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 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 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.

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.





Mindfulness and the FIRE Movement

what the financial independence movement misses

The FIRE (Financial Independence – Retire Early) movement is all the rage on the internet these days. Among physicians it seems especially popular with the younger crowd (<50 years old), though people of all stripes are interested.  I have been perusing many of the various blogs on the topic for months.  I have found something rather unsatisfying in the movement’s discourse. 

I want to make this clear: I am not opposed to financial independence or retiring early. It is a worthy goal.  I have used many of the discussions on financial discipline to improve my own financial position.  For instance, I now spend about 40% of my take home income paying down my student loan debt, which is the only debt I have.

I do not think people trying to FIRE are jerks, but I also don’t think the pursuit of FIRE is particularly mindful.  

Like so many things in life, the reality seems to be in middle. I do not believe that FIRE is inherently unmindful, yet I increasingly believe it can be slippery slope out of a mindful life.

In much of the discourse surrounding FIRE, the accumulation of money dominates the discussion, seemingly suffocating the reason for financial independence – a rich and rewarding life. 

Physician on FIRE seemed to touch on this in a post last year:

If I had discovered the FIRE movement as a medical student….I might have spent the last fifteen-plus years wishing life away. It would have been awfully tough to embark on a career with the express goal of finding my way out of it.  – Physician on FIRE

minduflness’ role

The basic tenet of living in mindfulness is living entirely in the present, as the present is the only moment that truly exists.  The opposite of “wishing life way.”

Much of the discussion about achieving Financial Independence seems to be of the “when I achieve FI, I will be happy because I will be able to X.” variety.  This is  textbook living in the future.

Being mindful doesn’t mean ignoring the future.  On the contrary, when planning for the future, being mindful requires being 100% present in the act.  But, spending 10-20 years of your life doing something you dislike just to have a future you like is NOT mindful.

You don’t have to wait ten years to experience this happiness. It is present in every moment of your daily life. – Thich Nhat Hanh

Addicted to delayed gratification

Doctors are really good at delayed gratification.  It is probably our primary coping strategy in life, especially early in our careers and training.  I can’t help but feel that a good number of physicians pursuing financial independence are falling back into the mindless trap of delayed gratification.

In particular, millennial physicians have arrived at the end of a long stretch of delayed gratification (training) and found the reward lacking.   Instead of doing the hard, soul searching work of learning to live in the present, I can’t help but see a retreat back into the protective shell of delayed gratification.

They put their nose back to the grindstone, hoping in vain that life will reward them afterwards.

Relegating grizzlies to Alaska is about like relegating happiness to heaven; one may never get there. – Aldo Leopold, A Sand County Almanac

I want to reiterate, I do not think think that people should life fiscally irresponsible lives and “treat themselves” with frivolous spending on things that don’t bring happiness.  The pursuit of financial independence builds multiple useful skills:  mental and behavioral discipline, learning to be happy with less, and long-term focus.

However, I do not feel the value of the skills comes from achieving financial independence.  Their value is only truly realized in the pursuit of a meaningful life.  A meaningful life is not easy, and happiness is not omnipresent therein.

We only have so much time and energy in our lives.  While I am in favor of sound financial decisions, avoiding debt, and maximizing savings, pursuing that goal to the exclusion of other aspects of life robs the present to give it to the future.   It is worth reiterating, we never actually get to live in the future.

Remember, even Moses never made it to the Promised Land.

FIRE isn’t good enough

My main beef with the FIRE movement is actually that simple.  FIRE is not enough. If the benefit of being financially independent is that you don’t feel enslaved to your job, that can be accomplished without having 25 times your yearly expenses saved. Unless, achieving financial independence is actually just about the money.

On the other hand, maybe others aren’t looking for anything more and I am the outlier.

“The greatest gift life has to offer is the opportunity to work hard at work worth doing.” – Theodore Roosevelt

Saying that being free to stop working at any time makes work better is like saying that being free to leave a marriage at any time makes the relationship better.  Maybe that is true, but as a married man, I don’t think that it is.

If you aren’t happy with the work you are doing, being free to quit isn’t going to make it better.  You’ll just stop doing it.  Finding work worth doing is the solution, not having more money saved.

In retrospect, I may have lucked out that I hadn’t reached Financial Independence when my daughter died and my partners treated me like shit. I probably would have just left Medicine entirely.

I still have not healed my wounds with Medicine. But I am being forced to try because I have not FIRE’d.  I am having to try to find happiness in the wilderness, instead of just wandering until I stumble.

I might have left Medicine an embittered, grieving former physician if I had had the chance.  Instead, I had to look around and forge a way forward.

In the end, Financial Independence should be the natural byproduct of a disciplined, well-lived life.  Achieving FIRE does not make your life disciplined and well-lived life.


Modern Medicine is Mindlessness

“If while washing dishes, we think only of the cup of tea that awaits us, thus hurrying to get the dishes out of the way as if they were
a nuisance… [then] we are not alive during the time we are washing the dishes. In fact we are completely incapable of realizing the miracle of life while standing at the sink. If we can’t wash the dishes, the chances are we won’t be able to drink our tea either. While drinking the cup of tea, we will only be thinking of other things, barely aware of the cup in our hands. Thus we are sucked away into the future – and we are incapable of actually living one minute of life.”
― Thích Nhất Hạnh, The Miracle of Mindfulness

can mindfulness and modern medicine coexist?

Often, especially when I practiced primary care, I felt the need to accomplish a task to get to the next one.  My task-oriented nature repeatedly stole my present and gifted it to the future.

Prescription refills, prior authorizations, signing documents that have nothing to do with patient care – all exploited this weakness.  I was always to trying to wash the dishes to have clean dishes.

I could not seem to live a minute of life while at work.

Joshua Tree NP – NPS Public Domain

After I had decided to quit my job, I went on a solo grief retreat in the Mojave Desert.  Among the joshua trees and cinder cones, I finally returned to the present.  I read the Miracle of Mindfulness for the first time.



While reading, I had a revelation: the basic structure of modern medical practice sabotages mindfulness.

working on self-compassion

In current practice, organizations expect physicians to welcome any and all intrusion into their work in the name of patient care.  However, increasingly non-patient centered tasks fall into this category.  Seemingly, the system has learned how to manipulate our value system.  Suddenly, anything anyone wants done is a reason to interrupt.

Sadly, even before I lost my daughter and things took a turn for the worst, I felt an intense pressure to try to fix what I found unpalatable in my worklife.  I put the pressure for resolving my discontent with the system entirely on my shoulders.

Now, I am no accomplished mindfulness practitioner.  In the Miracle of Mindfulness, Thich Nhat Hanh discusses the relative ease of being mindful alone on a walk in the woods rather than in company.  I should not have realistically expected myself to find a way to mindfulness surrounded by the least mindful workplace I have experienced.

every system is designed to achieve the results it produces

It is unfair to expect a novice in mindfulness to advance as a practitioner in such an environment.  Shift work has helped relieve me of this burden, an under-appreciated reason for its increase in popularity.  I can focus on medicine while at work, and focus on washing the dishes when not.

I hope someday I will be mindful on the scale of minutes or seconds.  On the other hand, isn’t that too much to ask of a novice?  Yet, that is what our system demands of doctors. Burnout is the natural outcome, not an occasional, unfortunate byproduct.

Nonetheless, hospital executives seem to think that a half-day mindfulness seminar is good enough to prevent physician burnout.  A lecture and some breathing exercises checked the box, no need for changes to systemic processes or organizational culture.

Thich Nhat Hanh- Public Domain

“Feelings, whether of compassion or irritation, should be welcomed, recognized, and treated on an absolutely equal basis; because both are ourselves. The tangerine I am eating is me. The mustard greens I am planting are me. I plant with all my heart and mind. I clean this teapot with the kind of attention I would have were I giving the baby Buddha or Jesus a bath. [emphasis added] Nothing should be treated more carefully than anything else. In mindfulness, compassion, irritation, mustard green plant, and teapot are all sacred.”
― Thich Nhat Hanh, The Miracle of Mindfulness

welcoming, recognizing, and treating ourselves equally

Part of learning to be in the world is coming to terms with our own frailties.  At first, I viewed my current position of a traveling critical access doctor as a transition until I found a new permanent practice.

I had phone interviews for perhaps a half-dozen practices.  A funny thing happened: by the end of every interview, I no longer wanted the job.

After having this epiphany, I eventually accepted I currently don’t have the level of accomplished mindfulness to face the mindlessness of modern medical practice.  In the middle of a busy clinic or call day, I just don’t have the mental discipline to wash the teapot like a baby Buddha or Jesus.

I then asked myself a second question, “Should I want to?”  I am still working on that answer.  So far, in my grieving state, I am just not willing to work so hard just to be able to survive the barrage of dysfunctional practices that are currently de rigueur.

An opportunity to not only survive medicine, but actually thrive, may someday yet appear.  We, as physicians and patients alike, can only hope.