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.”

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.

The Hard Work of Doing Nothing

I looked at my schedule and read Ed Schwartz’s name. I was surprised. Ed doctored reluctantly and never had much need to. He is 55ish, thin, athletic, and generally quite healthy.

Ed always refused to tell my MA his reason for visit. “Not any of her business” was the usual reason. So, I always went into the room not knowing what I was walking into.

I met him first for a wildland firefighter physical, his post-retirement gig. Not your average primary-care patient. He was proud that he could hike two miles with a 50-lb pack faster than most 20-somethings taking the wildland firefighter physical test.

In that visit, I had learned he had moved to the area from Northern Michigan. He had spent 20 years as a police officer, pensioned out, and then started and sold his own business thereafter. Now, he was partially retired and found odd jobs wherever he could to keep active.

Entering the room, he looked his normal stoic self. He was sitting the chair, upright and rigid. Thin and hard-looking with steel-gray eyes that could be intimidating when he needed them to be.

We began with pleasantries, he had finished his summer season (it was November now) and most of the fall chores on his property and things had started to get slow around the house.

“I’ve already piled all the brush up and now we can’t burn the piles til it snows. I don’t have much to do and have been gettin’ a bit squirrelly”

The reason for the visit finally comes out

With him being around the house more, he and his wife had started fighting. He owned that most of the conflict originated with him.

“If something doesn’t change, she might not put up with me much longer. Y’know, I don’t do great with the shorter days and I know the last two winters here have been harder because I don’t have something to do all-day, everyday.”

“Too much time can be a burden on a lot of people,” I offered.

He fidgeted a little, the heal of his cowboy boot grinding into the carpet.

“I have always been an active guy. In the force, I took all the overtime I could get. I worked all the time – nights, weekends – all of it.. Then, when I had my own business, I worked all the time, made good money, and eventually sold the whole business. I was damn good at it.”

“I can tell, Ed.” I agreed.

“Now, I see,” I think to myself. Addiction to overwork – the coping mechanism of the “successful.”

Ed softened a little. “But y’know, Doc, when I don’t have work, I get cranky, irritable, I snap at my wife. I get worked up easily.”

“Have you ever talked to anyone about this before?” I asked.

“Yeah, once Y’know. A few years back, over the winter, I was on a pill, Prozac, I think. It seemed to take the edge off. I was wondering if that might be a good idea again.”

Primary Care – Psychiatry without the time.

We went through the screening for major depression and generalized anxiety, he was mildly positive for both. More on the anxious side thought.

“I think that some medication would be a reasonable idea. Have you ever done counseling?”

“No, I don’t like the idea of talking with people about these things. It doesn’t seem like my thing.”

He then proceeded to talk with me about “these things” for quite a while. He talked about being first on the scene of a car accident with a dead teenager. The boy was the son of an acquaintance. He had never been able to tell the father he was the first on scene.

“Last month, we were visiting, and he brought up losing his son, I just stood there, feeling so mall.” His held his hand out, index and thumb fingers less than inch apart. “Just like a nothing.”

“That sounds very difficult. Sounds like you might have a lot of experiences from your previous lives you haven’t dealt with. It might be helpful to talk with someone about those things.” I offered.

He looked down. “Yeah, maybe, but I think I’d rather just try the medicine for now.”

We discussed the pros and cons of medicine, counseling, or both. In the end, pills were the plan.

I was not shocked.

Being still, wallowing in our avoided pains and anxieties is enticing to no one. Yet, it is necessary for growth.

Bison – wisely doing nothing. Photo Credit: NPS

Why Can’t We Do Nothing?

Doing nothing is hard work. Some of the ancient philosophers comment on the “laziness” of overwork. To them, breathless activity without direction, simply as a reaction to stimuli, could be seen as complete lack of discipline.

Never mistake motion for action. -Ernest Hemingway

What I have seen in my medical practice is that overwork is often used to keep the mind from reflection. Reflection is the time we take to examine our lives and actions. During reflection, we plot out future action and measure our relationship with the world.

Without reflection, we cannot separate our own action from motion.

Apparently, what lies beneath and inside many of us is very scary, or at least uncomfortable. I see so many people working or at least busying themselves to death, rather than confront their inner selves.

Reflection is difficult territory and requires great courage and discipline. This is why the Buddhists must have a “meditation practice” and why religious mystics have always hid in high, remote monasteries – because the pull of busyness is very strong.

Being still might be the hardest thing

It is likely difficult to have time to be still in all professions. Nonetheless, I have found time for reflection is highly undervalued in the world of medicine.

The thing is, taking the time to do nothing directly benefits only ourselves – at least initially. No one else will carve out time for us to reflect, to measure ourselves and our actions.

It takes extreme discipline to hold the line against Hospital-Pharmaceutical Complex and make room for doing nothing. It is arguably the hardest thing to do in a career of medicine.

I was reminded of this fact reading M’s recent post over at Reflections of a Millennial Doctor. The world will take everything and ask for seconds.

“But, Dr. HP, you could be making more widgets. You could be helping more patients. Isn’t that important to you, Doctor?”

Interestingly, the FIRE blogs are generally full of people whom life has forced, in someway or another, to be still for a moment. However, few seem to have chosen to take that time of their own accord – myself included.

There is always more we could be doing. The question we must answer first is what should we doing.

We cannot answer this question without first taking time to do nothing.

The Struggle is Real

I shake myself out of the blue light stupor of my computer screen, it is 11 pm on a call shift, I don’t have to be awake. It has been pretty easy – this place sees less than 1 person/24 hours in the ED.

But, I can’t stop my mindless scanning of real estate websites and various gadgets on Amazon. I don’t even like gadgets. We aren’t planning on a buying a house anytime soon. But I can’t seem to stop.

This is a known symptom for me. I rarely buy anything. Real estate browsing is pretty safe – I have never made a impulse home purchase at midnight on Zillow.

Even Amazon rarely tempts me into an impulse purchase. The closest I get is adding something to a wishlist – usually to be forgotten.

The disease attached to this symptom is feeling stuck. I do this when I feel like I am not working towards something, just living in a gerbil wheel holding pattern.

I am really, really bad at assembly line life. So, I start to browse Amazon, Zillow, Airbnb – fantasizing about something else. Mindlessness sets in.

It is not good for me. I almost always feel worse afterwards.

“You are imperfect, you are wired for struggle, but you are worthy of love and belonging.”

― Brene Brown

I am coming to think happiness is overrated. On the other hand, being miserably is obviously no good either. However, I think too many of us confuse elation or rapturous joy – that mountaintop emotion – with happiness.

The thing is, people have never lived on mountaintops, they live in the valleys. A life on mountaintops is unsustainable – ask someone with a Bipolar Disorder just after they have finished a manic phase.

Wind River Range Wyoming, Public Domain.

Moreover, no one has ever started down the road to a significant accomplishment with the phrase, “Things are pretty good right now, I am happy with this.” And per Brene Brown, human beings are wired for struggle.

Survival doesn’t just happen in the wild. Every day is a struggle and humans are no different. I tend to feel most alive and full when I am in a good meaningful struggle.

On the hand, when you actually complete something, like say becoming a doctor, it can be unsatisfying. Then you are back and stuck in between struggles.

Humans need a struggle, a purpose, something to strive towards. We are always looking for more, for improvement. It is a pretty good survival mechanism, constantly looking for advantage.

I think this is an impulse consumerism taps into. It is also why it can be a hard habit to break. Sure, sometimes we are trying to fill a void or a hole.

“If I can just solve this couch problem, I will have figured out life.”

Of course, more stuff never fixed anything. I have never been much of a consumer. I don’t like spending money – I never even get the fleeting joy of something new a lot of people describe. But, the temptation is still there.

So, if I am not actively trying to fill a void with more stuff but still feel the need for something more – where is the problem?

Is the problem I am not content with my current situation? If that is the case, then the solution is working on being content with now or trying to change my situation.

Or, is the problem that my struggle mechanism is just spinning in circles with no focus? If so, then I need to find some struggle to throw myself into.

In Northern Minnesota, where I have spent some time, it is common for families to have lake cabins or houses for family vacations. They are often old and the harsh climate requires frequent repairs.

The classic joke is that the old Norwegians and Swedes would only take vacations if they felt like work. As long as the cabin needed fixing, there was an excuse to head up to the lake.

Maybe I need a cabin….or at least more hobbies.

A Note of Gratitude to Medicine

The end of the year is always a time for reflection.  The darkness leads to more time indoors, more time with our thoughts, and often with our families.  Reflecting on this difficult year is a strange exercise for me.

A Tumultuous Year

My wife and I have passed the one year anniversary of my daughters birth and death.  Moreover, I am now more than 6 months into my new gig as a traveling critical access doctor.  Life has started to settle into a bit of rhythm. 

After all of the grief and upheaval of the last year, simply living a relatively normal life can be rather unsettling.  I seem to even seek out problems or reasons for dissatisfaction.  I have a bit of a restless soul – a blessing and a curse.  

For one, the holidays seem to be a negative trigger for me this year. 

I always struggle from the time the clocks change to the first week or two of January.  The loss of light affects my mood for the worse.  Prior to last year, I had a great ambivalence about the holidays – neither a grinch nor a lover of the season. 

The Shadow of a Loss

That being said, last year’s holiday season was not a good one for our family.  The holidays came very quickly on the heels of our daughter’s passing and I was on call for a good bit of both Thanksgiving and Christmastime.  

With those memories so fresh, this year’s holidays are hardly buoyant.  Sure, the pain is not as fresh and does not burn quite as bad, but its shadow stills falls on the season.  

Living through this holiday season is like walking through the burnt-out shell of an ash-covered family home.  The shock and wailing pain of watching the flames tear everything apart has past.  Nonetheless, an eery sadness lingers over everything. 

To keep myself from falling into a hole of self-pity, I have taken some advice to actively practice some gratitude.  God knows I have plenty reasons not to feel gratitude, but I also have plenty reasons to do so.

Giving Gratitude a Chance

Even last year, my wife and I took time to be actively grateful for the arrival of our daughter, even if her presence with us was far too short.  She taught us a great deal and the heart cannot be overfull of love.  

Finding gratitude about the current state of medicine and my role in it takes a little more effort. I have written a lot about my experience in medicine and life over the last few months (and it hasn’t all been rosy).

Yet, I also remember the ones and things we love are often what can hurt us the most.  My relationship with medicine is much more complicated than it once was.  

I struggle to accept the imperfections of a system charged with healing yet is highly profit driven and largely inhumane. 

This system charged me a steep entrance fee.  The cost comes in actual dollars but also in time and stress and tears.  In the end, I felt expendable.

Yet, I also have to remember the care our daughter received in that same system.  I cannot forget our neonatologist sitting in front of our house with us as we held our daughter without tubes or machines for the first and final time. 

Humanity does still course through the veins of our healthcare system, even if the system neglects it at every opportunity. 

Nonetheless, My Privilege is Great

Doctors are a pretty privileged lot, all things considered.   I don’t mean to minimize my own or other’s distress at the current state of affairs.  On the other hand, I see how my situation may have played out very differently for someone else.

Few other careers exist where you can quit your job, move to another state, and have to turn down work immediately.   That is how it worked out for me. 

I simply showed up and had my choice of work location and practice type within my speciality.  Not only that, but I have been able to improve my worklife balance with an acceptable sacrifice of income.  

Physicians skills are in such need that not only was I able to find a different job, but a completely different way of working.  Hard to complain. 

Medicine giveth, and medicine taketh away.

Work isn’t Everything

Even more importantly, medicine had given me wisdom.  Caring for people who were very ill or had suffered great loss or trauma gave me access to life’s most difficult moments.  Few other professions allow for the gaining of such wisdom without personally suffering those blows.

Learning how to help guide people through their struggles led me to read books and literature I never would have read otherwise.  This knowledge was invaluable when our daughter was born.  I didn’t have a how-to guide, but at least I knew the big ideas.

Most importantly,  I had learned the value of connection.  When our daughter was born, our gut reaction was to circle the wagons, raise the drawbridge.  My patients had taught me this was not the right move. 

Love and loss must be shared, inextricably linked as they are.  We called friends and family and offered for them to come to meet our daughter.  To be present with us in a difficult time. 

Without exception, the responses we received were full of gratitude.

“We are honored to come,” was the common answer.  

In our moments of grief, this might surprise us, but it shouldn’t.   Wouldn’t all of us respond the same way if someone we loved extended us the same offer?

Moreover, the decision has paid great dividends.  To those who met her, the people we love, our daughter is not simply the nameless baby we lost.  She was a person, has a name.  We can talk about the shape of her nose, or her special little movements with so many people. 

Having her in more people’s memories does not just preserve her memory, but means she was even more alive when she was here.  Hell, we even have a social security card for her.

It is the caring for patients that taught me this knowledge before my family needed it.  In the end, I am still thankful for medicine.

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

― Kahlil Gibran

Mindfulness on the Fly

The Walk

I can feel the increase in pressure as the shoulder straps dig into my shoulders with every heaving step up onto another piece of talus.  I just crossed the eleven-thousand foot mark.  Five miles and fifteen hundred vertical feet, not all that bad, considering.    

The dry winter has opened up the high country early, so I am heading to a small glacial tarn that is about 500 vertical feet and a half-mile off trail.  I have only put my rod together once in the last 6 months.

Struggling out of an alpine willow thicket, I drop my pack in view of the lake.  More like a pond really – but deep as a lake. 

The Water

This high water is not on the official stocking list for the state’s department of natural resources.  Yet, the trout seem to overwinter well in its deep cold water.  Moreover, it has no passable outflow to lower waters so the trout are safe from whirling disease and other such pests. 

They sit under the ice all winter, waiting for their brief 4 months of feeding.  I have timed it well – iceout was just last week it appears.  One full shoreline is still snowbound. 

I pull out some medjool dates and a water bottle, slowly chewing each date and rinsing it down with cold spring water from the lower slopes.  I stand up and start getting ready. 

A wind comes down the glacial valley from thirteen thousand feet and chills me.  Despite the physical discomfort, it feels good, or at least right.

The Ritual

I pull out my rod, closely inspecting and aligning the four pieces as I assemble it.  Shaking the handle, I watch the energy dissipate down the rod like a fencer preparing for a bout. 

I pull out my reel, attach it to the rod handle, and begin to string the line along the length of the rod.  With each narrowing loop the line passes through, I can feel the troubles left behind.  

The student debt, the house payment for the house that hasn’t sold yet, the crisis of faith in my supposed calling, I feel them each dropping off.  The only stress left by the time I have attached the leader is the loss of my daughter. 

Yet, hers is a welcomed sadness.  I didn’t come to forget her loss, but to be quiet with it – alone. 

Opening my flybox, I pull out a dry-fly – the elk hair caddis.  I know I’ll probably have better success with a olive bed-head wooly bugger – I almost always do.  Nonetheless, part of the ritual is the dry-fly.  

The First Cast

I hop out onto a large rock at the edge of the shallows.  Gently moving my right arm back and forth, I let out line.  After a half-dozen or so passes, I gently place the line down on the water’s surface where a trout might be cruising.

Island Lake, Wind River Range, WY.  Source: USFS

The tuft of elk-hair floats serenely on the water.  I give all my focus to watching the water and the fly.  It gently sways on the water as the wind moves over the lake.  I slowly gather line in my left hand. 

Feeling myself tense, I am fully in the moment with the water, the invisible fish, the mountain, and the sky.  I am nowhere else, neither in time or place.  I am fully present on the lake, on the mountain, watching this stupid fly. 

Now We are Fly Fishing

Nothing happens.  I try several more casts without any luck. I start to think about what fly I should try next: parachute adams, royal wulff, beadhead woolly bugger. 

At that moment, I hear soft “plop” from the lake.  The fly is no longer visible. I raise my right arm quickly, trying to set the hook, the fly emerges quickly from under the water – without a fish.  

Fly fishing is ritual mindfulness.  It seems that as soon as the future starts to steal your consciousness away, the fish and the water remind you of the pressing need of the present. 

The trout, the line, the rod, the fly, the wind all demand such attention that you cannot enjoy fly-fishing without being a 100% present.  When the mind wanders, you inevitably miss a strike, or catch your fly in stream-side brush.

Only 100% of you will suffice when fly – fishing.  No less.

Heed the Lesson

I take the hint.  I stop casting.  Taking the elk-hair caddis in my fingers, I cut the leader and place the fly back into my box.  I take out a woolly bugger and carefully attach it to the leader.  After checking its fastness, I hop back to shore.

I walk to the other side of the lake where the mountainside plunges in the water with rocky abandon.  Balancing on loose rock and snow I manage to dance over to a sturdy ledge which gives me lateral access to a cliffshelf.  Beginning to swing my arm, I let out the line again. 

I hear the bedhead plop softly into the water in front of the cliff as I finish the cast.  Waiting 20 seconds, I let it sink deeper into the water. 

I begin a slow figure of eight retrieval of the streamer.  The line gently wrapping around the fingers of my left my hand.  Suddenly, the line tightens and the tip of the rod bends sharply.  

The Fish

I firmly and quickly raise my right arm, I can feel the hook set well.  The fish cuts to the left, the line singing as it splices the water’s surface.  I can feel the strength of the fish – normally fish this high are small and hungry, barely fighting. 

I slowly give the fish some line, keeping the rod bent in the process.  The fish takes the extra line and jumps.  It sparkles in the alpine sun as it sails 18 inches about the water’s surface.  

I let the fish play for another 30 seconds or so and the resistance slackens.  I begin to retrieve the line again.  The fish protests, but with less vigor.  The distance between him and I narrows.  Soon, he is next to the ledge I am standing on, inches below surface.  A beautiful fish.  

With my left hand keeping the line taut, I extract him from the water with my right.  Placing him on the granite ledge and holding him in place with my left hand which still has the rod, I deftly grab my needle drivers and thread them into his mouth, catching hold of the hook and removing it.  

I gently place him back in the water and watch him swim off into the deep, clear water.  “That was a nice fish,” I say out loud. Only the wind responds.

The Moment

I clamber off the the ledge and over to my pack. Laying my rod against the pack, I sit down.  I take in the mountainside, the lake, the upper coulee in the distance. Snow still hangs there in the shade.

I watch a shadow of a cloud glide across glacier-scoured granite mountainside, a golden eagle rides a thermal.  The cloud reminds me of my daughter and how I would have like to have shared these moments with her.

I welcome the stinging sadness and let myself feel it fully.  It feels needed.  I breath the thin air deeply as a few tears form.  Not a wailing, gnashing of teeth kind of pain, just a simple reminder of a love lost – yet still here.  

I stop short of mourning the high country fishing trips we never had.  Because we never had them, the future has not yet been and never was.  Hell, she might’ve hated fishing, I don’t know.  But it is nice to sit and pretend we would have done this together. 

So, I sit for a while longer, feeling her fully.  100% present in this moment of grief and joy and peace.  For a short time, I am nowhere else. 

Reactions to Suffering in the History of Biomedicine

an introduction to soteriology and biomedicine

Soteriology is the study of systems of salvation. Every significant religion is occupied with the pursuit of salvation or deliverance.  That begs the question, “From what are we pursuing salvation?” Modern America’s soteriological crisis increasingly affects the world of Biomedicine.

Biomedicine is the system of medicine which relies on the application of physiologic and biochemical principles to attempt to heal suffering (in other words – modern Western Medicine).  This term is helpful as a contrast with other medical traditions which rely on spiritual or natural principles to heal suffering.

Over the last several hundred years, Western culture has had several changes in its soteriological orientation.   Prior to the industrial revolution, salvation was solely the realm of the church.   All sufferings: physical, social, psychological, spiritual were in the Church’s domain.

Christ after the flagellation and the christian soul, by Diego Velázquez

The Church provided actions and direction to people in an attempt to ameliorate suffering.  Prayer, supplication before God, and confession were central tenets and ways to address suffering.

Christianity largely places the attainment of the salvation on the other side of death.  As such, the Church had little to offer in terms of preventing, curing, and ameliorating worldly suffering.  Comfort – yes.  Solutions – not so much.

The rise of the enlightenment, the industrial revolution, and advances in all forms of study, including Biomedicine planted the seeds for Modernism to arise in the late 19th century.

the rise of modernism and medicine

Over the course of the 19th century, and into the early 20th, Western societies increasingly placed faith in science, technology, and “progress” to deliver societies from many of the woes of life.

However, Biomedicine was rather late to the party.  Rapid advances in Biomedicine did not really begin until the turn of the 20th century.  The Germ Theory of Disease was still only postulations until the late 19th century.

Thus, by the time medicine began delivering great advances (such as antibiotics), Western society was in the throes of Modernism and the worship of technology, science, and progress.  At the same time, psychology was providing competing ideas for explanations of human behavior beyond sin and virtue.

These allowed for the sidelining or religion in our soteriology.

World War II was a wake up call for many in the West. Wholesale destruction through intensely technological war caused a great many to doubt the cult of technology.  Suddenly, technology was not only a means of deliverance but a means of suffering as well.

Again, medicine seems to operate on a delayed timeline.  The Modernist phase of medicine seems to have continued well into the 1990s. During that time, Western society moved Biomedicine to a central role in its soteriological framework as religion was increasingly sidelined.

The emphasis on science, technology, progress and objectivity also often led to objectification in medicine.  The Tuskegee Experiments are an example, and on more mundane levels House of God is a critique of the worship of progress at all costs.

By the 1990s we had gone from worldly suffering as something to be endured for eternal salvation to a belief in technology’s ability to eliminate worldly suffering to the destruction of Modernity’s golden idol.

[M]edicine is deeply implicated in our contemporary image of what constitutes the suffering from which we and others hope to be delivered and our culture’s vision of the means of redemption. In a civilization deeply committed to biological individualism, one in which the spirit is an ever more residual category, the maintenance of human life and reduction of physical suffering have become paramount.  Health replaces salvation. – Medicine, Rationality, and Experience: An anthropological perspective.  Byron J. Good.

postmodern medicine

In response to Modernism’s technological hubris and blind spots, Postmodernism arose.  Postmodernism is primarily a reaction to Modernism’s inability to deliver on its promises and a critique of its excesses.  Most centrally, it rejects the idea of objective truth.

Moreover, Postmodernism offers no hope of salvation, no road for progress.  Many criticize the cynicism of post-modernism.

Postmodernism’s affect on Biomedicine is multifaceted and interesting.  The challenge to physician autonomy and authority can be seen as one of the first entrances of postmodernism into Biomedicine.

The patient-physician relationship’s hierarchical nature and the many times this led to ethical violations (again: Tuskegee Experiment, or HeLa Cells) made it a prime target for postmodern critique.

The culture-bound nature of  Biomedicine also leaves it open to the critique of objective truth on the part of postmodernism.  Think about your own practices.  How many different ways of practicing medicine have you seen?

Just like any other healing tradition, Biomedicine is subject to its own mores, traditions, and taboos.  Some of what we do is based in science, but much it is not.

Sure, some of the variation can be attributed to local differences in populations and disease, but most of it is purely cultural.

I.E: We do it this way because it is how we have always done it this way.

the postmodern patient

This has led to the rise of the post-modern patient.  As individual physicians are no longer arbiters of reality, patients feel empowered to have opinions on their care.  In the hands of reasonable individuals, I think this improves care.

People’s values and beliefs are important in their care.  I used to tell medical students, the most effective treatment plan is the one the patient will actually follow.

However,  many people have values and beliefs which are destructive to their health and well-being.  Physicians no longer have the cultural authority to offer corrections, as all beliefs are equally valid in the Postmodern office visit.

The main problem with postmodern’s influence in medicine, to my view, is it offers no hope or structure.  Postmodern Biomedicine has no soteriological framework.  It is simply a reaction, not a scaffold.

Additionally, many people are now so distant from their previous soteriological traditions (religion or other philosophies), they are drowning in meaninglessness. As the quote above states, health has replaced salvation for many in our culture.

Here’s the rub:  Everyone’s body will eventually let them down, everyone suffers, everyone dies.

In a world where health is a manifestation of your righteousness, illness threatens not just your body, but your soul.

How can you make sense of your suffering if it itself is evidence of your failure to attain redemption?  You can’t.

What’s the next best option: numbness.

existential crisis

“Today, our view of genuine reality is increasingly clouded by professionals whose technical expertise often introduces a superficial and soulless model of the person that denies moral significance. Perhaps the most devastating example for human values is the process of medicalization through which ordinary unhappiness and normal bereavement have been transformed into clinical depression, existential angst turned into anxiety disorders, and the moral consequences of political violence recast as post-traumatic stress disorder. That is, suffering is redefined as mental illness and treated by professional experts, typically with medication. I believe that this diminishes the person,”
― Arthur Kleinman, What Really Matters: Living a Moral Life amidst Uncertainty and Danger

In a worldview devoid of possible redemption in exchange for struggle, the struggle becomes meaningless.  Our existential crisis in the face of meaninglessness has been medicalized and medicated.

I increasingly view benzodiazepines, stimulants, narcotics for chronic non-cancer pain as a society wide attempt to anesthetize our collective existential crisis.

Our postmodern malaise is just too painful and we have no path to redemption no hope at deliverance. So, increasingly we seek a near constant anesthesia.

“We are healed of a suffering only by experiencing it to the full.”
― Marcel Proust.

is oscillation the answer?

Increasingly, Metamodernism in the wider world of art and culture is emerging as answer to the Postmodern malaise.  Metamodernism’s basic tenet is oscillation.  The world moves back and forth between diametrically opposed poles so quickly as to be effectively in both places at once.

Can we be naive and cynical at the same time?  Metamodernism posits yes.  This is inherently unwestern as an idea.  Also, it is inherently against America’s puritan roots.  The pursuit of purity is central to the birth of the American identity.

American’s don’t know how to do something 75% – we have to shoot for 100%.   Metamodernism challenges us to accept the world as made of dualities and imperfections.

At a very basic level, physics supports the idea in the natural world.  Is light a particle or a wave?  The answer: Both.

Christianity is very comfortable with oscillation as well.  Are God, Jesus, and the Holy Spirit one or three?  Again: Both.

Can we apply the same ideas to medical practice?

Can we accept Biomedicine is both a culture-bound system of healing and a science?  That no 100% objective truth exists, but yet some truths serve us better than others in a given circumstance? That suffering should be ameliorated, but it is also a necessary and important part of the human condition?

In an amusing twist, accepting oscillation as a necessary aspect of the universe means there can be no one answer to our postmodern malaise.  In order to thrive, survive, and heal we must oscillate as well.