mind slide out of the algorithm.

I look at the woman on the bed.  She is elderly.  I can hear the crunching of her multiple rib fractures with each compression.  Dying in a car crash after you have lived so long.  Such a violent death, so unexpected at that age.

“Doc, I have the family on the phone, can you talk to them?”

“Yes.” I grab the phone.  “This is Dr. HighPlains.  How are you related to Gladys?”

“I am her son, what is going on?”

“What have they told you so far?”

“Only that she’s been in a bad car accident.”

“Yes, she has. When she came in she was having difficulty breathing and had severe fractures in her legsand ribs. We had to put a tube into her lung to drain blood that was keeping her from breathing and put her on a ventilator. “

He sighed audibly in the phone.

“We started giving her blood as she was bleeding internally. Despite all of this, her heart has stopped and we are now doing CPR to try and restart her heart….I am so sorry.”

“We are currently doing everything we can do. However, in my experience, given her injuries, it is unlikely we’ll be able to get her heart restarted.”

Silence.

“Do you know what would your mother have wanted us to so in this situation?”

He regained his voice. “Well, I am her Power of Attorney. How long have you been doing CPR?”

“About 25 minutes.”

With a tired, tremble in his voice, “I need to get my head around this, Would you keep trying for 10 minutes, and then, if nothing changes, you can stop.”

So, the music continued. And again, we danced. And Gladys too, sacrificed her body for those who will grieve her. We all tried not to focus on the grating of the ends of her ribs past each other.

It is such violent dance, these days.

Time of Death, 18:00

12 minutes later, I made a phone call.

“Sir, this is Dr. HighPlains again. Unfortunately, we were unable to get your mother’s heart restarted…”

“Thank you for everything you’ve done…”

We share a few more words, and I hang up the phone.

The Strange Calm

The routine of operationalized death begins. I sit back and watch. I slowly peel off my trauma gown. The ball is over, no point keeping up the dress code.

I watch the nurses. They cover the body first. It is a body now, no longer a person, at least medico-legally. Staff has already notified the coroner. The transfer of care is in process. I no longer have a patient.

The nurses start gathering the detritus up and throwing it away. I help feebly. We draw the curtain in the trauma bay. It is customary to the give the dead their privacy.

But, whose sensitivities are we really protecting?

Breath, Light Awareness

I sit down at the computer. Documentation is impatient. I pause before I start typing. I sit and feel. I notice my breath, and my pulse.

Luxuries, I suppose.

I can feel the heaviness of death. I do not feel guilt, I do not feel shame. I did everything I could. Could we have used dopamine instead of levophed, sure. Could we have tried externally pacing when her heart rate started to drop, sure.

Nonetheless, I do not second guess. Death sits next to me in heavy silence. I do not shy away, nor do I linger in fascination. I allow my body and breath to relax in acceptance. All our paths end here.

Click…Click….Click

“Patient arrived by EMS transport in extremis….”

Walking the Ghost Road

Working as a doctor in small towns on the High Plains, I have learned to do without a lot of luxuries. Those practicing in larger centers would consider many of these things necessities, such as being able to consult someone to the bedside, ever.

I do, however, have one luxury that is exceedingly rare in world of Modern Medicine, time to reflect. As I often only see 5-10 patients in a 24 hour period, I sometimes have a good deal of this.

Moreover, now that I have an infant at home, the time I have to reflect while at work is even more precious. I have yet to find a way to sell my 2 month old daughter on the value of quiet contemplation.

Since high school, I have tended to reflect while walking. When I screwed up a test, or embarrassed myself at school, that evening I would go on a long walk, sometimes for hours. I would meditate to the slow movement of my small town past me.

I still do this. Today, I took a walk on the slight hill above the hospital. A “wellness path” winds its way through the buffalo grass, prickly pear, and yucca. I walked the path in laps, waiting to be called in.

Those Who Came Before

Halfway through a lap, I came to the single grave that marks the halfway point. It is a modest affair. A small white headstone with only three letters marks the spot.

The earth over the grave is covered in the same high plains vegetation as the nearby pastures. Prickly pear and rabbit brush grow up around the headstone. Eventually, someone erected a very sturdy pipe fencing around the grave, likely to keep cattle from rubbing on the grave marker.

Perhaps most interesting, this lonely, solitary grave belongs a fellow physician. In the late 19th century, a wayward doctor had settled in this water stop town on the railroad. The townsfolk laid him to rest on a slight hill that overlooks the shallow, cottonwood-dotted valley of a seasonal stream.

I lean against the iron fence and stare up at the night sky. It is a wonderfully clear and dark night. I savor the lack of light pollution and the horizon to horizon views. Scanning the southern sky I see the milky way.

The Ghost Road

In Lakota cosmology, the milky way is known as the Ghost Road. It is the path all spirits must walk on their way from this world to the next. I let myself get lost in the imagery of walking through the galaxy as a spirit.

As I imagine my spirit side-stepping stars, I remember my fellow physician next to me. He walked that road over 100 years ago as a young man. Less than forty, it looks like. It is near impossible to imagine the life and profession of a true frontier doctor.

Nonetheless, profession and location bind us together. We have both doctored and cared for people in this little town. Even if the march of time makes it impossible for us to know each other as people, we are related.

This is also a Lakota idea – Mitakuye Oyasin – We Are All Related.

I reread the plaque explaining this grave.

A Life in a Paragraph

The good doctor had arrived in 1880. Two years later smallpox erupted in town (could he have imagined an era when doctors would have never seen a case of smallpox?). An old cow puncher came down with disease, and the good doctor cared for him.

The old cow puncher recovered, but the good doctor contracted smallpox. He eventually succumbed to the disease and was laid to rest on the same lonely windswept piece of prairie where I talk my contemplative walks.

“A good doctor…and a good man.” The plaque states.

Does the brief story on the plaque have meaning for me as a physician?

This physician died in the service of others, and I complain about not feeling fulfilled by modern medicine. In his calling, he sacrificed everything. Noble? Maybe, but also a complicated legacy.

From the plaque I also learn that he left behind a wife, who had accompanied him from the East. It does not say what happened to her out on the alien High Plains, alone, in grief. He also left behind an isolated, frontier town without a doctor.

How many went undoctored in his absence? I will never know.

Doctors Get Sick, Too

The irony of his death from the disease he was treating is not lost on me. Physicians are part of the societies they inhabit. Inextricably linked. In medical school, I often heard vague citations that physicians have higher rates of heart disease than other professions.

Most of these statistics came from before we started to turn the tide on heart disease. This was before cholesterol drugs and anti-hypertensives were mainstream, but when smoking still was.

Now, on the internet, I read about the burden of stress, anxiety, and depression doctors bear. It is no surprise, mental illness and its complications (i.e. addiction) seem to be an epidemic sweeping our country.

Why should doctors be immune? Especially, if we spend hours and hours caring for people with these diseases, is it no surprise some of it might rub off on us? You cannot vaccinate yourself against despair, loneliness, and disconnectedness.

Yet, We Are All Related.

I step away from the fence, feeling indebted to this long departed colleague of mine. Many, many things have changed in Medicine. Nonetheless, some things seem not to change.

Being a doctor is a hard job. It demands a lot. More than any one person can reasonably be expected to give. Yet, we do give, repeatedly and sometimes to excess.

The good doctor on that hill on the High Plains gave all he had to Medicine. It was sacrifice, yes, but I don’t want to glorify it. I will not say Dulce et Decorum Est Pro Medicina Mori.

Nonetheless, for a moment, I feel connected to a different kind of Medicine.

Not the Medicine of RVUs and production targets and treatment algorithms, but a deeper calling to serve humanity.

I’d like to think I can be doctor without sacrificing everything. But it is a delicate balance, and more often than not and I am too far one way or the other.

My eyes trace the line from his headstone to the Ghost Road in the southern sky.

At least, I think, I am not alone on this road.

Rugged Individualism Dies a Slow Death on the High Plains

If the High Plains had an official philosophy, it would be Rugged Individualism. The Rugged Individualist bends nature to his will under his own might and survives despite all odds on his own ingenuity and hard work. He is the mythic paragon of High Plains citizenry.

Of course, the myth holds up poorly when we take a closer look. The High Plains are very lightly populated. As such, individuals are even more dependent on community and society at large than in many cities.

Sometimes those bonds are strikingly personal. I walk into gas stations on the High Plains regularly. Without fail, a collection jar for some young person injured in a farming accident or suffering from some unexpected disease greets me when I enter.

More commonly though, those dependencies are complex networks of support. They are often not apparent on the surface.

Indeed, the entire economy of the High Plains is largely based in government support (save for grassfed ranching). Subsidies for corn, wheat, and cotton support the agricultural economy. The states and federal government pay for the education sectors. Medicare and Medicaid pays for the care of the ill and elderly, who make up a disproportionately larger share of rural populations.

Medicare and Medicaid are the lifeblood of the few hospitals who manage to eek out an existence on the High Plains. The numbers of the privately insured are too low to fatten their bottom lines. Indeed, a state’s decision not to expand medicaid has been linked to increased rural hospital closures.

Nonetheless, the Myth Lives On…

Despite the evidence supporting the dependency that rural areas have on the government and community institutions, the myth of the Rugged Individualist lives on.

Some of this is understandable. Many people on the High Plains have grown accustomed to handling challenges on their own. In the day to day of their lives, their lived experience is one of having to be very independent and resourceful.

Moreover, people place a huge value on “straight talk” on the High Plains. The residents of the High Plains are quick to dismiss any delving into complexities and grey areas as a form of obfuscation. As such, discussions on how economically dependent the High Plains are on the federal government are easily shut down.

But Why the Rugged Individualist?

The Rugged Individualist is part of the Defining Myth of the High Plains. Be they sodbusters or cowboys, those myths give a sense of place and identity to the High Plains.

Myths are powerful things. To destroy a Defining Myth is to philosophically destroy a person. He/She will resist it all costs.

Communities and individuals cling tighter and tighter to such Myths when they sense risks to their survival. The popularity of Brexit among much of declining working class Britain may be an attempt to reassert the Defining Myths of Britishness.

Similarly, the High Plains are on a century’s long economic and demographic decline. Small towns throughout the High Plains are teetering on the edge of viability. Every ten years we see how they are slowly hemorrhaging population. As such, their Myths have increased in importance overtime.

People and communities need to take pride in something. If they cannot take pride in their economic vitality, robust institutions, and entrepreneurial populace, people will seek solace in their Defining Myths. In this case, it is the Myth of Rugged Individualism.

This even seeps into the culture of healthcare in the region.

Treating the Chronically Ill Rugged Individualist

Contending with the myths of Rugged Individualism is one of the more exasperating parts of my job.

I see many people with multiple chronic diseases requiring huge amounts of medical intervention. Despite this, they continue to live 20 minutes from town on a farm/ranch or even just an acreage.

They have little to no family support. This is usually because the kids all left for the city and jobs. Sometimes, it is just clearly because the individual is such a goddamn pain in the ass.

Acutely, they are often suffering from COPD/CHF exacerbation, lumbar fractures, chronic wound infections, chronic debilitation from limited activity, or any other number of chronic complaints. To any reasonable discerning observer, the root cause is chronic deterioration of their health without social support.

Nonetheless, they cling to their need to live “independently.” Somehow, routine hospital stays, home health, huge expenditures of time and assistance on the part of family do not constitute “dependence.”

The Rugged Individualist often confuses stubbornness for strength.

An Encounter With a Chronically Ill Rugged Individualist

I am sitting in the clinic office finishing a note and the phone rings. A nurse from the hospital calls and asks if I can take a look a patient. The patient is here for some outpatient wound care.

The nurse goes on, “We had her in swing bed last week for rehab. She has been home for less than a week. I am worried that she might have cellulitis under her pannus.”

I walk into the room. The patient is laying diagonally across the hospital bed, feet dangling off the edge. The position is awkward and unnatural. I introduce myself.

“I am the On-Call doctor, do mind if I look at your wound?”

She barely acknowledges my presence “Go ahead.”

The nurse and I retract her pannus. Underneath is the characteristic beet red color with cheesy accents of a massive yeast infection in the folds of skin.

“Ma’am, you have a yeast infection. Are you able to keep the area dry and clean at home?”

“No, I can’t reach it and no one’s ’round to help.”

Afterwards, I learn the two home health agencies which service the county refuse to work with her.

“Yeast lives in warm, moist environments, like in between your skin here. All the medicine in the world won’t keep this from happening if you can’t keep it dry and clean.” I begin to explain.

“But I can’t reach it and I ain’t got no help.”

I continue. “So, you can’t take care of it yourself at home and you have no help. The only other option is living in a facility where there is help. Like a nursing home.”

She bristles as expected, “I ain’t going into no damn nursing home.”

“Well, then this is going to keep happening.”

She nods her head in reluctant acknowledgement and says nothing more.

An Institution Funded through Enabling

A good number of the acute inpatient admissions I do are effectively the result of chronic ailments getting so far out of control so as to justify admitting someone to the hospital. Basically, the hospitals stay afloat through enabling the untenable living situations of the chronically-ill.

This is largely achieved through federal tax dollars. Those hospitals prevent people from dying alone in their homes or being dispositioned to a nursing home in a larger town after a hospitalization.

I recently related a story about intubating a woman with end-stage COPD. As far as I know, this was her 3rd-4th time in a year. She had only been home 2-3 weeks after a long hospital and rehab stay. In the nursing home, she had done well and improved with simple, attentive care.

She spent 10 days intubated in the ICU, at which point they placed a tracheostomy tube sent her to a facility which specialized in long term ventilated patients. It only took a few weeks at home without attentive care for this to happen.

After years of hospital admissions, intubations, and nearly dying multiple times, she is now ventilator dependent. This will likely be for the rest of her life. I don’t know if her staying in the nursing home would have kept her off a ventilator, but I do know that attempting to live “independently” hastened the course.

I have watched her story play out over and over again. In residency we referred to it as “tuning ’em up.” We’d admit someone, diurese them, and send them back to the same dysfunctional environment which allowed them to get so out of balance in the first place.

The hospital bills Medicare, we all collect a paycheck, and we do it all over again.

The Costs of Healthcare Individualism

Americans believe in the rights and importance of the individual above all else. Similarly, we place patient autonomy atop the ethical totem pole in US healthcare, even if it leads to harm.

The incentives in our medical system have created a structure which ignores the interconnectedness of the patient to their broader world. We spend little on the social determinants of health even though they are far more predictive of health outcomes than clinical medicine.

The importance we place on the individual ignores the reality of human existence. Connection and dependency define humanity. Humans are inherently social animals. We need each other and our surroundings affect us immeasurably.

In attempting to treat the chronically-ill as rugged individuals, we deny their connectedness. Ignoring those bonds, especially with the chronically ill, continues to lead to enormous inefficiencies and harm within our healthcare system.

Back to Work

I haven’t posted in a while. Not surprisingly, I have been somewhat occupied. Our new baby requires plenty of work, time, and love. Blogging hasn’t seemed all the important in comparison.

However, I am back on the High Lonesome, which brings with it periods of down time. This time is ripe for blogging.

Being back in the doctor’s role is an interesting transition from new father. Especially, after all the struggle over the last year and a half.

A Baby Brings Perspective

In some ways, I have a newfound acceptance of the failings of medical culture. All the pettiness, greed, and self-importance of many of the actors in a hospital are easier to tolerate, because the reason I show up is so much more important now.

Sometimes the work is its own reward. The times when I actually connect with a patient can sustain me – for a time. The rare critically ill patient who my team triages, treats, and transfers effectively can boost morale and help add meaning to the work.

Nonetheless, the reality is, most of any profession or job is mundane. Having a reason to go to work outside of paying off of my loans and funding my own diversions adds meaning to the mundane – especially when you are paid by the hour.

Knowing that my daughter is home and depends on me adds a certain nobility to the simple paycheck. It helps put a little shine back on the tarnished image medicine has for me.

Yet, on the first day of returning to work at one of my frequent work locations, I end up in my first meeting in over a year. Somehow, we are now having meetings….as locums.

I was scheduled to work and the ED wasn’t busy, so it didn’t turn out to be a big deal.

Of course, the main action item of this meeting was how to improve our billing and reimbursement. After only 3 years in practice, I am almost positive no other kind of meeting exists in healthcare.

This one specifically focused on improving critical care and procedure billing.

Good to be Back!

Other than this inauspicious start, the first day of the shift went fairly well. Going back to a familiar site was a good call for a first shift back. Weirdly, I seemed to actually enjoy being in the hospital.

The hospital had changed the way the local docs rounded in the hospital. This had actually improved communication and the nurses were asking me less questions about patients whom I didn’t know.

Finally, a change whose goal was improving patient care that delivered some results.

The first two patient’s were turfs from clinic for a DVT rule out and a CHF exacerbation. I quickly and efficiently ruled out the DVT. The CHF patient was known to me so the work up and admission to the hospital ended up being fairly straightforward.

Having wrapped up this work, I noticed a lull had set in. I went to the doctor’s quarters in a nearby house to rest and put some space between me and the hospital (it always seems to make the shifts go quicker). I felt good.

Watching some Netflix and making dinner, I waited to be called in. Around 11 pm, I got a call. An ambulance was out for someone who was found down and unresponsive.

An Actual Emergency

I find this chief complaint to be one of the most varied in actual cause. Benzodiazepine overdose, DKA, patient already deceased, sepsis, vasovagal episode, seizure – it could be practically anything.

In small low acuity EDs it tends towards the more mundane. Nonetheless, I headed back the ED and arrived right as the patient was being wheeled into the ED bay.

I recognize her immediately. She is a chronic respiratory disaster.

At 57, She already has end-stage COPD with multiple intubations in the last 12 months. This is, of course, coupled with right-sided heart failure. Shockingly, her kidneys are okay.

Her family has been told multiple times she may never come off the ventilator and she always has – so they now think she always will.

I know her to be angrily, vehemently, and obstinately FULL CODE, despite her terrible chronic disease and inability to care for herself at home.

She has had repeated blood transfusions for anemia which is of unknown source because her respiratory status is too tenuous for endoscopy. Not surprisingly – she also has terrible veins and recently finished a prolonged course of IV antibiotics through a PICC line (which I noticed sadly had already been removed).

“Oh, Shit,” I think to myself.

I look at her on the gurney. She is on a nonrebreathing oxygen mask. Oxygen is actually reading in the high 90s – remarkably good for her. But you can hear her audibly wheezing. Her chest heaves almost off the bed as she breathes in, and then her breath just slowly leaks out.

Her GCS is 3. Yelling, sternal rubs, nail bed pressure – nothing.

Getting to Work

We all get to work. An intraosseus line is placed in one leg – she gives no indication of being aware of a needle being drilled into her tibia. The nurses draw blood and send it to lab.

We give her narcan – she is on a large number of narcotic pain medications. Again no change.

I have the team set up for her intubation as her oxygen levels are starting to drop. Positioning myself at the head of the bed the intubation kit lays ready. I tell the nurse to push the anesthetic, then the anxiolytic, and finally the paralytic. She stops breathing.

Opening her mouth, I slide the laryngoscope into her mouth, visualize the cords, and slide a number eight endotracheal tube into her trachea.

We secure the tube, verify correct position, and begin to breath for her. All in all, it goes pretty well. The chest X-ray shows pulmonary edema, possible infiltrate, ET tube in good position.

Her labs come back, possible sepsis, blood gas shows a PCO2 of 124 prior to intubation. Methamphetamines in her urine. We start sepsis and influenza anti-infectives, give steroids, and get her ready to transport to ICU.

All in all, from arrival to transfer, we do this all in less than 3 hours. Not bad for a family doc in a two-bed emergency department 100 miles from the closest trauma center. Also, it is snowing, so the helicopters won’t fly – she has to go by ground, of course.

The Thrill of Being Present

As she leaves in the ambulance. I am feeling pretty good, alive. We just saved a life – for now. I just spent three hours completely engrossed in something pretty amazing – working as a team with people who gave a shit on something important. It can be intoxicating in small doses.

I like critical care. I like obstetrics (though I don’t deliver babies non-emergently anymore). What I love is the focus on the task at hand. The power of a small group of people fully engrossed in what is happening in that very instant can be amazing.

Both critical care and obstetrics demand this kind of focus. We should all strive for that kind of focus in all aspects of our practice. Sadly, this is difficult given the seemingly coordinated effort to destroy it going on around us.

The High Fades

After a rest and a drink a water, I walk back to get some sleep – it is 2:30 AM after-all. On the walk, I can’t help but feel a tension between the excitement of caring for a critical patient and the ethics of how we spend healthcare dollars in this country.

How many intubations is too many for one person? Is it ethical to repeatedly intubate and, God forbid, actually code someone who lives on death’s doorstep every day?

Does one person have a right to unlimited medical expenditures to prolong their life? How many childhood vaccinations could that cover? How many addiction treatments, or early parenthood interventions could we pay for?

The methamphetamine in her urine and her 3 different narcotic prescriptions are evidence of a life of great suffering. That suffering predated her current illness. Indeed, the smoking and drug use which caused it were likely attempts to numb that suffering for decades.

Is it ethical because these are the patient’s stated wishes? Or are we just hiding behind a weak patient autonomy argument so we don’t have to wrestle the suffering we witness – and prolong.

The things we do to save a life, needles drilled through bone, tubes into bladders and lungs. It would be torture in any other situation.

I feel guilty about how excited I was afterwards – even though I saved her life. I also kind of feel guilty about that…

When is it too much? When is continuing to torture someone to keep them alive, and suffering, unethical – even if they demand you do it?

Are these even questions we can ask in American Healthcare?

Recognition

A week later I get an email from our new ED medical director:

“Doctor HP,

Great job with the care of patient #1234567 in the ED last week. Your documentation of the intubation and critical care time was excellent!

Sincerely,

Your Medical Director”

I sit back and sigh, good to back working again….

Are Population Health Initiatives Doomed to Fail?

In the world of medicine, population health is a hot topic. This is especially true in primary care. Our longitudinal relationships with people over years (at least in theory) and interest in prevention make us a logical starting point.

However, as I have said before, our healthcare system encourages increasing specialization, fragmenting of care, prioritizing acute problems over root causes, and increasingly using customer satisfaction as a metric.

As a result, it is particularly poorly constructed to address population health.

Medicine

Definition: The science and art dealing with the maintenance of health and the prevention, alleviation, or cure of disease.

The science and art of medicine does not trace its roots back to basic scientific inquiry, but rather to the universal role in human societies of the Healer. We have always been Healers first, scientists second.

Medicine incorporated science to improve our healing abilities. We did not come out of the lab and decide to start healing because our science gave us that ability.

Healing has always been an individualized art.

The first step in the treating a patient is to ask personalized, individual questions. This is quickly followed by the laying of hands. It is a deeply individual and personal ritual.

Physicians are not public health workers (though some do get involved). No one trained us to treat whole communities or groups of patients with a certain diagnosis or condition. We treat individuals.

This is an inherently different task than improving the health of communities.

Population Health

Definition: The health outcomes of a group of individuals, including the distribution of such outcomes within the group.

Intensive, individualized therapies are unlikely to be effective at addressing population-wide problems. These problems require population-wide treatments. Even large physician/hospital conglomerates do not possess such a level of power and influence.

For instance, the evidence the USPSTF uses to recommend for obesity screening is that intensive (12-26 sessions per year) behavioral interventions resulted in a 6% average weight loss in studies.

This is a hugely expensive intervention on a single individual. Does it work, yes. It is an efficient use of funds? Probably not.

On the other hand, emerging data shows us soda taxes do result in statistically significant BMI reductions across a population. Not a clinically impressive amount, but still significant on a population level. This is most noticeable in poorer subgroups – people most likely to suffer serious complications of obesity related diseases.

This was done without the expenditure of public or insurance funds, or the involvement of physicians and expensive healthcare infrastructure.

Nobody’s Business

 The truth is, no one in the public or private sectors currently has responsibility for overall health improvement.

-David A, Kindig MD, Phd

Policy makers are looking at our healthcare system, seeing its huge expense with relatively poor outcomes, and want us to do better. In steps the idea of population health. In theory, a worthy goal.

However, no institution or sector currently has responsibility for this goal. Since we spend so much money on healthcare, that industry seemed like a good place to start.

Sadly, it seems policy wonks are trying to avoid the politically difficult conversation of funding of our public health infrastructure.

Instead of using public health – a developed field with solid data and methodologies – they seem to being trying to use a highly specialized and individualized tool to do a brute force job.

It is like using a coping saw to clear cut a forest. I guess you could do it, but it isn’t going to work well.

Responsibility without Power

I see this as a larger and larger shift in healthcare where the Corporatists are trying to burden clinicians with as much responsibility as possible while controlling levers of power.

The inherent task of designing the assembly line is to divorce the cognitive aspects of a task from its execution. (i.e. Clinical algorithms designed to help clinicians now being used as metrics) Thus, the managers maintain the power, prestige, and wealth of the task without the responsibility.

For instance, clinical care accounts for only 10% of a patient’s total health. Thus, we have little to no influence over the vast majority of what determines a person’s health.

Yet, population health initiatives want to hold clinicians accountable for it.

Moreover, populations are not static within even the largest health systems in this country. People change insurers, they move, they doctor shop. To influence the rest of the pie, the population must have a long term relationship with the institution/clinician.

That is not American healthcare.

Good Money After Bad

But perhaps most importantly, why would we give the same organizations which have spent astronomically large sums of money creating an ineffective system more responsibility to improve our health?

They have more than proven they are not up to the task.

I am in favor of improving population health. The attempt to redesign an already bloated and dysfunctional system to do a task for which it is not prepared simply seems like a waste of time and resources to me.

We need a robust healthcare infrastructure to address the needs of the ill in our society. We also need a robust population health infrastructure focused on efficiently improving the our health so we require less of the expensive healthcare infrastructure.

These are two totally different tasks.

An attempt to blend these goals into one endeavor is classic “straddling strategy.” Rather than choose one goal and pursue it, we are trying to to do two inherently conflicting tasks at once.

The end result will be failing at both.

The Freedom Fallacy

Freedom so often means that one isn’t needed anywhere. Here you are an individual, you have a background of your own, you would be missed. But off there in the cities there are thousands of rolling stones like me. We are all alike; we have no ties, we know nobody, we own nothing. When one of us dies, they scarcely know where to bury him… We have no house, no place, no people of our own. We live in the streets, in the parks, in the theatres. We sit in restaurants and concert halls and look about at the hundreds of our own kind and shudder.

– Willa Cather, My Antonia.

In all the talk of financial freedom/independence, we often forget to address the underlying fallacy in that assertion. Freedom or independence is impossible and possibly not even desirable.

We can be independent of many things. We can be independent of debt, wage work, even the power grid. However, that independence always comes with a cost (except maybe debt).

If we save enough money to stop working, we become dependent on the market, the value of the dollar, etc. Living off the power grid makes us dependent on sunshine, a gasoline generator, or our own ability to cut, split, and stack firewood for heat.

Indeed, living off the grid is satisfying not because of the freedom from industrial society. Rather, the connection to the natural world that it provides satisfies the soul.

Besides, connections and interdependency are essential traits of humanity. We need community, belonging, and purpose to live rich rewarding lives. Independence and freedom should not be the goals.

Rather, the things of which we desire to be free are often creating harmful relationships. We should not spurn connection, but those things we are connected to which are harming us.

The Value of Work

Far and away the best prize that life has to offer is the chance to work hard at work worth doing. – Theodore Roosevelt

I have started reading Shop Class as Soulcraft, by Matthew Crawford. I am not very far in, but it seem our desire to be free stems from our devaluation of work. Our society has been chronically and inexorably devaluing work since Henry Ford.

As work itself is devalued, the Corporatists are able to alter it in ways that make it less and less rewarding for individuals. They buy our silence with increased remuneration so we can pay for things we don’t value.

We cannot value a thing if we don’t respect the work inherent in its making.

The reward of operating a drill press repeatedly in the same way day in and day out is far less than building individual pieces of furniture which can you can admire in completed form and be proud of.

In my own craft of doctoring, we see the finished product – healing and the healing relationship – increasingly being pulled from our grasps as physicians. The system is cubiclizing our craft.

Our patients, so accustomed to this reality in every other part of their lives they do not seem to care all that much. As long as they get their product, a Z-pack for a viral cold, narcotics and benzodiazepines for the pain of existence, unnecessary orthopedic procedures, they are satisfied customers.

The sad thing is, I could make more money doing 30-40 of those visits in a day as a medical automaton (and I have witnessed plenty of physicians who are doing so) than I could truly trying to heal.

Freedom vs. Fulfillment

While I think financial independence is worthwhile, by focusing on the end-goal we often forget to do the hard work of examining why we desire them in the first place.

This desire stems from a deep satisfaction with our work. As a people, we seem to inherently no longer find satisfaction and value in our work. Now, some might argue this is just Millennials being lazy.

However, isn’t it just as possible that something in the world of work has inherently changed over the last 50 years? That work is literally not what it once was.

Two trends are crossing right now. The trend of devaluation of work has continued unabated since Henry Ford and is reaching parts of our economy that were previously immune. This trend is intersecting with an increasing realization that money and consumerism lead to empty lives.

What is a person to do in an economy which requires us to do a thing we find repulsive to buy shit we don’t want? FIRE is one answer, but it simply postpones a reckoning.

We actually want fulfillment, and if we put the barrier of financial freedom between us and fulfillment, we increase the likelihood we will never get there.

Oh, So Many Red Herrings

Why do so many bloggers who have reached financial independence keep blogging? Because it is a path to connection and creative work.

We can obtain both of those things before FIRE. We do not have to postpone a meaningful life until we have “Fuck You Money.”

What pushes people who have enough money to stop? Not the number in the bank, but the dissatisfaction the work provides.

So, like most things in life the problem isn’t money or lack there of, it is more difficult. It is life, and it is much more difficult to rearrange one’s life and build meaningful work and relationships than to keep working for Fuck You Money.

The system is extremely adept at using money to keep us on the gerbil wheel. Even Fuck You Money can just be another carrot to keep the gerbil wheel cranking.

Accumulating money cannot be the answer to our existential woes, since it is clearly the cause.

Courage is not the Absence of Fear

The position of strength that John Goodman talks about in the Gambler does not require a a dollar amount. It requires courage, discipline, and clarity of purpose. We can learn and practice these things without a lifetime of money in the bank.

I said Fuck You (not literally, I do not recommend that) with over $300,000 in student loans and similar sized mortgage. What I had was Fuck Me Money, not Fuck You Money.

I still made the decision from a position of strength because I understood my marketability and cared more about the health of my family than anything else.

A year later, I have no mortgage (renting), and my student loans are over $100,000 smaller. We live in a 1500 sq ft house without air conditioning, the bumper of my work vehicle is kept on with duct tape and baling wire, and we are much happier.

Again, it had nothing to with a number and everything to do with living a life more true to ourselves.

So, go ahead, get that Fuck You Money, but don’t neglect connection and work worth doing in the process. If you do, you risk ending up all alone with no bills.

Hemingway and the Danger of Persona

I love reading Hemingway. I am unabashed about my love of his writing. Before everyone freaks out and starts listing all of the problematic aspects of Hemingway when viewed through a modern lens, I am well aware of all of the arguments against Hemingway.

Those arguments are part of the reason I love his writing. Simple, perfect people are useless when it comes to extracting lessons for life. No writer worth reading stays perfect through the centuries.

One of the best parts of reading Hemingway is the existence of a decent companion work which puts nearly every major piece of his work in perspective.

While I could write a book on these various topics, one that I have come to appreciate during my struggle to reclaim my humanity from medicine is the cautionary tale of the Hemingway Persona.

Personality vs Persona

When you read about Hemingway’s early personality the evidence largely points an idealistic, sensitive, and very motivated young artist. He wrote a lot about “manly” pursuits (fishing, hunting, etc) even his early days, but they are almost always a backdrop for extremely human and vulnerable emotional struggles.

Additionally, he drank too much, a common form of self-medication for the overly sensitive in this insensitive world. He was desperate for approval in his professional life and intimacy and adoration in his private life.

Big Two Hearted River illustrates this the best. I read those stories as a form of literary meditation repeatedly the winter after my daughter died. Indeed, I channeled a little of that story into one my posts.

In 1926, he published the The Sun Also Rises to critical acclaim. The literary persona of Jake Barnes (based off of himself), who fished the Basque Pyrenees and dodged bulls in Pamplona, captured the imagination of readers.

From that point on, Hemingway became that persona more and more in public. Over time, the work of putting on the mask invincible masculinity took its toll on Hemingway. It is worth noting that he projected that persona strongest in middle life, when men most acutely have to reckon with their inherent vulnerability.

Hemingway’s public narrative of invincible masculinity became increasingly untenable overtime. This, as well as a genetic predisposition to depression, alcoholism, and chronic pain from injuries in plane crashes led to increasingly deep depressive bouts.

In the end, he killed himself. After a life of building a persona which conflicted so deeply with his underlying personality, this is the only way Hemingway could have died. His public persona could only allow Hemingway to kill Hemingway. No other could have been up to the task.

Does the Doctor kill the Person?

Physicians, arguably more than most common professions, have a strong public image. Strong yet caring, never tiring, cocksure at times, in pursuit of the care of their patients.

Physician culture is very intolerance of aberrancy in this personality type. This is on display in a recent back and forth in the comments by a Douglas Hoy of one of M’s Posts over at Reflections of a Millennial Doctor.

A good portion of my medical school’s non-basic science or clinical education was spent indoctrinating us into the professional image of the physician. We all must wear professional masks. However, the pressure to fully become the mask of the physician is stronger than most.

While I think some people already are or become “the Doctor.” For the rest of us, those who were pretty satisfied with who we were before being physicians, this personality dissonance can be a deep struggle.

As Hemingway’s struggle with his persona show us, if the dissonance is too great, it can be fatal. In many of the stories of physician suicide, people reference this personality vs persona dissonance.

“She was always so happy.”

“Everyone loved him.”

“She was so successful.”

Dissolving the Narrative Dissolves the Self

For many, the risk of “being found out,” or having the persona destroyed is too great a risk. As I have said before, narratives are extremely powerful. We construct ourselves through narrative, if ours is at risk of dissolution, it can seem no different than death itself.

For instance, the country of Macedonia is changing its name to North Macedonia in order to join NATO. The narrative of Macedonia and Alexander the Great being Greek is so important to Greek identity that Greece has blocked Macedonia’s entrance into the organization. And people are still pissed off.

That is how strong narratives are. I am not victim blaming or minimizing the importance of clinical syndromes of Ddepression and anxiety.

However, part of the road to healing is identifying paths and actions we can take to work back towards health. One of those paths is the work of creating a physician persona that is concordant with our native personalities.

As usual, Hemingway says it best in his writing:

“The most painful thing is losing yourself in the process of loving someone too much, and forgetting that you are special too.”

― Ernest Hemingway, Men Without Women

In loving our idea of the doctor more than the person we are, we risk forgetting that we were already special, already worthy.

In the work of healing it is important to continue to be our authentic selves. I believe we will be most effective and keep ourselves and patients safer if we reclaim our humanity and leave our personas at the door.