In Praise of Collegiality

Working in small emergency departments without any local back up often demands “phoning a friend,” so to speak. I encounter patients who present with findings and disease processes with which I am unfamiliar.

One warm Fall day, I got called in for a kid injured at football practice. Tom was a 16 year old who was hit head on (axially) in a football game. On exam, he had complete numbness and significant weakness in all four extremities.

Strangely, this was only from about 3 inches above the knees and elbows down (not a well recognized anatomic distribution).

Moreover, his CTs were totally normal. I had no surgeons on site, and the MRI is only available 1-2x/week. My next move was in no way obvious.

My questions almost always stem from the vagaries of practicing medicine in the real world and in resource-limited settings. Those limitations often mean the algorithms only get me so far.

On the other hand, I can only imagine how difficult it would be to practice Critical Access Medicine without uptodate and other electronic resources. Thank God for the internet.

So, I phoned a friend.

With Tom, I called the closest Children’s Hospital, I talked to Neurology first who felt he needed an emergent MRI. The neurologist was thorough and business-like. Then, I was routed to the Peds ED Doc, who was similarly helpful and gave me recommendations of immobilization and transfer.

They admitted him to their Neurotrauma ICU, and he made a full recovery without intervention. Diagnosis: Transient quadriplegia, or aka cervical cord neurapraxia. This was a first for me.

This was a neutral phone consult. I get the information I need to help the patient and we expedite his care. Generally, the physician’s at the Children’s Hospital are more civil than most.

In fact, a Peds ED consultant is to date the only accepting physician to tell me I did a good job. The patient was a pediatric DKA. By the time I called, I had fluid resuscitated the patient, the insulin drip was going, and a bag of D10 with 40 mEq of KCL was y-ed in to allow for titration on the 2 hour transfer ride based on POCT glucose testing.

This was the first time since residency a fellow physician had told me I did a good job with the clinical care of a patient. I am not particularly dependent on praise (honestly probably much less so than the average millennial). Nonetheless, it felt damn good.

I was surprised how good I felt being told I had handle a complicated case well. It made me realize how rarely we get positive feedback from our colleagues. And, if I am honest, how rarely we give it.

How much more pleasant would our days be if we battled a dysfunctional and inhumane system with our colleagues rather than in spite or even because of them?

The Normal Experience

Ruminating on my surprise reaction to a little bit of positive feedback, I started to think about my usual experience. After a time, I realized the marker I now use for knowing I did good a job with a transfer is the absence of snark.

If all I get from a hospitalist after I give the report of a patient is a begrudging, “Ok,” I know I have done a good job in setting up a patient for transport.

John’s Story

For instance, John, a 65 year old man with diabetes who had been struggling with recurrent infections of a diabetic wound on an old amputation site came into my emergency department the other day.

Three days prior he stopped his latest round of oral antibiotics. The wound had increased purulent discharge, pain, and surrounding redness. I looked into the putrid hole at the end of his leg, clearly infected.

Moreover, His blood pressures are soft, he was mildly tachycardic and febrile.

“Likely early sepsis,” I thought to myself, a lactate of 2.9 quickly confirms my suspicions. I order a wound culture and blood cultures, fluids, and antibiotics.

After examining the surrounding area, I took a sterile probe and inserted into deep into the wound. It slid past the slimily infected tissue and felt the sure, soft thud of bone at the end of the probe.

“Shit,” I think, “No way infection isn’t in his bone”

“John,” I start, “I think we need to get an X-ray (MRI is of course not available today) to look for infection in the bone.”

The techs wheel him off to X-ray.

Sitting in the reading room, I (the humble ED doc) can clearly see the lytic lesions at the of the bone indicating infection, and the likely need for surgery. My nurse starts the antibiotics and I call a hospitalist at a referral hospital.

I get the hospitalist on the phone. I run through his story ticking off all the important information: Vitals, lactate, white count all point to early sepsis with a clinically infected wound. X-ray showing acute osteomyelitis – he will need a surgeon and long term IV antibiotics.

I detail the care I have already given the patient. I feel he is stable for transfer. Moreover, John and his family requested transfer to the this specific hospital (multiple hospitals are effectively equidistant for transfer).

On the other end, I hear a long pause. Then, the quiet, begrudging, “Ok, we’ll take him.” Those are the last words he speaks to me, switching to addressing the operator to arrange bed placement.

I apparently don’t even merit a good-bye.

The sad thing is, I now interpret this kind of interaction as evidence that I have done a good job. No snarky comments, no prolonged questions and second guessing, no arguments as to why going to some other facility or service would be better.

And I felt good about it. I had won in the battle to deny him any reason to do any of the above.

That is how low my general expectations for civility have sunk when talking to another physician. Moreover, this is a physician with whom I am technically collaborating on the care of shared patient.

Civility is the Grease of Teamwork

Now, the art of the long distance phone consult is a delicate one. I don’t always nail it perfectly. Walking the line of giving someone all the information he/she needs while still making a coherent narrative of why you need his/her help is often difficult.

To boot, my phone call is almost always interrupting some other work the consultant is attempting to accomplish.

Furthermore, as physicians, we all work in high stress environments where it can be difficult to find a moment to focus on the problem at hand. We all have bad days, I get it.

I talk to all sorts of consultants – board certified ED docs in a large trauma center, Peds ED docs, surgeons, OB/GYNs, cardiologists, stroke neurologists, or hospitalists and intensivists for transfers.

I need all kinds of help out here on the High Lonesome.

In particular, hospitalists at large referral centers are slammed with work which is often effectively clerical. I.E., admitting a pre-op hip fracture patient so that Ortho can focus on more important (ahem, profitable) endeavors.

I know civility is rarely at the top of our lists. Nonetheless, I think we as a profession are forgetting or have already forgotten the importance of civility and collegiality.

Afterall, we are all in the game of trying to help sick people, together.

If I am uncivil to a nurse who is caring for a patient of mine, he/she will avoid calling me. If that patient crumps when we could have avoided the situation, I need to take some responsibility for that outcome. 

Civility and collegiality are the social tools we have to reframe our interactions from oppositional to collaborative. Without them, our profession splinters and we are all little Lone Rangers fighting our own pitched battles day in and day out.

So, I for one am going to try and put a little more civility back into my interactions. It costs me nothing, and I have found more often than not, it pays dividends over the course of the conversation.

And, most importantly, my patients get better care when their physicians collaborate with, instead of battle against, each other.

Bad Financial Decisions I Don’t Regret

financially deleterious decisions in hindsight

Many physician and non-physician finance bloggers share their financial stories and their mistakes.  Xravzn’s story of trials, tribulations, and the financial decisions he had to overcome was particularly inspiring for me.

Financially, the first two bad decisions dwarf the rest:

  1. I went to possibly the most expensive medical school in the country (this might end up being about $500k by the time I pay it all off)
  2. I did not choose a particularly high paying specialty (Family Medicine averages 180-250k/year)
  3. Buying a house within a couple of months of starting my first job, having already figured out that we weren’t going to stay there for more than a few years.
  4. Taking a three month trip through Paris, Spain, Morocco, England, and Iceland in between residency and starting my first job (probably about $20,000).
  5. Going on a 4 week trip to Odessa, Ukraine and Bulgaria with my now wife, brother, and mother in my 4th year of medical school ($4,000 of student loan debt funded that adventure)

Could I have made some smarter moves with investments, decreased costs, etc.  Sure, but none of them compare to the first two on the list.  They are rounding errors in comparison.  Do I regret these decisions?  I am not sure.

#1 – Expensive Medical School

I certainly wish I had less student debt, but I met my wife where I went to medical school, which was her hometown and where we now live.  My wife gave brith to our daughter, whose loss has brought us even closer together.  I never thought I could love someone so much, so the debt doesn’t seem that important when you phrase it that way.

#2 – Low-Paying family medicine

As far as my specialty goes, I have mixed feelings.  Would it be nice to be able to pay off my loans faster, yes.  On the other hand, rural family medicine docs are in such demand that job security is not really a concern for me.

Indeed, my current position allows me to turn traditional family medicine (low acuity emergency department, inpatient medicine, as well as clinic) into shift work.

I get paid by the hour – 24 hours a day, often when I am sleeping overnight.  this means I can make 1/2 of a normal family medicine doctor’s months salary in 5 days of straight call in some of the locations.  I might see an average 7-12 patients (ED, Clinic, and IP combined) per day at these particular sites.  Unlike a busy ED doc, I am usually seeing only 1 patient at a time.

I have complete veto power over my schedule.  I often work a total of about 10 days/month currently.  It is a pretty chill lifestyle.  This is made possible by my low paying specialty which is in short supply.  If time is the currency of life, this job pays pretty well.  So, I consider it a wash.

#3 – buying a house

I do actually regret this one.  On the other hand, I am not sure I had many other great options.  We moved to an area dependent on tourism.  Many of the rental properties had been bought up to use as short-term rentals.  Long term leases were difficult to come by.

We ended up buying a house on 5 acres that bordered public land.  It was pretty sweet.  By urban standards, it was very affordably priced and well within our price range.  We moved after 13 months.  Luckily, it appreciated about 5-10% in that time, so we only lost about 10% of our down payment plus the $6,000 we had to pay rent and a mortgage.

Looking at it a different way, my wife and I realized that we don’t like spending a lot of time and energy on our house.  Cleaning a large house was a pain in the ass and neither of us enjoyed it.  Finding out that you don’t want to own a large piece of property early in life is probably worth a lot of money and headache in the long run.  So, I even found a silver lining here.

#4 and 5: Travel with people you love

These trips were worth every goddamned, interest-bearing penny.

Have you eaten grapes and brie with a warm baguette under the shade of the chestnut trees next to the canal St Martin on a warm, summer Paris afternoon? Have you done it while polishing off a bottle of wine with the woman who will be mother of your children? WORTH IT

Rila Monastery – Bulgaria

What about taking an overnight Soviet-era train with your soon to be wife, mother, and brother from the beaches of the Black Sea to an ancient Orthodox monastery nestled among the spring acid-green of a Balkan beech forest?  Retiring to the old monks quarters after watching the Alpenglo fade from the Peaks? WORTH IT.

Waterfall in Iceland

Or, hiking back from a glacier-fed waterfall, eating roasted Icelandic lamb, and washing it down with a cool, crisp beer? WORTH IT

Or, remembering sitting next to a spring in the shade of a walnut orchard at 6,000 ft in the mountains of North Africa.  Relaxing there with your wife of 13 months while being served a three course meal of salad, mint tea, tagine, and fresh fruit that was packed over a mountain pass on a mule by your grouchy but affable Berber muleteer. WORTH IT.

Standing on the summit of the highest mountain in North Africa and the Arab world with her two days later? WORTH.  IT.

There are times in one’s life when you realize the window for a certain type of adventure is fading quickly.  Is it worth letting the window close because that money could get you a 7-8% ROI?  Life is complicated, messy, and that’s what makes it great.  I refuse to give that up in the pursuit of financial stability and gain.

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.