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Mental Healthcare, Still Excising the Stone of Madness?

My phone rings.  I stop walking.  The sudden change in velocity causes the gravel under my feet to let out a slow grinding noise.

I often walk the gravel roads on the edge of town when things are slow, even at night.  Maybe especially at night.  Getting away from the few lights allows the full grandeur of the night sky of envelop me.

It is an expanse I rarely get to appreciate in the city where the smog and light pollution only let a few key stars shine through.

Of course, I am always within 20 minutes of the ED, but at my walking speed, that could be over a mile away.  I answer the phone.

“Hello?”

“Hey Doc, the police are bringing in a guy who has been acting strange and his mother called a safety check on him. So, they are bringing him in for evaluation.”

“I’ll be there shortly.”  I turn and head back to the hospital at a slightly faster pace than before.

The Rural Mental Health Crisis Team

I walk through the doors into the ED.  The standard mental health crisis is now assembled: Two small town police officers, an ED nurse, and myself.  God help this poor soul, because we probably won’t.  At least, not in any way which changes the trajectory of his illness.

“Hi,” Char, my nurse cohort for tonight begins. “So, this is Tim, his mom called the cops because he has been acting strange the last few days.  He is talking all the time, wouldn’t let his mom into his room in the house.  He has had a lot of problems with meth, so, y’know…”

I acknowledge Char’s statement, but also mentally try to put it on a back shelf.

One of the double edged swords of small town doctoring is everyone knowing everyone.  On the one hand, it is quite a bit easier to get a detailed and relevant social history on people.  On the other, people often have their story made up in their mind about who a person is and what is going on.

Could Tim be on meth? Sure.  Does the fact that he’s done meth before mean he is one meth now?  Not necessarily.  I have developed a technique of trying to mentally disprove the suggested theory while also proceeding as if it an equally likely possibility.  It seems to help me find balance in diagnosis.

If You Get Hurt on this Rotation, You Fail.

We did our emergency psych rotation in medical school in the ED of the county hospital, a level 4 trauma center in the middle of downtown.  It was the quintessential urban ED.  On orientation day, safety was the first and last thing addressed.

The attending psychiatrist, a tall, thin man who projected both bookishness and a tempered, pulled bowstring kind of hardness, listed some maxims:

  1. Do your first cursory exam from the door
  2. Never let a patient get between you and the door
  3. Try to project calmness
  4. If you feel unsafe, leave

He finished his talk with this warning: “If you get injured on this rotation, you will fail this rotation.”

Honestly, this was the scariest threat he could have made to a room full of medical students.

Whenever I find myself back in this situation, I stop at the door and do my initial exam.  I look Tim over.  He sitting in the bed, his hands flailing over his head in somewhat rhythmic circles.  If he’d had glow sticks, he would have fit right in at a rave.

“Tim, what’s going on?”

“Just keeping everything together.” He spat out in between his rave routine.

“Are you feeling okay?”

“Oh yeah, I feel great. I just got to keep everything moving.”

“Have you been doing any drugs?”

“Nope.”

“Do you know where you are?”

“Yes, the hospital.”

“Do you think anyone is out to get you?  Do feel in danger?”

“No, but people have been watching me, talking about me.”

“Who?”

“Everyone”

I review the chart.  His heart rate is quite elevated and his blood pressure his very high.  It could be meth, but he also seems to have some paranoia and something else going on.

Of course, true psychosis and meth intoxication are not mutually exclusive diagnoses.

“Give him 4mg of lorazepam IM, if he calms down, start an IV and give him and a liter of normal saline, he’s probably dehydrated and we’ll need some urine.”

Collateral History

I leave and call his mother.  She tells me he smokes marijuana still (of course, I think to myself, marijuana is just a vitamin these days). But, she continues, he hasn’t been acting like he used to when he was on meth.  He has been saying that he has been talking to his deceased father and repeatedly saying everything would be okay because they would be seeing him soon.  He has not been sleeping, eating, or drinking she goes on.

She runs through a disconnected description of the past few days.  She is clearly very shaken.

I return to the ED about a half hour after Char gave Tim his sedative.  He is out cold.  Rousable enough to avoid intubation, but way more sedate than someone psychotic on methamphetamine would be after that much lorazepam.  His vital signs have normalized.

His story is starting to sound more and more like true psychosis, possibly a manic episode.

“Okay, Char, I don’t think this is meth, we should get mental health here.”

“They won’t come til we have a U Tox which shows no meth.”

“Of course, well let’s get that urine then.”

We Count the Hours…..

What is understood between us is how long this is going to take.  The closest emergent mental health evaluator is 90 minutes away.  So, even if we immediately had a magical urine sample at that very moment, we would be 2 hours from someone actually evaluating him (which has to happen before we even discuss placement).

2 hours later, we finally have a urine sample.  We call the mental health evaluator.  She agrees to come.  I go out for another walk.

After Julie, the mental health person has evaluated him, we talk.

“He is psychotic and needs placement?  Right?”  I prod her.

“Oh yeah.  He definitely needs placement.  I have already placed him on a mental health hold. I am going to go start making calls looking for placement.”

“I love you already, Julie.”  She smiles back.

This is music to my ears.  I hate placing people on holds.  It is a huge legal move to restrict their rights and comes with a lot of paperwork.  I love it when someone else does it.  And placing them on a hold pales in comparison to the work of finding a mental health facility to take him, which she is already starting.

Seriously, I love Julie right now.

I stand up and turn to Katie, the nurse who has replaced Char.  This has already gone on so long shift change has already come and went for the nurses.  I am here for 48 hours, so no such luck for me.

“Call me when you have paperwork for me to sign, I am going to go to sleep.  He can have more ativan if he gets agitated again, I wrote for it already.”  I think about ordering him an antipsychotic, but since he is compliant enough on the ativan, I would rather the psychiatrist get to see him in his full psychotic glory rather than already partially treated.

I trudge off to the sleep room.

A New Day Dawns

I wake up to the phone ringing again.

“Hello,” my voice comes out a froggy moan.

“Hey Doc.”  It is Char again, shift change has already happened again.  He has now been here for 18 hours. “Need you to come out and sign Tim’s transfer paperwork, we have placement and transport is on their way.”

“Okay, I’ll be right there.”

I scribble the legal necessities on the paper work and finish my half typed note from the night before.  Honestly, I am pretty pleased at how relatively seamless this was.  It took a long time.  I feel like it went well.

Cynicism Creeps Back In

However, my cheerfulness quickly fades as I am honest with myself about the situation.  Sure, we did what we were “supposed” to do.  Theoretically, the ramshackle network of mental health on the High Plains worked.

If I am honest with myself, all it succeeded at was passing the buck.

I know from experience how this will play out in the end.  He’ll get stabilized on medications in an inpatient setting, then he will be sent back to the High Plains to the care of his elderly mother, where the closest psychiatrist is 2 hours away.  Even then, the psychiatrist is only available 2 days a week.

No one will have the power or will to make sure he stays on his medications.  One day, he’ll stop them, because self-medicating with marijuana feels better than antipsychotics, and eventually the cycle will repeat.

Who knows if he or anyone else will get hurt next time.

Dividing the Care of the Person

This is how we make ourselves feel better so our souls don’t rip in half.  We break down the tasks involved in caring for human beings into such small parts so we can all feel like we’ve “done a good job,”  All the while, for the person, nothing really changes.

This is our “system” of mental health in this country.  A revolving door of failure.

Sadly, I shouldn’t even complain.  I was thrilled to find out such services even existed. In large parts of rural America, the same patient would have been placed in the local jail.  In many towns, the jail is the only secure location in town for these people until placement can be found.  At least Tim avoided that fate.

I played my part in this farce brilliantly.  We efficiently and effectively “placed” Tim.  Who could find fault with my actions?

Of course, it is not my fault we have such a failure of a mental health system and my participation does not mean I own all of its sins.   Nonetheless, it is just one more of the millions of tiny cuts physicians endure to our souls while working in our healthcare system.

The history of mental healthcare is filled with terrible and inhumane practices. Will we look back on today the same way?  We might not be lobotomizing people anymore or cutting into their heads looking for the “stone of madness,”  but we should not delude ourselves.

Repeatedly sending ill people into a world their brains cannot process to self-medicate with drugs and endure repetitive trauma through physical and sexual abuse at the hands of each other is not a more humane choice.

At least the old quacks cutting the stone were actually trying to cure something.

Featured Image: Cutting the Stone, Hieronymus Bosch, 1494 or later.

What is Adulthood?

The tumultuous diversity of America is great gift.  Our dynamism as a country surely depends on the constant exposure to new ideas and ways of thinking.  On the other hand, it comes at a cost, too.  Community cohesion seems to be the cost we are paying for this wonderful engine of our country.

One of the binding forces of community is ritual.  Traditional cultures have rituals for all major life events.  These rituals bind us to one another and help us feel rooted in our people and place in the world.  One such ritual I often feel is missing in our culture is that of passage of into adulthood.

I think many of us reach adulthood at different times in our lives.  Clearly 12 years old is no longer the time for recognizing our transition into adulthood.  Yet, I think clarity would be helpful.  Those of us in Medicine often seem to have a prolonged entrance into adulthood due to the many years of schooling and training.

When did I become an adult?  At 18?  When I graduated college, or medical school, or residency?  Maybe, for us Millennials, the transition to adulthood happens when you have to start paying off your student loans?  I had a long slide into adulthood, slowly gaining more and more responsibility.

A little ritual to mark a moment might have provided some clarity.

Is responsibility what marks our transition to adulthood?  I am not so sure.  I always had a fairly large amount of responsibility, often more than my peers.  Yet, it did not make me feel more “adult.”

Growing up, adults are the ones who have the answers.  They teach us the rules of life.  They provide structure and certainty to young, expanding minds.  I know more thing than I ever have, but often feel like I have fewer and fewer answers to the questions which matter.

I still don’t really feel like an “adult.” I certainly don’t feel like I can offer anyone else any certainty.

Feeling Old

Yet, I do know what it means to feel old now.  Unlike adulthood, I learned what feeling old feels like within a matter of 2 months.  After the first, burning, searing weeks of grief gave way to a smoldering, tired blanket of grief.  Our first daughter dying made me feel old.  All of the sudden, I was world-weary and inexplicably brain-and-soul-tired.

It seemed as though the world had gone gray, and taken me with it.  Everything took more energy than it had before.  Then, the hospital-pharmaceutical complex came and demanded I keep performing my RVU tricks.  Any hope I had had of finding some comfort and solace in work and my supposedly noble profession was dashed.

I have hurt more deeply than I knew possible.  Yet, life keeps going.  Now, I visit my grief at times.  Sure, sometimes I feel guilty I can not feel it for a few days to even a week at a time.  Sometimes, when I feel guilty about having joy and pleasure in life again, I got back to the day we had to say good bye.  I remember holding her as she stopped breathing.  Soon, I am softly crying, and I know I haven’t stopped feeling her loss.

The grief of losing my daughter was by far more painful of the two wounds I sustained at that time.   No one should have to lose a child, but people do.  Sadly, it is more common than many realize.  A path exists, there are books, and people want to be supportive (even if they are often bad at it).   Maybe because of this, I have found the process of coping with her loss and healing from it to be simpler, if not easier, than coping with my disillusionment with Medicine.

You Can’t Turn Back The Clock

The repeated grief of coming face to face with my disillusionment with a calling I had had actually grown to believe in seems to be never ending.   The Hospital-Pharmaceutical Complex seems to take joy in reminding me of its callousness and love of profiteering.  It never fails to slip comfortably under the already low bar where my expectations are.

While I have come more to terms with the reality of modern doctoring, it still makes me sad.  Sure, sometimes I am angry, too.  But really, it is mostly sadness.  I don’t have the energy to be angry at a giant faceless industry.  That sadness seem to be the well which feeds my feeling of elderliness.

Before, I felt like I was participating the arena of Medicine.  I was an eager young pupil, ready for action. Now, I view the going-ons of all the little hospitals as an old man on a bench dispassionately watches a cat stalk a squirrel in a park.  It is a drama, but a small and distant one, separate from the man’s life.

Sure, it will be sad for the squirrel, but the world is simply this way.

Welcome to Adulthood

Maybe, I wonder, this is what adulthood is.  It is not rituals, nor accomplishments, nor financial responsibilities.  It is the world teaching you it is not a place of endless possibilities, at least no longer for you.  Is adulthood the place and time where we realize life can be just as cruel as it is wonderful?

Do we become adults when we transition from an excitement about how the world could be to a acceptance of how it is?  No longer the young revolutionaries, we become harnessed bureaucrats and accept our fate?

Maybe then, I was lucky to make it to 32 before I became an adult.  I had a long and wonderful childhood, full of joy and discovery.

On my better days, I hope to return there.

Maybe that hope means my transition to adulthood isn’t so foregone, after all…

 

Is This Path Sustainable?

I suffer the curse of rumination.  I ruminate, overthink, and ruminate some more  Strangely, I don’t tend to worry all that much, but I think on things, repeatedly, and often.  My ruminations have a tendency to make the simple complex, the joyful a morass of conflicted emotions.

A recent drive home across the Big Empty was fertile grounds for such rumination.  I had completed a 78 hour shift on the High Plains.  It was an easy shift.  I saw 10 clinic patients, 5 ED patients, one of which I admitted to the hospital.  None of it was particularly complex nor emergent.

For that amount of work, I made roughly 1/2 the salary that most outpatient family docs make in a month.  That is right, for 15 patients, I made about over a 1/3 of my income for the month.  You would think I would have been driving back home thinking about how I lucky I am to have found such a gig in modern medicine.

Instead, I became what my wife terms “thinky.”  I couldn’t help but feel somewhat guilty.  Imposter syndrome quickly followed the guilt.  Is someone going to figure this out and get rid of this?  What will I do then?

This clearly is not sustainable for the country…Is it sustainable for me?

The Stories We Tell Ourselves

Obviously, from a financial standpoint, I did not generate enough income from my physician fees to justify what I was paid (not to mention what the company I contract with got paid). I generally justify what I get paid with this knowledge:

The hospital pays me to keep the ED open, not to generate revenue. 

It is true, of course.  And a true free marketeer would simply say, “If someone will pay you to do it, it is the market’s will.”   A lot of people don’t want to do what I do, so my willingness to do it is worth a high price.

It may just be that simple.

Nonetheless, I often still feel like a profiteer.  My services are expensive. I can’t help but wondering why someone hasn’t figured out how to avoid using me.

Of course, this is not my problem to solve.  Plenty of people are paid quite well to manage these little hospitals, and if they can’t figure out a better solution, why does it bother me?

I keep speeding along open highway…

I stare at the prickly poppies in the ditch as they race past fenceposts along the green and tawny plains.  I can feel my brain chewing its cud.  The anxiety behind the above question is, of course, what will I do if they do figure out something better?

It is a real, yet remote anxiety, I turn down work every month.  There is too much need on the High Plains to fill.

How is there still so much work available that I am constantly turning down shifts?

Of course, I know the answer.  The High Plains are not for everyone.  It is tough country.  There are no beaches nor ski resorts to attract and retain doctors like resort towns have.

Moreover, hospitals tend to ask more and more of their staff until they quit.  Succession planning is not in the vocabulary.  Rural hospitals live from crisis to crisis. Part of this is the natural result of having shallow benches.

If a town only has 3 docs, all it takes is for one one to get sick, retire, quit, get in trouble with the medical board and you are suddenly asking your docs to take every other day call.   The call schedule for the rural Emergency Departments is like Jonathon Edward’s God:

The God that holds you over the pit of hell, much as one holds a spider or some loathsome insect over the fire, abhors you, and is dreadfully provoked;

-Jonathon Edwards, Sinners in the Hand of an Angry God

The Rural ED Call Schedule takes but a faintest provocation to throw the lives of its participants into absolute chaos.  It only knows how to ask for more.  Living, day in, day out, under the guillotine a rural ED call schedule is knowing your kids’ games, family dinners, trips with friends all hang in a delicate balance.

They could all be lost at a moment’s notice.

It is not for the faint of heart.  It is also a stress which the non-clinician cannot know.  Managers of rural hospitals ignore the psychological effects of living under that cloud at their peril.  Unfortunately, most do and turnover is constant.

As long as a cost-based reimbursement continues to be a policy of Medicare, I will have more work than I know what to do with.

Cost-Based Reimbursement, the Lynchpin

I have mentioned cost-based reimbursement before.  It is absolutely the only reason Critical Access Hospitals are able to use me and not go broke.

The basic tenet of Cost-Based Reimbursement(CBR) is that for a given hospital stay in a Critical Access Hospital, Medicare will pay 101% of the “cost” of providing services to that patient.  Who gets to decide what is included in that cost?  The hospital.

So, because my fees can be included in the cost of providing an inpatient stay, they can be written into the CBR formula.  Of course, if I am in the ED seeing a bunch of patient’s, this cannot be included in an inpatient cost report.

So, hospitals have to report how much time a physician spent on an admission, rounding, other inpatient tasks.  Then, they can roll that percentage of my fee into their cost report and get reimbursed for it.

In short, without cost-based reimbursement, I would likely be out of a job.

Though I am technically a “business” as a 1099 sole proprietor, my entire income hangs on government spending at its root. This is the reality of most of healthcare in this country.  Sure, some people have private health insurance, but public healthcare spending is what keeps the lights on around this county’s hospitals.

We would do well not to forget that.

So, is it Sustainable?

I decided to write this post for one reason, to break my rumination cycle.  Sometimes, putting thoughts down on the blog helps release them.  The reason a cycle keeps going because I have no definitive answer.

Clearly our current healthcare system is unsustainable.  Cost-based reimbursement may be as well.  However, I am hardly alone in making a very good living off the healthcare system without necessarily adding that much value.

On the other hand, rural locums is common in plenty of other countries with systems less screwed up than ours (New Zealand, Australia, UK, and Canada).  So, this might be plenty sustainable.  Like every thing else in healthcare, we all know it can’t keep going like this forever, but it might go like this long enough for me to finish my medical career.

I guess this is gig will be sustainable until it isn’t.

Featured Image:  Path in the Forest.  Spruce Forest.  Ivan Shishkin, 1880.

Can Physicians Resist? Or Only Vote with Our Feet?

The Culture of Medicine values orthodoxy.  The requirements for getting into medical school are extremely rigid and in no way value aspects of an applicant not easily testable or quantifiable.

Indeed, the various hoops, tests, and checked boxes of getting into medical school seem more designed to weed out renegade, innovative, creative types than to assure a high caliber of applicant.

They select for the correct quality of applicants, not the high quality of applicants.

Medical school admission seems primarily designed to identify individuals who are adept at learning the rules of the game and then driven to win the game.  Anyone who questions the game is summarily excluded.

As a cadre, physicians are poorly equipped to resist the Hospital-Pharmaceutical Complex.

We are acculturated to shrink our purview to the smallest area possible. This makes it easier to control all of its aspects, which soothes our control-oriented personalities (also selected for in the admissions process).  However, it also dilutes our influence and robs us of seats at the decision-making tables.

Yet, many, if not the majority, of us are extremely dissatisfied at the state of American Medicine. I have written plenty about this.  If we are so dissatisfied, why aren’t physicians across the country rising up and demanding change?

We don’t know how to Resist

Physicians spent their high school and college years languishing in libraries and study halls.  We didn’t go to trainings in direct action.  In residency there are no rotations in “managing organizational change.”

We are so focused on getting the “right” answer, we have rarely had the opportunity to demand those asking the questions defend their choice of question.  Give physicians a set of rules to a game, and we fight tooth and nail to prove we can be best.

Ask a group of physicians whether or not the game is just, worth playing, or if the rules should be changed and we just stare blankly back at you. Those questions have no winners, it does not compute.

For sure, we are raising our voices at higher rates than we ever have in the past.  Yet, the machine keeps jugging along.

Debt, Competition, and Greed

Maybe it is as simple as too many of us are debt-indentured.  The vast majority of us start with $200k+ in debt in our early thirties and then add a mortgage and often some other consumer purchases as well.

Are so many of us permanently debt-indentured to the point where all we feel we can do is just keep our heads down, pay off our debt, and get out?

I slammed my head against the wall for 12 months in my first job. I tried incrementalism from the inside.  It was terrible, and when tragedy hit, I didn’t have the stomach for it anymore.

No one ever articulated what we were working towards. What change were we really trying to make?

Of course, I learned no one was trying to make change.  They were just trying to make as much money as possible, for the system, and then for themselves.

My partners just agitated for more money for less work with a better schedule without the EMR. Their passion had withered to greed and self-interest, cloaked in the name of patient care.

Effectively, they were still applying to medical school.  They were just just trying to win the game.

They didn’t care that the game was corrupt and the purpose of the game was completely divorced from its original purpose.

Or, has this always been medicine?  Has medicine always been a dichotomous beast of greed in the name of helping others?  Test, cut, prescribe until we are wealthy enough retire to a golf course community?

Have those who couldn’t hold their noses any longer always just left?

Is that our only option, to vote with our feet?

Is There Another Way?

At least in rural medicine, it seems as though all physicians can do is vote with their feet.  It seems so dissatisfying to have that left as our only option.  Also, as the problems of the healthcare industry are truly national in scope, there are few places left to run.

No real competition for physicians exists because the industry leaders have all embraced the same models which perpetuate burnout. As we are squeezed more and more to “produce,” our time and energy doesn’t allow for resistance and fighting for change.

Normally, it is the young and energetic who push for change.  The newest generation of doctors emerges into a field where all their excess energy must be tapped towards getting out from under a debt load. One reasonably measured in fractions of a million dollars.

We debt-laden young physicians have nothing left at the end of the day to offer the fight for change.  As such, our voices are largely silent in the national arenas, except of course on the impotent platforms of social media echochambers.

Instead, healthcare “industry groups” and our National Academies usurp the right to speak for us.

Our supposed representatives mostly seem hell bent on protecting or increasing reimbursements for their loudest members, not on making doctoring a fulfilling vocation again.

Surviving the healthcare industry has sadly become our goal.

I certainly hope something or someone comes along as a realistic option to fight for change, but my hope is mostly vestigial.  It is a mere remnant of an idealism and passion which seem a bygone memory.  Pretty soon, the only place left for our feet to go will be out of medicine entirely.

Honestly, I don’t think I am smart enough, connected enough, nor strong enough to find this other road.  I would love for someone to show it to me, though.  I would love to follow someone on that journey.

I do not believe I have the strength or skills to lead anyone in hacking a path out of the wilderness we are in.  Besides, I have proven myself to be more than content with wandering.

After all, the wilderness is a fine place, we could use more of it.

But the Restlessness was Handed Down…

But the restlessness was handed down,

and its getting very hard to stay.

-Billy Joel

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

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

We all lie somewhere on this continuum.

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

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

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

Who Was I Kidding?

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

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

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

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

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

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

A nomad cannot be fenced.

I Know the Grass Isn’t Greener

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

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

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

How can I say no?

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

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

Unknown Unknowns

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

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

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

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

Rural Medicine: Reaching the Limits

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

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

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

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

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

Making Do

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

This hospital does not even have the robot.

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

Finally,  tech X-ray tech arrives.

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

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

The bed scale registered an astounding 472 lbs.

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

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

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

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

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

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

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

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

We sent her by ground ambulance as quickly as possible.

We Don’t Have That

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

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

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

“We don’t have that.” I am told.

“Fosphenytoin?”

“Umm, I don’t think so.”

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

“I don’t know, maybe ketamine?”

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

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

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

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

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

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

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

Somewhere with a functioning ventilator and some damn Keppra.

I looked around that the remaining EMTs and nurses.

“Well, that could have gone worse.”

Why Do This Job?

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

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

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

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

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

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

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

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

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

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

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

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

 

 

What is Being Present Worth to You?

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

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

“Doc”

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

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

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

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

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

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

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

Cancer Just Sucks

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

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

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

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

To be Present or…not

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

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

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

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

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

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

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

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

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

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

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

“Yes, it does.”

You Don’t Have to Ask a Dying Man

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

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

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

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

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

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

He misses that.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Down the Canyon and Up the Mountain

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

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

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

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

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

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

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

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

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

10 Years Back to Zero

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

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

10 years later

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

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

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

Accounting for Life

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

Medical School

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

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

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

Residency

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

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

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

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

Attending

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

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

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

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

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

Life is Rich

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

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

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

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

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

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

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

 

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

Back From the Great Wide Open

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

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

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

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

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

That Ribbon of Highway…

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

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

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

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

I never listen to the praise channels.

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

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

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

It is a moment bordering on intoxication.

The Interstate

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

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

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

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

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

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

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

The Modern Travelers’ Bazaar

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

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

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

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

The onslaught continues, I am powerless to modify it.

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

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

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

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

The Edgelands

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

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

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

-Edward Abbey

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

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

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

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

Artificial Eden

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

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

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

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

And just like that, I am home again.

 

 

 

Brene Brown and Seneca Walk into A Bar

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

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

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

Foreboding Joy

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

-Brene Brown

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

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

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

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

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

Premeditatio Malorum

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

-Seneca

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

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

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

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

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

Tragedy as My Teacher

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

I came face to face with all the terrible possibilities.

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

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

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

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

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

Foreboding Joy or Premeditating on Evils?

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

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

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

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

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

Courage is the Difference

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

-Ambrose Redmoon (James Neil Hollingsworth)

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

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

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

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

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

Knowing our Fears

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

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