But the Restlessness was Handed Down…

But the restlessness was handed down,

and its getting very hard to stay.

-Billy Joel

I have not stumbled into this life of an itinerant doctor through some accident.

Ever since Cain and Abel, humans have been telling stories to try and understand why some sew and harvest while others roam with the seasons.

We all lie somewhere on this continuum.

On one end are the constant roamers, the nomads.  Those whose breath is the very wind over the plains, constant motion.  On the other end are the sewers, reapers, and builders.  Those settled ones who grow deep roots.

Most of us are in middle, but we all lean one way or the other.  I am center-nomad.  From the top of a far bluff, I look down at riverside settlements and envy the apparent stability and contentment.  Nonetheless, despite my longing, I am not of townsfolk blood.

I envy that life until I have it, then I quickly feel a deep need to move, to travel over the next hill, to see new country.  35% settled, 65% nomad.  These are impetuses difficult to resolve within one’s soul, let alone with the outside world.

Who Was I Kidding?

During medical school and residency I read a lot of the “happiness” literature.  A consistent theme in the happiness literature is community and connectedness.  As I started to make plans for a future practice, I folded in the importance of connectedness into my plans and landed on family medicine for a specialty.

I thought putting down roots and developing deep, long relationships with my patients would be satisfying and fulfilling.  In retrospect, this seems a little foolish – knowing who I am.  From graduating high school until residency, I never lived in one city longer than 9-10 months. Even in medical school, I figured out ways to spend months away from the city my medical school was in.

I spent 2-3 times longer in one place during residency than I had in the ten years prior.  What made me think I was going to suddenly want to settle down and become the “town doc” for 20 years?

I even thrived on the rotational nature of residency.  I loved having something new to learn and focus on every 2-8 weeks.  I probably would have gone crazy without it.

Indeed, family medicine is the nomad of medical specialties. The variation in family medicine was also a huge pull for me. We are not confined to an organ system, an age group, a location of practice, we can go where the wind of medicine takes us.

Pretty much immediately upon starting practice after residency, the sense of permanency began to suffocate me.  I couldn’t shake the idea of “this is it?”  Was this really the end point in the long journey towards becoming a doctor?

A nomad cannot be fenced.

I Know the Grass Isn’t Greener

Some may scoff at my acceptance of my rolling stone nature.   “Sure,” they say, “we all fall into the trap of thinking the grass is greener on the other side of the fence – but it isn’t.”

I agree.  I do not think the grass is greener on the other side of the fence. In fact, experiencing different places has helped me know this more definitely.  Rather, I seem to possess a deep desire to simply experience the grass on the other side of the fence.

I don’t feel the pull to roam because I am looking for something or somewhere better.  I simply have this greedy urge to experience everything I can.  Life is so short and there is so much out to feel, know, and experience in this world.

How can I say no?

There is so much to learn about the other side of the fence I could not have known until I was there.   Up on crossing a fence, I have realized the grass may be the same, but the fence is totally different from the other side.

I may not have crossed the fence to experience this, but it was a new experience all the same. An experience which I could not have anticipated.

Unknown Unknowns

To paraphrase Donald Rumsfeld, the world is full of unknown unknowns.  We can only experience them if we go new places, if we challenge ourselves, if we allow ourselves to be uncomfortable.  Discomfort is where growth happens.

This change in perspective, when repeated, is vivifying.  I am constantly learning to see the world through new eyes, which has added value to my life, if not wealth.

Some of us build monuments and harvest crops, others roam and explore.  We only thrive when we embrace who we are.

Featured Image: Der Wanderer uber dem nebelmeer (The Wanderer Over the Sea of Fog), Caspar David Friedrich.  1818

Down the Canyon and Up the Mountain

Ten years ago this summer, I started a journey.  I made a decision to climb a mountain.  The path is well travelled and well marked, but supposedly so arduous few are allowed to start the journey.

Setting off to summit this peak, I first had to descend into the depths of a canyon.  Others had told me of this canyon.  They did not, however, explain its diabolical nature.  They did not warn me the sides of the canyon are loose scree fields, easy to get down, very difficult to get up. 

Going down wasn’t too bad, and everyone around said it would be worth it on top of the mountain.  The scree seemed to let me almost surf the way down.  However, the bottom of the canyon was dark, cold, and filled with sharp brush which abused the body. 

“You’ll get through,” they told me. “You’ll survive.”

Finally, though, after I reached the bottom, I began the journey back up.  I waded the cold creek.  I took a brief rest.  Then, I set out on a long hard climb up.  I could see neither the canyon rim, nor the original peak I had envisioned climbing.  

The loose scree gave way under me and sent backwards, 6-7% with every step.  It seems as though every possible handhold belied some danger: thorns, scorpions, snakes, and the like. 

Finally, after a long slog, I have reached to the canyon rim.  From the rim I can now look up and see the mountain that had been my goal.  I am tired, hot, sweaty, and forever changed from who I was before I descended into the dark of the canyon.  

I gaze longingly up at the mountain, it is visible, yet still so far away.  I turn around, and realize I am at the exact same elevation I started at, 10 years before, just a chasm of time away.  I am closer to the mountain, yes, but no further away from my starting point. 

This is what it feels like to reach Zero Net Worth after 10 years of medical training and working as a physician.   So much has changed, and yet, financially, I am only back where I started. 

10 Years Back to Zero

My net worth was barely above zero prior to medical school, but it was positive. That was the last time I had a positive net worth. The massive debt of medical school sent my net worth south of negative $300,000 at its lowest.

I recently calculated my net worth and, I have officially reached a positive net worth.

10 years later

Technically, somewhere in the last 6 months I reached Zero Net Worth. It took me a few months shy of a decade, but I have crawled back from the financial hole medical education put me in.

To be clear, I am not debt free. All of my assets just now officially outweigh my debt.

Getting back to zero is a necessary part of building wealth as a physician (assuming you took out loans for medical school). Nonetheless, the idea of 10 years of hard work, missed sleep, and sacrificing time with family and friends leading only getting me back to even is depressing.

Accounting for Life

Of course, money is a poor way to track life’s ups and downs. The value I place on different periods of my life over the last ten years correlates very poorly with their contributions to my net worth.

Medical School

The most striking example of this is medical school. By far the most expensive part of my life up to this point. I feel, at best, neutral about my medical school experience. It was okay, but certainly not worth the money it cost (from an experience standpoint).

I learned a lot in medical school, relatively little of it has much bearing on the actual practice of medicine or my life today. In my opinion, medical school is merely the price of admission to medicine, not much more.

By far the most significant value add to my life that came out of medical school was my wife. Meeting her is the great redeeming factor of my time in medical school, and worth it all.

Residency

My financial footing in residency probably changed little overall. I saved some money in Roth and traditional IRA, so the cost of my interest on my loans was probably offset by this.

On the other hand, residency has been and likely will always remain my favorite time in medicine. I had a great group of co-residents and humane faculty who were most interested in teaching first and foremost.

I worked like a dog, but it seemed like it had purpose and I was doing something that mattered, with people I enjoyed. Sure, was I happy to give up the 80 hour weeks when I finished. Nonetheless, I would have traded a lot of money from my first job to keep the sense of camaraderie and joy in medicine which I knew in residency.

In contrast to medical school, marrying my wife in residency seems not redeeming, but complementary. The memory of getting married in my R2 year blends with the frenetic sense of energy, growth, and progress of my residency years. Altogether, it was a good time to be young, in love, and doing something which felt like it mattered.

Attending

Obviously, working as an attending has been the most financially valuable part of my time in medicine, however it has also had the most ups and downs.  I was seriously looking for ways to quite medicine entirely 6 months into my first job. 

I was making more money than I ever dreamed possible and I was miserable. Honestly, the work of seeing patient’s wasn’t bad, but it wasn’t good enough to make up for the toxic culture, uninspired and vapid leadership, and burnt-out, greedy partners.

Having our first daughter and having to say good-bye in less than a month was a whirlwind of emotions.  I would not trade anything the experience of knowing and loving her for anything.  It was nonetheless a trying time.  

My current job is entirely satisfactory.  I have times where I get a good deal of satisfaction out of what I do, times when I am entirely fed up with it, and most of the time it just seems like a decent enough way to make a more than decent living. 

The joy of having our second daughter grows exponentially with every day.  It has been a relief to experience fatherhood with the joy and hope we are told to expect.  Life keeps moving. 

Life is Rich

I read a lot of physician blogs at times, and enjoy most of them.  Many physicians correlate their discovery of financial literacy with improvement in their overall happiness and life.  

I think this improvement actually comes more from simply moving to a more disciplined approach to life.  Finance simply provides an easily accessible framework on a topic that matters. Money matters, it can be the source of great stress and anxiety.   However, it will never bring happiness.  

Looking through the last ten years through the lens of my net worth is actually really depressing.  If life were about net worth, I probably should not have become a doctor.  The jury might still be out on that decision anyway.  Life is so much richer than numbers. 

I have developed a much richer appreciation for the human condition and experience in medicine than I ever would have in almost any other profession.

This richness cannot be quantified nor repossessed.  It does not earn me interest, yet pays me great dividends.  The discipline to examine our finances opens the window to examining ourselves and our lives, if we follow the breadcrumbs. 

Discipline is one of the great keys to a life well-lived.  Financial literacy, not as a competitive sport of amassing net worth, but as a training ground for personal discipline, is a useful tool for honing the skills which actually lead to a rich life. 

If the trail is only a means to peak-bagging, we are already lost.  To gain the most important benefits from financial literacy and independence we must remember they are not the goals, but merely training grounds for the personal skills which can help us live a life worth reveling in. 

 

P.S. I have really enjoyed looking for images of classic artwork to use as my featured images, as they are all public domain, I do not need to reference them, but I think think I am going to start adding information about each featured image at the bottom of each post with a link to information on the painting for those interested. 
Featured Image: Chasm of the Colorado by Thomas Moran 1873-1874

Back From the Great Wide Open

I open the door of the little, rural hospital I have been tethered to for the last 96 hours.  The bright, plains sun slams into my eyes. I squint and don my sunglasses.  I haul my call bags across the small, gravel parking lot and through them into the back of my car.

My car has become quite the road warrior over the last year.  12 years old, it shows its age. The front end is largely held on with baling wire.  The body is heavily dimpled from hail damage (an eventuality if you spend much time on the High Plains).  After the fifth rock extended the windshield spider web to an unsafe degree, I finally replaced it.

Nonetheless, I hold onto it.  It is effective basic transportation.  More importantly, after fixing the struts, head gasket, oil sensor, windshield etc, I need to get a little return on my investment.  Old, decaying homesteads dot the back roads of the High Plains and remind you of the legacy of the Dust Bowl and its deprivation.

If you spend enough time here, frugality seems more of a moral duty to those who survived than a way to get ahead financially.  Ostentation seems blatantly disrespectful.

I slide into the seat, turn the key, and the engine rolls over obligingly.  Turning out of the gravel drive onto the paved two-lane highway, I feel the first change that marks the return journey to my modern City-State.

That Ribbon of Highway…

I ease down on the accelerator and little four cylinder engine slowly increases frequency until I am at cruising speed.  I pass the grain trucks grinding slowly out of town and engage cruise control.

The City is still sufficiently distant that its radio waves don’t reach me yet.  I rarely use my smartphone to listen to my music, or medical CME, or audiobooks.  I like to listen to the local radio, even though it isn’t particularly good.

I like to hear the classic country and rock songs punctuated by advertisements for farm financing, announcements about the local county fair, and today’s corn, wheat, pork, and beef prices.  The only other options are Christian praise music or Norteno corridos on the Spanish-langauge station.

Occasionally, I listen to a few corridos before I tire of the wailing of lost loves and betrayal.

I never listen to the praise channels.

I drink in the never ending sky and the limitless horizon.  If you are from the lands of big sky, nothing is more comforting and inviting than the long, distant horizon.  You revel in your smallness.  If you aren’t native to the sky, it is nothing but a barren, foreign, emotionally disconcerting country.

No matter what you call it: plains, prairie, steppe, or llano, you either love it or you don’t.  Big sky country demands an emotion.  I have never met someone who is indifferent to it.

Wrapping up a shift and sliding onto the open highway combines two great sensations: the freedom of being both off the clock and off the grid.

It is a moment bordering on intoxication.

The Interstate

An hour later, I take a left turn and merge onto the interstate.  The wet, acrid smell of the nearby feedlot invades my car.  Immediately, I am in a different world.

The large UPS truck trailers remind me of modern e-commerce and our intense, modern interconnectedness.  I navigate the huge RVs doing their seasonal migrations.  I pass turn offs for the large truck stops with chain fast-food restaurants attached.

The local radio station starts to crackle with static.  The City’s more powerful antennas have already begun to crowd out the rural stations.  I give in and switch to one of the City’s stations.  The finely polished voices badges me to consider refinancing to roll my high interest debt into a low interest mortgage.

Or, advertisements bombard me for questionable hormone replacements therapies, which will apparently making aging optional. Not to mention the not-so-subtle adds for clinics specializing in phosphodiesterase-5 inhibitors.

I have officially crossed a boundary.  I have moved from a land where suffering is accepted as an unfortunate part of life to the regions where we are promised the power to opt out of suffering entirely.

“Life should be easy,” I hear. “Just buy this product and all the struggle will disappear.  We have plenty of financing options available for you…”

I flip the channel, hear the start of an old Sheryl Crow song, and settle in for a five minute break from advertisements.  I set the cruise control 10 mph faster than it had been on the two-lane.

The Modern Travelers’ Bazaar

About an hour later, I ease off the interstate, tacking a right into the parking lot of a truck stop.  I pull up to the pump, insert my various plastic forms of identification: my rewards card, my credit card.  I push the fuel selector, remove the pump handle, slide the nozzle into the gas tank and pulled the lever.

The fuel makes soft whooshing sound as it plunges into the tank.

Again, advertisements bombard me. This time a screen on the pump rages at me. “When did these become a thing?” I wonder to myself.  The squawking from the screen is overlain by barking from a loudspeaker informing me of all the deals to be had inside.

It reminds me of an electronic version of market stalls with vendors harassing you for attention and shoving their wares in your face.  Only, I cannot politely decline with my hand across my chest, and slight bow, and say, “Maybe later.”

The onslaught continues, I am powerless to modify it.

The pump thunks, and I replace the nozzle.  I lock my car and record the receipt in my smartphone, for tax purposes.

A dizzying array of crap I don’t need greets me inside.  I rush past the racks of pseudo-cowboy regalia, t-shirts with not-so-witty sayings emblazoned on them, and canes with “Vietnam Veteran” logos on the pommels.

I make it into the bathroom, and even relieving myself, I cannot avoid the advertisements for more shit I don’t need.

A man can’t even piss without being sold something in this country any more.

The Edgelands

Back on the interstate, I see the City starting to spill out and infect the plains.  The traffic picks up, the drivers who were content to go the speed limits now need to go 15 mph faster, driven by innate feelings of competition with the increased road population. I disengage my cruise control.

Billboards for urgent cares, liquor stores, and music festivals start to appear by the side of the highway.  Warehouses and distribution centers pop up like weeds.  Soon, the first exurban shopping center edges into view next to the highway.  The chain restaurants, discount clothing stores, all surrounded by their own asphalt plains.  I am told these are signs of the healthy economic growth…

Growth for the sake of growth is the ideology of a cancer cell.

-Edward Abbey

I look to the horizon, now obscured by scraggly trees, buildings, and semi-trailers.  It has taken on a sickly brown hue.  It is the color of a week-old bruise.  The air, now visible, starts to obscure the sky.   Without the visual escape of the horizon, I am drawn down to the human landscape, so paltry in comparison.

The detritus of homeless camps under the overpasses or next to the channelized, polluted rivers and the irrigation canals sucking them dry greets my gaze.   I turn up the pop-indie-folk-blues-autotune whatever coming out of the speakers.  Numb out.

I slide off the interstate into a cloverleaf and slide back onto another.  I smell the exhaust of the oil refinery waft out of my cars vents.  Soon, but never soon enough, I am at my exit and gratefully leave the interstate.

I jockey into position for the lane which will allow me the smoothest turn into our neighborhood.  The aggressiveness of the other drivers sends an electric energy up through the cars tires.  I let my mind drift back to the serenity of the sky I left behind.

Artificial Eden

I take a left at the park across from our house.  It is broad and flat, colored a deep, artificially green.  European Pines, crabapples, and Elms dot the small plain.  It contrasts with the light, airy green of native grasses and winter wheat I passed on the plains.  The trees on the plains had been ash and cottonwood lining the water courses, while wild plum and chokecherry in bloom clustered slightly higher.

I stop in the alley, step out of the car and open the back gate to our rental house.  The air smells mostly of nothing, but with the faint perfume of exhaust, asphalt, and cigarette butts.  Our old hound bounds out of the back door, wagging her tail excitedly.

Shortly after, my wife comes out, our daughter in her arms, excitedly telling her “Daddy’s Home!”  At 4 months, she is not particularly understanding.  But, I move my face into her view and she smiles her big, unbridled, infant smile.  The bridge of her nose crinkles and she lifts her arms in front her face in apparent embarrassment at her excitement.

I pick her up, kiss her cheek long and hard and she laughs.

And just like that, I am home again.

 

 

 

Brene Brown and Seneca Walk into A Bar

Back in residency, I read a lot of Brene Brown.  We saw a lot of very damaged people in our residency clinic and the ideas of vulnerability, armor, and perfectionism were very helpful in understanding many of my patient’s struggles.  Also, those ideas helped me understand many of the physician personalities around me.

Since then, I have dabbled with Buddhist, Stoic, and modern psychological thought. Much of this was to help me deal with my own grief.  Most of these ideas overlap and complement each other.  However, occasionally ideas conflict.  When they do, I feel a need to resolve this conflict.

One such conflict was the idea of “Foreboding Joy” in Brene Brown’s work and “Worst Case Scenario Thinking (premeditatio malorum/premeditation of evils/negative visualization)” in Stoic thought.  The Stoics recommend the latter, whereas Brene Brown views the former as a detrimental practice.  Initially, they seemed very similar to me, so I was perplexed.

Foreboding Joy

“Joy is the most vulnerable emotion we experience, and if you cannot tolerate joy, what you do is you start dress rehearsing tragedy.”

-Brene Brown

The idea of foreboding joy is the imaging terrible things happening as a way to protect ourselves from the vulnerability of feeling joy at the prospect of something.  In protecting ourselves from vulnerability, we rob joy from our lives.  Obviously, Brene Brown argues, this is detrimental to our overall happiness and a life well lived.

How, she argues, can we live our lives fully if we won’t let ourselves experience joy?  Is the risk of pain worth removing joy from our lives?

I think we would all generally agree it isn’t.

Foreboding Joy becomes a mental trap we lay for ourselves, protectively and instinctively.  The work then, is catching ourselves laying this trap and slowly and repeatedly undoing it.

The Stoics, on the surface, seem to recommend the opposite approach.

Premeditatio Malorum

The man who has anticipated the coming of troubles takes away their power when they arrive.

-Seneca

Seneca and others actively recommended the practice of imagining the worst possible outcome of a scenario to prepare ourselves for tragedy.  They argued it strengthens us in the face of tragedy.

On the one hand, they argued we would be better prepared to combat any ill which may befall us if we had anticipated it.  On the other hand, if there was no way to combat the ill, we would be better prepared to accept it if we had anticipated.

Does this not seem like contradictory advice to Brene Brown’s?  Doesn’t imagining all the negative outcomes ahead of time rob us of our present joy?  How is it possible to both anticipate evils which may befall us and no forebode our own joy?

For weeks after reading of the practice of premeditating on evils, I struggled with how it intersected with the dangers of foreboding joy.  Like most things in life, I came to the conclusion that it depended on the execution and one’s approach to the question.

I came to this by meditating on our own great tragedy, the loss of our first daughter.

Tragedy as My Teacher

When my wife called me in the middle of a clinic day and told me she was to be induced for polyhydramnios, I immediately did a quick literature search.

I came face to face with all the terrible possibilities.

Based on a quick rule out of maternal reasons for polyhydramnios, I concluded something could be very wrong with our baby.

As the pines zoomed past me on the drive to the hospital, I though of the possibility that our child may not live.  It was a terrible possibility.  I also remember thinking, “We’ll deal that if we have to.”  There was nothing to do in the moment but have our baby.

In no other moment in my life have I been so present as during the labor and birth of our first daughter.  Knowing what I knew about the future and my powerlessness to affect it drove me deeply into the present, beside my wife.

I sat next to her as she breathed through contractions. I supported her as she swayed and moaned around the room as Latin music played softly in the background.  For 6 hours, I knew no past or future.

The world reduced to my wife and I and the electronically registered heartbeat of our baby.

Foreboding Joy or Premeditating on Evils?

A year or more later, as I wrestled with the concepts of foreboding joy and negative visualization, I thought back to these moments.  Had I not visualized the worst possible outcome?

Yet, it had not destroyed the joy in being present with my wife during her labor.  It may not have intensified the joy of the birth, but it did intensify my immersion in the experience.  My imagining of future ills had not, in fact, robbed me of my present and its joys.

I thought of another moment of intense emotion: when we decided to try for another child.  We were still grieving, our loss was less than 1 year old.  And here we were, sitting in another state, planning to start down the path again.

Knowing better than most the possible tragedies which could befall us, we jointly made the decision to start our journey.  We both knew we could lose a second child.  We could not ignore it.  We were terrified, yet also knew we had survived it – even as painful as it was.

We did visualize losing this new person we would attempt to bring into the world. We did not dance around it, we faced it head on.  We decided it was worth the risk.

Courage is the Difference

Courage is not the absence of fear, but rather the judgment that something else is more important than one’s fear.

-Ambrose Redmoon (James Neil Hollingsworth)

I believe the apparent conflict of foreboding joy and premeditation of evils can be resolved by understanding the problems of uncertainty, fear, and courage.  It all depends on how one practices the premeditation of evils.

If we practice negative visualization as a way to wall ourselves off from possible harm and disappointment, it is a form a foreboding joy.  It is an attempt to emotionally shield ourselves from vulnerability.

On the other hand, we can choose to use negative visualization to better understand our fears, worries, and possible consequences.  Instead of walling off vulnerability by imagining terrible things, we consciously accept them as possible.

Then, we must decide it is worth the risk.  If, knowing the risks, we move forward, not rashly, but deliberately; we are being more intentionally and, I dare say, courageously, vulnerable.

It would not have been courageous to ignore losing our second child was not an option.  Naming and knowing our fears, letting ourselves feel them in a conscious way, and deciding something else is more important, is a courageously vulnerable action.

Knowing our Fears

I believe the ideas of foreboding joy and premeditation of evils are not opposed.  However, their dangers and benefits depends on our approach to them.  Are we practicing negative visualization intentionally? Or, are we succumbing to unintentional, unfelt fears and pulling back, hiding from risk and loss?

Naming and letting ourselves feel our fears can be used to help us live more courageous and vulnerable lives.  However, if we run from them and only know them in short blips of foreboding, which we then try and scrub from our memory, we are hiding from life.  We are letting our intolerance for uncertainty, risk, and loss control us, not embracing of life and its complexities.

 

 

 

 

 

The Psychology of My Debt

My debt weighs on me, both financially and psychologically. Interestingly, this was not the case in medical school or residency. Then, about 3 months into my first job its specter began to grow, even though the actual number started declining for the first time in 7 years.

Overtime, the psychological importance of my debt balooned in inverse proportion to the speed at which I was paying it off. I would spend hours per month tracking it, trying to find ways to pay it off faster.

I stared at the screen, as if by sheer will I could reverse the nature of compound interest. This did not work.

This was always going to be a bad thing for me, psychologically. Money has never motivated me. Having more money has never made feel better about life or myself. It felt unnatural to be so concerned about numbers on a screen. It just wasn’t me – but I couldn’t stop.

Turns out, having lots of money won’t make you happy, but owing lots to someone else can make you miserable.

My wife tells me sometimes our marriage feels like a terrible love triangle between me, her, and my debt. Yet, after leaving my first job, the problem did not improve. It actually worsened.

We took a significant hit in income and any hope at loan repayment went away with transitioning to 1099 work. I felt the pressure of paying off the debt land squarely and intensely on my shoulders. I focused all the energy I had previously given to medical training onto paying down my debt.

It had become my white whale.

Obsession is Never Healthy

At first, I had assumed my debt weighed on me because I hated my first job. I had jumped from the cloistered, privileged, insincere nobility of academic medicine into the cauldron of RVUs and the greed driven Hospital-Pharmaceutical Complex. The disillusionment was scalding.

More disturbingly, my partners were lining up at the trough to eat the unethical slop. The system was playing them like fiddles, and they were happy to oblige. Never mind the fact they were actually miserable.

Yet, they played the part of selfless, caring physicians – even if all we ever talked about at meetings was how much money they could make. I felt tainted by association. The guilt gnawed at me.

That guilt did not immediately go away upon changing to my current locum tenens work, it morphed into a different kind of guilt. I felt guilty for abandoning the noble aim of continuity of care and my former dream of being the “local doc.”

So, my obsession grew, despite changing my work situation.

Kids Change Everything

Having our second daughter gave me a chance to refocus. Having a family has changed the relationship I have with medicine again. I have slowly been able to let go of some of the anger I had at the way my partners and health system treated me.

I had directed a good deal of that anger at the institution of medicine. I have since come to realize it isn’t particularly helpful to hold an amorphous profession accountable. I will never be able to have closure with a profession.

I have also released myself of my burden of accountability to the profession. If the profession is not accountable to me, I am not accountable to it. This has greatly improved my relationship with work.

I have managed to lower my bar for satisfaction drastically. My relationship with medicine has evolved from complete devotion, to resentful hatred, to a simple acceptance.

This evolution has allowed me to see how much power I was giving my debt over my life.

We Give Things Power over Us

Most people seem to have the problem of not realizing how detrimental debt is to their financial health. I had the opposite problem, I gave my debt complete control over my enjoyment of life.

I had made eliminating my debt into the dreaded “next step.” That next accomplishment I had to reach before I could be happy. Even though I knew that trap all too well, it had caught me again.

Debt had become a binary state. I was either in it or I wasn’t, progress did not exist. And, as long as I was in debt, I was beholden to medicine. And that pissed me off.

Eventually, I realized it had gone too far…

Around tax time, I was able to throw a huge amount of money at my debt. As this was the first year I have been paid substantially as a 1099 sole proprietor I apparently had over-saved substantially for my tax bill. In one fell swoop, I eliminated over 15% of my remaining debt burden.

But, I was not pleased. Instead of congratulating myself on making large progress in eliminating debt, I was emboldened to try and move up the timeline on making myself debt free.

I felt the need to pay more faster because I had made so much progress so quickly. I knew this was not a reasonable reaction.

I was chasing the dragon…

I had something to decide. I could continue to be angry and resentful for 2-3 more years and hope it got better when I paid off my loans (the go to doctor coping mechanism). Or, I could actually wrestle with my emotions and try to find a way to happier in the present.

Perspective Change

So, instead of continuing to think of my loans in binary terms of being chained to or free from medicine. I asked myself a bigger question.

“If I had already paid off my loans, what would I do differently?”

Turns out, probably not much.

I would probably work a little bit less. We would travel more(I hope), probably buy a house. But, most importantly, I wouldn’t quit medicine and try a different career.

This was hugely freeing.

The emotional benefit of being debt free is the idea you could walk way if you wanted to. So, realizing I would not walk away took away a lot of the power of the loans.

Doing The Math

Once I deflated the emotional power of my debt, I could look at it a bit more rationally. I had made a lot of progress. I decided to run some scenarios.

I ran various amortization schedules based on refinancing vs not and at different time intervals (2-5 more years). Instead of the shackles vs. freedom emotional response to debt, I tried to give myself more of a dollars and cents view.

Turns out, depending on various scenarios, my debt will likely cost me another $10,000-$25,000 in interest. Also, it turns out I should probably refinance my student loans.

So, those numbers are not nothing. However, it allows for a more rational conversation about my loan debt. Instead of a binary choice for happiness, I can ask:

“How many more months am I willing to be in debt to enjoy my life more for the net 2-4 years?

Since I am not going to go out and buy a Tesla or mega-house or anything like that, it is mostly about how gentle am I going to be with myself about how choosing to work a little less so I can spend more time hiking, fishing, traveling, etc.

Turns out, I am probably willing to spend up to 6 months more in debt to have more time doing other things I enjoy.

I am tired of waiting for the next thing, I am living right now. 2 years of living a happier, more balanced life seems worth a few more months of debt.

Wherever I Go, I am a Stranger

Spring is the best time on High Plains, especially on the Northern High Plains. The snow has melted. If the springs rains came, then the grass has greened and the winter wheat is growing in the fields. Verdancy is everywhere.

The birds have returned and their sounds can be deafening. The mourning doves and prairie meadowlarks fill the evening with their calls.

The wind brings the scent of sweet clover and moisture. Later, in July, it will feel like a dusty blast furnace. But now everything is pleasantly fresh and new. It is a good time to get out of the City. The sense of possibility and abundance surround you as you walk down dirt streets.

Towns on the plains are of two camps, clod hopper towns or shit kicker towns. This roughly divides them between towns that rely on farming and those that rely on ranching, respectively.

Farming requires more machinery, more labor, and is more lucrative. As such, these towns have a more robust tax base and generally more funds for services. They tend to have greener lawns and more orderly, well-kept homes.

I am on shift in one such town today. School has ended for the year, children run feral throughout the town, down lanes of arts and crafts homes and mid-century ranches. It reminds me of my childhood.

Upon going out into the world, I found out that even in the 1980’s and 1990’s, I was living a childhood out of a different time. Now, these children are having an experience downright foreign in comparison to their urban and suburban counterparts.

In this little pocket of America, the end of school year does not simply mean a transition from one overly-scheduled, hectic routine to a different overly-scheduled, hectic routine.

It means the freedom to roam, make mistakes, get hurt, and learn and grow. Freedoms now so rarely afforded children in our society.

I sit in the well-manicured park next to the baseball diamond and let myself dream of a simple life in a little world like this. Where my daughter could roam the streets in relative safety.

Forever the Rolling Stone

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, O Pioneers.

It is a silly little fantasy. I am a stranger here. I always will be. Even if we moved in and I set up shop as the town doctor, I would always be an outsider. I would be a little suspect, I wouldn’t really “understand” the town. That is the way it is.

As long as I am temporary, the staff and patients treat me well. They treat me like a guest. They are very kind and obliging. On the other hand, I know cultures which place the most importance on hospitality towards guests are also often the most closed.

As long you are a guest, you have no rights in community decisions. You are otherized and compartmentalized into a nonthreatening entity, ever so politely.

So, I roam, continually a guest, an outsider, an observer. Nonetheless, the dream of simple little corner of Americana is a seductive one…

To Dream a Little Dream

When I discuss these little flights of fantasy with my wife, she sighs and rolls her eyes. She knows why a simple, pleasant, little life for us is only a dream. We are not simple, pleasant, little people – and I am likely the worse of the two.

I don’t know if we dream of bigger things, but we do not fit into molds well. We are not terribly pliable people. We have not melded back into the city well, either. The self-indulgence, easy conveniences, greed, commercialized spirituality, and glorification of self have rubbed us raw.

I often wish I could be satisfied with a simpler version of what life was about. I wish I could still believe working in healthcare is about helping people.

But some things cannot be unseen, some hurts cannot be unfelt.

Simplicity is Complicated, Too

The funny thing is, my life actually is much simpler now that I travel for work. I roll in, do my work, and I roll out. Back at home, I live a life with plenty of unstructured time spent with my wife and daughter.

Work is far less draining. I don’t go to meetings to be harangued about productivity, my life is not held hostage to a call schedule. Yet, I am perpetually a stranger at work, and in the City.

It turns out, after a certain age, most of the people in our lives we meet through work. And most people don’t have 10-20 days a month free to spend as they like – they are at work.

It is an odd paradox, my life is honestly much simpler than it has been in years. Yet, that simplicity has not necessarily made it richer.

Without the demands of Medicine following me day and night, I have had to let myself be a human again. To let myself do nothing, without guilt, which has been the hardest part, by far.

After 9 years of being fashioned into a bow and strung tight, always ready to react to some new crisis, it is hard to unstring oneself. Sometimes, I force myself to remember I was a whole person before Medicine, and will continue to be so if I were to leave it.

The Stranger, only Human

So, this is the trade-off. I am perpetually the stranger, but much more human. I am not defined my role and relationship to my career and coworkers. Now, two thirds of the time I am simply me, not Doctor HighPlains, but just a guy with a family.

I also remember grief and disillusionment have led me here. They have forever changed my relationship to the world. Initially, it is all destruction and chaos. That is the painful part.

The world expected the pain after we lost our first daughter, it expected me to hurt. But then, as the pain transmuted from a gaping, burning wound to an ember of love and sadness, the next part came.

The awkwardness of building of a new self and a new world. This struggle is harder for people to see and relate to. It is a constant tension. I make progress and lose it all within seconds.

And really, even though we are 18 months removed from the loss of our daughter, only now has the pall of crisis started to lift from our lives. We lost our daughter, quickly moved states, set up new lives in new jobs. Then, we had survive the stress and anticipation of another pregnancy.

We had the normal stress of a newborn baby, mixed with the guilt of feeling the pain of losing our first fade. Only now, has our breathing seemed to slow to a normal pace.

Without crisis and loss and disillusionment, who am I? The Stranger, forever it seems now, the Stranger. I have become, it seems sometimes, a stranger to everyone including myself.

So, I accept this task. The awkward, slow task of getting to know this new me in this new world. I am bad at it, but I am doing it.

Across the Great Divide….Part 3

It is Memorial Day on the High Plains. The small, well tended town cemetery is full of flowers. People mill among the headstones. I often walk by this cemetery while I am on call and this is the first time I have seen anyone else.

On the other side of town, the town pool is being prepared for summer and children play baseball in the town park. American flags line main street. It looks like Normal Rockwell threw up all over this little town.

These are all small little rituals that maintain an identity of Americanness for people in small towns across America. There is no Walmart parking lot to negotiate, no traffic to fight. Simply the rituals family, country, and community. It is seductive, in a way.

Twentieth century White America needed all these rituals to form a cohesive identity. Many of the adults were children of European immigrants. On the High Plains alone Irish, German, Germans from Russia, Czech, Polish, Italian, Scandinavian, and Latino immigrants mixed in communities.

So, people got together in these rituals of Americanness in public. Even if in their own homes they cooked their old foods, read their old prayers, and told their own stories.

But, in public, it was all about being American. It was a communal effort to support the idea of being one people, bound together by location and a national ideology. Even if they did not share a historical culture, language, religion, or history, they could share a hot dog, a beer, and a baseball diamond.

America is a Fragile Idea

People tripped over themselves trying to be publicly American. Assimilation was all the rage. My father’s mother spoke German. After WW1 and WW2, his father discouraged her from teaching the children any German because of anti-German sentiment.

In the Southern High Plains, school teachers and classmates mocked and punished Latino children for speaking Spanish. I won’t even delve into the brutality and cultural genocide of the Indian Boarding Schools.

People paid the price of this cultural loss to assimilate and be “American.” Only the oldest resident’s of the High Plains have memories of their European immigrant ancestors speaking the Old Language and practicing their Old Ways.

The modern generations only know that their parents and grandparents did assimilate. They don’t realize it took decades or 1 or 2 generations for their ancestors to assimilate into “Americanness.” Nor, do they acknowledge the change their assimilation brought to American culture as a whole.

Immigration did not bypass Fly-Over County, then or now. The first Arab-American Senator in this country was Lebanese Maronite Christian from a small farm southern South Dakota – James Abourezk.

Fort Morgan, Colorado made news a few years ago. Somali immigrants working in industrial agriculture sued under religious freedom grounds for breaks at work to pray the requisite number of times per day.

What I hear and see when people on the High Plains talk about new immigrants is a feeling that the rules have changed. Their ancestors bartered one culture for another. Now, in the Cities and even in their own communities, they feel new immigrants are not forced to make those same concessions. I don’t know if this is true, but it is what they feel.

I doubt any of this is conscious. Much of it comes out as simple nativist, scapegoating for the pain of being in a world that is changing rapidly and leaving them behind. Nonetheless, I wonder if deep down, there is a jealousy. A sense of “Why did my parents and grandparents have to forget their culture and these new people don’t?”

Rituals of Americanness

Of course, new immigrants are assimilating, but it doesn’t happen overnight. Whereas their presence can change the fabric of a community or neighborhood in what feels like overnight. And, as they assimilate, they change the fabric of America.

Americanness is an identity based around ideas. These ideas have ebbed and flowed over time. Their relative significance has changed as well. Periods of time when these ideas were under debate have always been the times of great discord in American society.

The 1910s and 1920s saw race riots and a swell in anti-immigrant fervor. The debate over slavery that lead to the Civil War was a time of arguing over what it means to be American and who got to participate in the idea of America.

When your national identity is based on ideas, it is so very fragile. You cannot rely on history immemorial to bind you together. Every 3-4 generations we as a country must decide that we still want to be a nation together.

Group rituals are what bind a people together. In many cultures, the communities commitment to a given ritual is necessary to keep the world moving. The planting and harvest rituals are essential to the world continuing to function as it should.

Similarly, in a Russian Orthodox Easter service, Christ ritually dies and is resurrected every year. The community re-enacts it, together, to bind them in a sense of history, purpose, and collective emotion.

The Rituals of Rural White America: the baseball games, the laying of flowers on headstones on Memorial Day, the fireworks and backyard barbecues of the Fourth of July – they are held dear because in their completion, the idea of a certain kind of America is reborn, reformed, and confirmed.

The fragile existence of an American identity is solidified, if only for another year. When White Rural America perceives the mockery and dismissal of these traditions, they feel their identity, their nation is literally under attack. Because, at least ritually, it is.

Stories are what bind us together. From the vantage point of Rural America, the polyglot, postmodernist, multicultural milieu of Urban America is not a force of creative disruption. It is simply disruptive, even destructive.

I live in the City, and even there, I don’t hear anyone offering a new American story, I only hear them railing against the old story. Which is understandable, the old story was exclusionary.

Many in Urban America cannot see themselves in the old story. White, male, Christian Americans jealously guarded membership in the old story and its benefits.

You cannot simply be against something, you must be for something as well. If a large portion of the country, especially one with significant electoral power, cannot see themselves in that story, they will fight it with all their might.

I like the idea of a big, messy, diverse country striving together to make itself and the world better, safer, healthier. So, I am asking Urban America to remember to offer a New Story in return for subsuming the Old Story.

Rural America has its faults, but it is still part of the multiculturalism of this country that you purport to love and admire. So, tell them a story that includes them, don’t just shit on their story.

Student Loans: Modern Indentured Servitude

When it comes to my finances, everything else besides paying off my student loans seems trivial. I mean, I am attending physician. We have no shortage of money to survive on.

Nonetheless, 6 years out from my medical school graduation, almost half of my after tax income goes to servicing my student loans. Indeed, I might have quite medicine altogether after my daughter died if not for my student loans

Given that our finances provide more than enough for a comfortable life, all other financial decisions take a back seat to my student debt. Pretty much anything I forego financially is because of student loans.

My student loans are financial and emotional albatross that weigh on me constantly, even when I am not consciously thinking about them. Currently, I am an indentured servant to the medical profession. The debt changes the relationship physicians have with their chosen calling.

Debt is a trap, especially student debt, which is enormous, far larger than credit card debt. It’s a trap for the rest of your life because the laws are designed so that you can’t get out of it. If a business, say, gets in too much debt, it can declare bankruptcy, but individuals can almost never be relieved of student debt through bankruptcy.
-Noam Chomsky

The Long Road to Freedom

I prioritize paying off my debt above all other significant expenses. This has led to some significant improvement in my student loan balance. This has tracked about like this:

Graduate from medical school: ~$285,000 principal + interest.

6 months later, interest capitalized: $330,000 principal.

Finished residency: $330,000 principal+$65,000 interest=$395,000.

Currently, almost 3 years out from residency graduation: $188,000 principal+$30,000 interest= $218,000.

So, progress is being made. On the other hand, it comes at a cost. I have avoided contributing to the economy in significant ways because of my debt.

Some are basic consumer activities which I am more than happy to forestall. These include buying newer cars, new furniture, etc. These thing bring me little to no happiness, so foregoing them is not a sacrifice. The economy might miss those purchases some, but relatively little.

These, on the other hand, are significant:

  1. Saving for retirement: Back when I was employed (W-2), I took advantage of my employer’s match and maxed out my 403b. However, now with SEP-IRA which has no match, I still contribute, but at a much lower rate than maxing out (partially because the max is so high relative to my income (>50,000). The 6.5% guaranteed return on my debt is hard to dismiss.
  2. Home ownership: we tried this, got lightly burned. We will probably rent for a total of 3-4 more years before we try and buy another house. Another significant investment in the economy delayed.
  3. Pursuing activities other than working and finances. I have to focus a great deal of time and energy on paying down debt. So much so, it sometimes feels like I am in debt residency. I read about finances, scheme on ways to increase my debt payments, etc. Sometimes, it leads to neglecting other parts of my life.

Who Cares?

A reasonable response to my hand wringing over my debt is, indeed, “Who Cares?” I am in no way living in destitution. I will, in the next 2-3 years be able to pay off my debt entirely without any real deprivation (we live on about $90k/year for a family of 3 – very comfortable).

Additionally, one could point out I went to medical school knowing what it would cost and was not forced to accept loans in exchange for education. This is also true.

Moreover, what will likely end up being a total $500,000 investment will have moved me from a childhood of living on about $50-70,000/year in today’s dollars with a family of 5 to 4-5x times that income/year. I was never going to be an investment banker, tech entrepreneur, or engineer, so it is unlikely I would have made that jump in income any other way.

If you feel these things, that is totally legitimate. I do not need anyone’s pity for my financial situation, but you might want to stop reading now.

On the other hand, if this affects a privileged actor in the economy such as I, imagine how it holds the lives of less privileged students hostage.

Paying to Play in the Modern Economy

This plays out in the broader economy. We have placed increasingly expensive layers of education in between poverty and opportunity.

This is key.

The increasing cost of education and student loans, in particular, have made opportunity only available to the wealthy and those willing to live a good portion of their lives in indentured servitude.

I want to emphasize this point: for a huge number of students the price for the access to opportunity can only be paid with student loans. They do not represent an investment with a guaranteed return, but the only the opportunity to collect.

On top of this, unlike almost any other business debt, educational debt is non-cancellable. For example, I know someone who started medical school. Her mother got cancer when she was in medical school. She was able to finish, but with great difficulty and still has not been able to start residency. But her debt keeps accumulating interest….

In any other business situation, if you took out a loan to invest in a business and something terrible happened, you could declare bankruptcy and at least get back to zero. Educational debt just sits there, continuing to accrue interest despite your inability to collect on the investment….for the rest of your life.

Medical Schools Hold Abnormal Bargaining Power

Medical schools have disproportionate power when negotiating with potential clients (students). They are the gate keepers to a prestigious and historically wealthy profession.

What bargaining power do individual students have?

The average age of beginning medical students is 23 years old. Many of them have spent close to a decade striving towards medical school admission. Every physician they know has taken on loans to become a physician, so who is going to say no?

Are the risks of being unable to repay your loans explained to first year medical students before they sign on the dotted line?

I think not, because medical schools don’t care.

As long as medical students graduate, they don’t care about their debt. They just want all four years of loan payments.

It is inaccurate to say medical students really understand what they are getting into when they accept loans. For instance, I think few understand the cost of the interest compounding while they are in residency.

Moreover, no first year medical student knows how long they will be in residency. So, it is literally impossible to know what the cost will end up being when beginning medical school.

However, no student agreeing to take on loans can understand how the yoke of student loan payments will make them feel. The way it might weigh on their lives for 10-20 years. That can only be experienced and doesn’t have a cost measured in dollars.

Still, most physicians with discipline, and some luck, can pay off the loans relatively quickly.

Student Debt will have Long Term Effects

Beyond the specifics of my or any physician’s experience is the reality of student debt becoming a giant drag on the overall economy.

As a society, we are trading a large prolonged stimulus to the higher education sector in exchange for a significant drags on future productivity and consumption.

Moreover, we have provided the education sector with a way to be almost completely cost insensitive. In the days when state and federal dollars made of the bulk of their budgets, public universities had to be cost sensitive. Now, they just increase income from students, almost overwhelmingly from student debt.

We expect the most financially vulnerable of our population (young students) to enter into lifetime binding contracts with these institutions.

Meanwhile, where are they getting most of their financial advice?

From these institutions themselves, whose main goal is to keep up their class sizes. They certainly don’t have the long term financial health of their students as their primary concern.

We have yoked an entire generation with the personal responsibility for our penchant for deficit spending.

Back to My Indentured Servitude

A colleague of mine who paid off his student loans with hard work and sacrifice told me, “I am so glad I did, it has completely changed my feeling about practicing medicine.”

He gave voice to what a lot of young physicians know: their ability to get creative, tack risks in business, and try and improve the healthcare system is hamstrung by the need to get out of massive debt.

The Hospital-Pharmaceutical Complex has been very adept at exploiting this as a way to keep a churning stream of physicians willing trade their profession for escape from financial bondage.

As for myself, we are yet to see if it turns out to be worthwhile investment. I could have been earning income and saving for retirement since my mid-late 20s instead of accruing debt. It largely depends on how long I work as a physician.

Luckily, I have found a practice arrangement that I can imagine working in for quite a while. The freedom to take a couple of months off from a particular working environment has greatly extended my working life.

2 years ago I was thinking about trying to FIRE like so many physicians and possibly switch to a non-clinical job in the process. Now, as long as I get my debt paid off soon, I can imagine a reasonably lengthy time career as a physician.

However, not all physicians are so lucky, and most non-physicians don’t have anywhere near the options physicians.

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….

Courage, Hope, and Other Faults

As you know, if you have read my story up to this point, my wife and I gave birth to a daughter who had congenital complications about 18 months ago. We ended up making the decision to take her home on hospice where she passed peacefully.

The last couple of years have been trying, to say the least. I have vivid memories from the days leading up to when we brought her home.

Courage doesn’t make you feel you better

My wife and I, as well as some of her extended family, were sitting around a table. We told them what we were planning to do. One of my wife’s uncles responded with a simple, “That is brave, so brave…” Tears welled in his eyes.

We had not thought of ourselves as brave. We were simply her parents, doing what she needed of us, even it hurt us deeply.

Being told we were brave, while very kind, was a poor salve for the wound we would nurse.

And so we rode through the mountains, with her on a portable ventilator, talking to her as we went. We watched her pulse oximeter drop with deceleration, her lungs unable to maintain with the additional pressure of her organs on her diaphragm.

So fragile was she born.

Yet, we have never second guessed and we do not regret. Such is life, we are promised nothing.

Hope can feel like a Fool’s Errand

Grief is a hell of a ride. The loss of our daughter, coupled with my disillusionment with medical practice, dealt me a double blow. I often found myself wondering what the point was.

Not the point in living, I was never suicidal – though I now have more empathy for those who get there. I do mean the point in trying.

After spending years pursuing a degree and training to help people, I found myself among the greediest, least introspective, and least honest people I have ever known. I doubted my own integrity simply because I had ended up among them.

And then, as my wife and I decided to start a family, we were gifted a gorgeous little daughter, who was not destined to remain with us.

The universe seemed out to teach me something, in the most painful way possible. Fate brutalized the two most significant parts of my life in short order.

Why try, then? Why hope?

We Don’t Have a Choice

Much like time, human beings must only move forward.

Hope, for my wife and I, was not simple. I quit my job. Luckily, this required a 90 day notification, so we were able to take some time to grieve. Then, we moved back to her home city. She got a job to secure health insurance and started working 1099 locums.

This was all done less than 6 months after our daughter died. It was a matter of survival. We were running on fumes.

Finally, after finishing our dash for survival, we had to truly face the future. We had to decide whether we had it in us to hope, to risk, and strive all over again.

And we did.

My wife recently gave birth to our second daughter. She is gloriously average. She is of normal weight, normal length, normal appetite, normal irritability. In a blissfully ignorant way, she is making stupidly adorable baby noises next to me as write this.

A Harrowing Gestation

As you might imagine, the nine months of this pregnancy have been gut wrenchingly anxious. The medical staff of a large research University, as a rule, made this worse.

Our new daughter did as well, by waiting a full 41 weeks before showing up – without an induction (though we had scheduled one).

We had so many instances of fear and hope and grief over the course of this pregnancy. While I plan on exploring these in more detail in future posts, it didn’t seem appropriate to do so before her birth.

“Our stories are not meant for everyone. Hearing them is a privilege, and we should always ask ourselves this before we share: “Who has earned the right to hear my story?” 

-Brene Brown

Both my wife and I felt that exploring these emotions prior to her birth on the blog was somehow not the right thing to do. It would have been inappropriately vulnerable.

The time for chronicling the complexity of awaiting the arrival of a child after loss was, for us, not until she had arrived safely.

And so we waited, and she is here, and we are happy, in a complicated way.

Shortly after my wife told me she was pregnant for the second time, we sat together in fear and grief and cried.

She looked at me and asked, “Why are we doing this? Why are we even trying?”

My heart broke. Of course, I felt the same way at times. I looked back at her and mustered a simple and resigned, “Because we are brave people and this is what we do.”