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.

Horseshoes and Hand Grenades

Reason for visit: cough – follow up from urgent care

6 weeks from the end of my intern year, I met B first time. I walked into the room and saw a healthy appearing 33 year old, dressed in the uniform of kitchen staff from my training hospital .

B had visited a local urgent care twice in the last month for a cough and shortness of breath. He received azithromycin and a cough suppressant both times. The second time, the urgent care doctor referred him to the residency clinic so that he could have a more thorough evaluation if it hadn’t resolved. The cough and shortness of breath had not improved.

I proceeded to do my normal initial patient visit history and physical. B had a couple of interesting past medical history items. He was being treated for glaucoma and had had his spleen removed as a child for Idiopathic Thrombocytopenic Purpura. Interesting, but nothing directly related to his chief complaint. He denied any history of asthma or other chronic lung problems.

History of present illness

Me: What has been going with your cough and breathing?

B: For the past few weeks, I have had an annoying cough and feel increasingly winded doing simple activity.

Me: Can you describe how winded you feel?

B: well, like on my way over here, I had to stop and rest coming up the stairs in this building.

Now, my clinic rooms were only on the second floor. I checked his vital signs again: heart rate, respiratory rate, and oxygen were normal. His lungs were clear, his heart sounds were normal.

An otherwise healthy 33 year old should be able to walk up a flight of stairs, even with bronchitis. Maybe not with a significant pneumonia, but his vitals didn’t suggest that.

a closer look

I turned and just looked at B. Up and down, looking for some other clue in his visage that might point me in a direction. He had short cropped sandy-blond hair, wearing wire-rimmed glasses. He looked comfortable. His skin was a bit pale, not hemorrhaging GI bleed anemic pale, but enough to favor a portrait of a Victorian-era consumptive.

I didn’t know much as an intern, but I had learned people who get rare diseases tend get other rare diseases. I was nonplussed. Other than the fact that his story just made me worry, I didn’t have a direct line of inquiry. Just to give myself some time to think, I had my nurse take him up the stairs with a pulse ox, see if that pointed anywhere.

He started up the stairs, oxygen stayed steady, but within a few steps, his pulse shot up to 120. Something isn’t right here. I talked to my faculty (still an intern – have to precept every case). My thought process had frozen, I knew something wasn’t right, but what other tools do I have in clinic? She helped me out, “how about a chest x-ray and an EKG?”

ORDERs: CXR and EKG

His chest x-ray wasn’t very impressive. I thought maybe his heart seemed a little big for a 33 year old, but the radiologist wasn’t impressed. His EKG was a different story.

EKG didn’t show any ischemic changes, he had sinus rhythm and no conduction problems. Those were pretty much the only normal parts.

Axis was confusing, but seemed rightward, P waves were huge, T waves were either inverted or gigantic. He didn’t have obvious hypertrophy, but voltage on his precordial leads seemed moderately elevated. To this day, it was the most bizarre EKG I have seen. I wish I had a copy.

admit to hospital

I went into the exam room.

“B,” I said, “There is something not right with your EKG. I am not sure what it means. It doesn’t look like a heart attack or anything like that, but I think we need to get you to the hospital to figure out is going on.”

B seemed neither relieved nor worried, “Okay.”

I called my fellow on-call intern and the chief resident. Presented the case and arranged for B to admitted to the hospital. The work up began in earnest. Most favored a pulmonary embolus as the cause of B’s symptoms. The team ordered the requisite CT Angiogram of the chest. The read came back.

NO pulmonary emboli identified. pulmonary arterial trunk measures 4.5 cm, highly concerning for severe pulmonary hypertension.

The echocardiogram the next day confirmed that B did indeed have severe, end-stage pulmonary hypertension (PH). Right ventricular hypertrophy. The cardiologist and pulmonologist were called in. The work up provided no treatable cause of B’s PH. The label became “Idiopathic,” which is doctorspeak for “we don’t know.

Henry Vandyke Carter [Public domain], via Wikimedia Commons

When the cause of a problem is unknown, treating it very effectively becomes rather difficult. The cardiologist scheduled a heart catheterization for an arterial dilation test. This was to determine which therapy might be appropriate.

His pressures were too high to complete the test safely. The cardiologist aborted the procedure. He arranged transport to the nearest university medical center. B needed to be on a transplant list. 33 years old.

good catch, man!

My classmates congratulated me on my “good catch.” A well appearing man walked into my clinic with a rather benign complaint and I started a work up that caught a zebra. We rapidly identified a diagnosis, involved the correct specialists and provided, I do believe, excellent care.

I went to see B in the hospital the day before his transfer out of the city I trained in. He was cautiously optimistic and glad to have an answer and to be getting to where he needed to be. He thanked me.

I asked him if he had family coming. He said his parents would meet him at the university hospital and his sister was flying in from out of state.

“That’s good,” I reflected, “Family is important when you are going through something like this.” We shook hands and said goodbye.

Nothing puts swagger in an intern’s step like catching a zebra where one least expects it. I felt pretty damn good.

when your best isn’t good enough

One of my favorite things about traveling around rural parts of the country is picking up rural aphorisms. One that I grew up on in my household was, “Close only counts in horseshoes and hand grenades.”

Two weeks after B left our care and hospital, I went into his chart to show a colleague his EKG. The computer attacked my vision with the notice:

YOU ARE ENTERING A DECEASED PATIENTS CHART.

I sat back stunned. We came close, but medicine isn’t horseshoes or hand grenades.

Later that day, I talked with my fellow intern who cared for B in the hospital. I let him know the news, he had a similar reaction. We had felt so good about the care we had provided to B. We were at the top of our intern game and yet, he died.

humility is a punch to the gut

Did we do anything wrong? I certainly don’t think so. Diagnosis, treatment, transport to appropriate care in a timely manner. All done better than average, I would argue. We were proud, especially for a team of family medicine residents and interns.

By Rama – Own work, CC BY-SA 2.0 fr, https://commons.wikimedia.org/w/index.php?curid=3632261

By the stars aligning, my fellow intern’s significant other was an ICU nurse who moonlit in the university ICU. On her next shift, she asked around. It turns out B was admitted there, kept in the ICU for monitoring. One night, shortly after his arrival, he went into ventricular tachycardia, an unstable cardiac rhythm.

The ICU team attempted to revive him for 2 hours through the use of every life saving medication and procedure they had. Codes are normally called after 30-45 minutes. He was 33 years old.

reconciling polar opposites

Sitting in my bed one night, staring at the ceiling, I talked about B’s death with my wife. I don’t talk about patients with my wife often. So, when I do, she knows the patient affected me deeply.

Usually, when someone dies or there is a bad outcome, I am able to derive a lesson for honing my art. Next time, I will do XYZ, and it’ll go better. I make sense of the loss through striving for improvement. It helps add meaning.

What happens when you did better than would be expected and it still goes south? “Nothing we could have done better, that is just life in medicine” seemed like a poor salve for my wounds.

Overtime, I thought back to the last conversation I had with B. His family was coming to see him, they new the diagnosis by the time he died. The grief doesn’t disappear because of knowledge, but every removed uncertainty helps, I think.

Most importantly, I believe they had a chance to see their son and brother before he might have suddenly died of a cardiac arrest. That was a gift I gave him and his family: some answers, and some time. We can’t always save, but we can always heal.

the dead are never gone

Having now gone through my own loss, my perspective on B’s story has evolved. Families carry the care and comfort we give to patients who die, just as they carry the memories and lessons of their loved one. This can be a blessing, and it can be a burden.

If we can give patient’s families memories that their loved one’s time under our care was full of support, strength, and understanding – it can be a great gift. It is invaluable in their grief and healing.

Anger is an all too easy trap for grief. It is a natural and normal part of the process, but it can be seductive. Anger is often easier to feel than the unending sadness or permanent loss. Anything we do as healers that makes the transition from anger to the other parts of grief easier, is of immeasurable value to patients and their families.

I now know this all too personally. Death is not an option, only a matter of time. Yet, we as human beings, and especially as physicians, have the power to meet it in different ways. We can meet death with love and the support of family and community, it can strengthen the bonds between those who are left behind.

As physicians, we have the power to facilitate that journey. It is a terrifying journey, people need guides. We have that power, if we choose to use it.

If we choose to help people meet death on their own terms, we choose to help them know life in the richest way possible.

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.

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.

The Peripatetic Patient

“I reached some plains so vast, that I did not find their limit anywhere I went, although I traveled over them for more than 300 leagues . . . with no more land marks than if we had been swallowed up by the sea . . . . there was not a stone, nor bit of rising ground, nor a tree, nor a shrub, nor anything to go by.” – Francisco Vázquez de Coronado, letter to the king of Spain, October 20, 1541

lost on the llano

On the High Plains of the Panhandle of Texas lies the Llano Estacado, the Staked Plains. These are the plains Coronado described. Navigating their featurelessness proved so difficult he instructed his men to drive stakes into the ground, from which they took their bearings.

It seems many wander into the High Plains and never think to pound stakes into the ground. Under the blue sky, they wander through their lives, unable to orient themselves, running from one crisis to another, finding only the slightest bits of respite in between. Often those wanderings lead them to my ED.

vagabonds and ramblers

The ED is our society’s safety net of last resort. Entry is guaranteed to all, the law requires hospitals to provide an examination and stabilization. As such, many crises with social roots land the Emergency Department.

As a traveling doctor, I see many of these peripatetic souls. Unfortunately, the happy wanderers and jaunty pilgrims don’t end up in my High Plains ED.

I have cared for the meth-addled, the anxiety ridden business drunk, the chronically ill truck driver who just couldn’t quite make it to the end of his run. The elderly RVer with COPD or CHF who never seems to remember oxygen is sparser at higher altitude is a frequent visitor (they are called the High Plains for a reason).

The challenges of caring for the itinerant are many. Treatments are often not portable. The lack of family members, who are a mainstay of support during illness, puts more burdens on the medical and nursing team. Often the best you can do is get them patched up so they can get back to somewhere with better support.

high plains drifter

All of the above characters have parts of their stories that are touching or sad.

For instance, I once did a trauma evaluation on very stoned young man who had been driving a car that a train demolished in a collision. I evaluated, observed, and released him unharmed, though he did annihilate several microwaveable burritos in the process.

Apparently, he stole that car two hours away and drove until he passed out, high-centering the car on the rails. Luckily he wasn’t actually in the car at the time of the collision, though his inebriation prevented him from telling us this when he arrived in the ED.

What did he do when after his discharge into a town where he knew no one and had no transportation? He stole another car, lead the police on a high speed chase, and earned himself three hots and a cot for an unspecified amount of time.

Occasionally, something hits you like a train.

marooned on the high lonesome

On recent shift, a local foster family brought in a child for suicidal ideation and threats of self-harm. The child was newly in foster care, less than 10 years old. Already, it is a pretty sad story.

When the child arrived, we talked.

Me: How are feeling, how is your mood?

Child: Sometimes good, sometimes bad.

Me: Is it getting better or worse?

Child: Worse

Me: Do you want to die sometimes?

Child: Yes.

He was in a new school in a new town with a family he didn’t know. It was stressful, he was angry. He hadn’t made any friends in his new school.

I asked where he was originally from – a state over 1000 miles away. He had no blood relatives nearby. I didn’t understand how he ended up in this hamlet.

Son of farmer in dust bowl. Cimarron County, OK. April, 1936. Arthur Rothstein, FSA.

As the story unfolded, he was traveling with his mother, a long haul trucker. She stopped at a truck stop and law enforcement apprehended her for some previous violation, placing her in custody. He went into the system. After her release, she fled the state. Here he stays, marooned on the Llano – no landmarks, no stakes, no family.

For now, he will continue to live with a foster family he doesn’t know, his mother having abandoned him to the wind and sky.

Me, Anemically: That must be really hard

Child: Yeah.

That, and a referral to mental health, is all I have to offer this poor kid. It is better than nothing, yet so insufficient. This small child has rendered all my advanced diagnostic and medical technology impotent.

Like a tumbleweed on the Llano, it all seems powerless in the face of the incessant wind and limitless sky.

Good Money after Bad

when is a relationship worth salvaging?

My second clinic manager in my first job (he left about 3 months before I did) told me once, “Spending more money on a bad investment doesn’t make it a good investment, just a more expensive bad investment.” So, the trick is knowing when putting any more effort into a relationship, job, investment, etc. is just making it more expensive.

The problem is, if you follow Boglehead logic, timing a market opportunity is fraught with risk. The likelihood of bailing too soon, or staying too long, is high.

In my first job, I quickly came to the realization that I was throwing time and energy into a black hole of dysfunction and left. Now, six months out, I am trying to figure out how much I damaged my relationship with Medicine by staying so long.

I increasingly recognize that I hold the Modern Institution and Culture of Medicine personally responsible for how I feel about my career. The problem is – they have no personhood. They don’t care how I feel.

I have not absolved my ex-partners of their complicity in what happened, but I also recognize that ignoring the systemic processes and blaming individuals risks repeating the past.

If you don’t know why you end up in abusive relationships, you are doomed to keep falling into them. Attempting to prevent myself from doing so, I have run head-on into my own smoldering anger at the Institutions of Medicine. Can I repair this, or does my relationship with Medicine have a expiration date?

can you even have a relationship with a machine?

The current iteration of medicine treats medical care as an assembly-line delivering medical procedures, treatments, medications and consultations. Can a physician actually have a relationship with this?

Healthy relationships have boundaries, reciprocity, and are based in genuine affection. Bureaucratic assembly lines don’t have any of those.

I think in the past, physicians owning their own practices and having more professional autonomy buttressed this imbalance. Indeed, working as a traveling doctor has allowed me to have full control over my schedule and clinical autonomy. Putting our relationship on ice for a couple of years seemed the only way to save it.

anatomy of a breakup

Medicine and I had a heady first few years. I spent the night at her house at least a few times per week. When she called in the middle of the night, I was always there to pick up. I spent more time with her than with my wife, and I put more time into my relationship with Medicine than any other.

I thought that if I put in the time now, I would be able to cash in after residency, get some relational reciprocity. I’d put in my effort, now Medicine would help take care of me for a while.

WRONG!

Every time I tried to pull back, Medicine tried to suck me in harder. Crises that were out of my control seemed constant. Medicine was jealous of my newfound interest in anything else.

I bailed, put some physical distance between us. I still go and visit her a few days a week on average, but I don’t pick up her calls anymore when I’m home. She doesn’t get to meet my friends or family. It is an uneasy relationship, but not broken yet.

can our relationship be saved?

The thing is, for a short period of time in residency, I actually did love Medicine. I was exhausted, but felt I was doing something worthwhile. Sometimes, in the middle of a shift on the High Plains, I still touch those feelings. I catch a glimpse of professional satisfaction and efficacy.

I want to love medicine, I really do. The problem is, machines don’t love you back. How do I forgive the machine for hurting me so deeply when it is not even aware? Can the bonds be repaired?

Or, am I the idiot for thinking of this whole thing in terms of a relationship? Machines don’t love, they cannot be in relationship. Is Medicine just a job, no longer a calling? Can it just be that? Will Medicine be comfortable with being just a job, or will it always strive to be the most important thing in my life?

Only time will tell. Maybe we’ll evolve together, find a new equilibrium. For now, the uneasy visiting routing continues. Perhaps, I’ll even get over my anger and learn how to love the one I’m with – eventually.

And if you can’t be with the one you love, honey
Love the one you’re with. – Stephen Stills, of Crosby, Stills, and Nash

It’s the High Lonesome for a Reason

The plain gives man new and novel sensations of elation, of vastness, of romance, of awe, and often nauseating loneliness. – Walter Prescott Webb, The Great Plains (1931)

By Leaflet – Own work, CC BY-SA 3.0, Source: Wikimedia Commons

Yet, America remains attached to the idea of Yeoman farmer and the rural bucolic existence. It lays deeply burrowed in our collective mythology. Many people who live in small town America are very proud of this association. Indeed, I have been to some places that seem to live this ideal every day. They are very rare.

rural america is no spring chicken

Firstly, Rural America is much older than America as a whole (interestingly, the places where this is not true are largely in areas where refugees and immigrants are moving in to work in industrial agriculture – but we won’t touch that lightning rod for now). Some of this age difference is due to youth moving to cities and larger towns for jobs.

However, I also increasingly hear narratives about people on fixed incomes – the disabled, the elderly, the rare retired military, government, or railroad worker who actually receives a pension moving to the small towns because of affordability.

This is especially noticeable in places not too far from larger towns/cities on the borders of the High Plains. So, young people are leaving and older people moving in – a demographic double whammy.

what kind of person retires to high plains?

It takes a special kind of soul to thrive on the High Plains. You have to love the sky and the wind and the sun. You also have to be pretty self-reliant. Self-Reliance is the central tenet of High Plains life, help is usually not close and may be unreachable.

Unfortunately, no amount of grit or curmudgeonliness will keep you healthy and independent forever, though it does seem to help. I have seen dozens of people who retired to a rural area and bought a small acreage in their fifties or early sixties when they were still quite healthy.

This seems to last a good 5-10 years. Property is a lot of work. Roads may be plowed by the county after a snowstorm, but your driveway won’t be. A half-mile snowed-in driveway is a glacier to a wheelchair. Moreover, 48-72 hours may pass before the county gets the road clear.

chronically ill in the middle of nowhere

One of my first patients in my real practice was Kathleen (obviously not her real name), an older woman who was supposedly in for a diabetes check up and establish care. We sat down to go over her A1C and her medications. A quick chart review revealed that she was undergoing treatment for Stage III-IV ovarian cancer, at 79.

Ovarian cancer that is this far along is not a curable disease. It is what the patient will die from (if the treatment doesn’t kill them first). Kathleen had already gone through surgery, chemotherapy, and radiation. She was struggling to keep her medicines straight.

Her oncologist had told her this cancer was incurable. Despite this, she still suffered through treatments thinking that a cure was possible. We had hours of conversation about goals of care, she still wanted treatment. It took me a while to understand this, seeing how much she was suffering.

caring for the seriously ill requires community

She lived on 2 acres on a gravel road, miles out of town. They could be snowed in for days at a time. She was too weak to cook for herself, she was losing weight. Then I met her husband, he had significant dementia.

SHE was the caregiver in the relationship. She felt she couldn’t leave her husband and his dementia made it impossible to reason with him. Children were in other states and not helpful. Elder protective services were involved – but to no avail.

She was in and out of the hospital and the ED. When you have no one to give you a ride and you are not doing well, the only option is the ambulance. An ambulance can only take you to ED. Discussions about nursing homes, hospice, assisted living went nowhere for over a year.

In the end, she had a chronic pneumothorax with an indwelling chest tube with a valve. She was constantly in pain and short of breath. Finally, one of my partners transferred her to a hospice house an hour away, almost against her will. She was simply too weak to fight.

This is an extreme example, but it is easy to imagine a bunch of hardheaded, tough people who are now on oxygen due to smoking, or with arthritis and limited mobility, or early dementia as yet unnoticed (no one has visited grandma in 6 months).

My experience doctoring over the last 2 years around rural America has left me feeling that the social isolation of rural America is literally killing people.

social isolation is a growing epidemic

The New York Times has written 2 articles on it within the last 2 years. Additionally, an increasing amount of psychological and health publications are delving into the risks of social isolation, and it is more acute in rural areas. These risks even include increased mortality. This risk can be up to a 50% increase.

As a traveling doctor, I often feel powerless in the face of these realities. I see people in the ED who are just destined to float back and forth between the hospital, nursing home, home (see hardheadedness above) and back until death or a permanent stay in the nursing home. And I often just feel myself helping keep the assembly-line moving, unable to help renew the sinewy bonds of community.

Loneliness, thy other name, thy one true synonym, is prairie. – William A. Quayle, The Prairie and the Sea (1905)

On quiet evenings, when I walk around the edges of the little High Plains hamlets where I work, I stare up at that fantastic sky and think about my own isolation. Watching the windmills turning wind to electricity on the ridgetops, I find the space to feel my loneliness.

By USFWS Mountain- Uploaded by Magnus Manske, Public Domain, https://commons.wikimedia.org/w/index.php?curid=21102582

The loneliest kind of loneliness is the that felt when surrounded by a sea of humanity. The High Plains welcome those feelings of isolation. The sky seems to open up and embrace the lonely. Some of my loneliness stems from the grief of losing my daughter, I know. However, I also feel the professional isolation.

physicians are not immune

As I have said before, there are times where I am the only doctor in an area the size of Rhode Island. I am almost never physically adjacent to others of my profession.

How does one stay connected to the community of healers without a home base? How do you discuss tough cases when you are the only one in the doctor’s lounge?

Increasingly, researchers are identifying feelings of isolation as playing a role in physician well-being and burnout. I know that the isolation I felt in my acute grief and how my partners reacted was worse that than anything I feel now. It is one thing to be lonely by physical distance, another when social and professional exclusion and competition isolate you.

I think that the rise of the physician blogging community is a reaction to these feelings of isolation that we have in our work space. Physicians are supposed to be social people, to connect with people. We need our community to thrive.

Self-reliance and rugged individualism appear to be contributing to significant suffering and premature death in rural America. Am I too at risk? I don’t know, but I am trying to do something about it, and hopefully it helps.

A Birthday without the Birthday Girl

Wandering the Desert for A Year

Death Valley Sand Dunes – Public Domain

The memories of a child lost so soon after birth are the definition of bittersweet. A birthday is supposedly important, a time to celebrate. Everyone else seems to think so. People have sent us birthday cards, notes, texts, things to let us know they are thinking about us. They are all very kind and sweet.

a day to remember

However, everyday for the last year has been a day of remembrance for my wife and I. For her especially, there is someone palpably missing in the ether. She feels it deeply, in a corporeal way.

In beginning, the world seemed a darker place. Colors had less shine and everything was off kilter. I notice those thing less nowadays. Yet, I still haven’t decided if that means that things are brightening, or I am just forgetting what the world was like before our daughter left?

the sun came up today, like it usually does.

In the end, today is just another day without her for my wife and I. The difference is that other people are thinking about her and her absence. They are letting us know they remember. Again, it is bittersweet.

The notes and cards and flowers are a helpful reminder that we are not alone in our grief. Grief brings a sense of emotional solitude, so it is nice to have that reminder of others.

On the other hand, the notes are also reminders that my wife and I share a solitude in our grief. We don’t get to take a day off. We can’t choose to get off the grief train for a while and rest. We are always there. And, as far as we can tell, we aren’t going anywhere.

life in the hessian crucible of grief

Grief is a crucible. The forces that it brings to bear on a person are immense. Yet, crucibles are amazing tools for reshaping things. Metals are melted, combined with strong reagents. In the end something, hopefully stronger, emerges at the end of reaction.

Chemical reactions can go poorly. Reagents in wrong amounts, too much heat, rapid changes in temperatures, etc. These can force the reaction to go terribly, terribly wrong. On the hand, the reaction can get stuck in a chemical purgatory. The reaction has transmuted the initial components, but not delivered the final product.

The same is true for grief, it defines us for a time. We must let melt into our identity, where it can combine with the pre-existing pieces of our being. However, we must be careful. If we hurry it, if we had too much pressure too soon, things can go very, very poorly. If we ignore it, if we do not tend it, we can become moored in a netherworld. There we may stay, beyond the reach of who we once were, but not delivered into we might have become.

to live a life in 3 weeks

Over the next three weeks, my wife and I will live through the entirety of our daughter’s life, one year removed. It seems a strange twist of fate that it is an entire life. Yet it is. On a long enough time-line, 3 weeks and 90 years are indistinguishable. They are equal in their measure – lifetimes.

And her presence was immense for someone who couldn’t even muster 5 pounds. As measured by the emails, the cards, and the dozens of people who travelled from around the country to meet her during her brief time on this plane, she was mighty.

So, my wife and I enter the bittersweet season of her life. Three weeks, forever marking October in our minds. We walk along in her shadow, remember the beauty and the loss. For you cannot have without the other. Grief is the shadow that beauty and love cast when they are lost. Yet, I would rather live in a world of shadows than one without light.

A Tale of Two Medicines

Bias in Medical Practice

If you have read some of my other posts, you know I have an interest in the culture of medicine. More specifically, how cultural biases in medical training and the culture of medical practice affect the care of patients. I think one of the starkest examples of this is the reaction to deaths from rofecoxib (Vioxx) and those from opiate pain medications.

tale one: rofecoxib

Rofecoxib is a non-steroidal anti-inflammatory drug (NSAID) pain medication. Ibuprofen and naproxen are common NSAIDs. At high, sustained doses they have a range of negative side effects – GI bleed, kidney damage, hypertension, heart disease, etc. Rofecoxib was biochemically more specific to inflammatory pain. Therefore, it was a new generation of NSAID with supposedly fewer side effects.

Rofecoxib was on the market from 1999-2004. The FDA pulled it from the market after discovering evidence that it increases rates of heart attack. Doctors prescribed it primarily to treat arthritis pain, which is more common in the elderly, who are also more likely to have heart disease. It turns out, a deadly combination.

Hand Arthritis – By Internet Archive Book Images, via Wikimedia Commons

“Dr. Graham and colleagues estimate that during the five years Vioxx (rofecoxib) was sold in the United States, it caused between 88,000 and 140,000 excess cases of serious heart disease. Based on national statistics of heart disease and deaths, the researchers estimate that close to half of those cases, or 44 per cent, would have resulted in fatalities. This means anywhere from 39,000 to 61,000 deaths in the United States could be linked to Vioxx.” – Daily Globe and Mail

tale two: opiates

Opiates are a class of pain medications originally derived the opium poppy. The category now also includes a number of synthetically created compounds designed to act on the same biochemically receptor. These include oxycodone, hydrocodone, fentanyl, heroin, tramadol, etc. I am sure the current opiate epidemic is not news. People are dying at an unprecedented rate from opiate overdose.

Like NSAIDs, opiates have a wide range of known side effects. These range from constipation and urinary retention to addiction, respiratory depression, and death. Let me clarify here: addiction and death from respiratory depression have been known complications from opiate use for over a 100 years.

In fact, roughly 21 to 29 percent of patients prescribed opioids for chronic pain misuse them and between 8 and 12 percent develop an opioid use disorder (addiction). This is NOT new data coming out in research papers.

In 2017, 63,617 people died from drug overdoses. At least two thirds of those were linked to opiates. Almost as many people who died from rofecoxib over FIVE years died in ONE year from opiates. Many will say that most of those are from illegal use of the substances, which is true.

However, in 2008-2009, a study showed that 86% of injection drug users started with prescription opiates. That means that conservatively, around 36,491 of those deaths can be traced back to prescriptions given by a physician or healthcare provider. We don’t even have good data on how many people are currently struggling with addiction (the corollary to heart attack in this comparison).

To reiterate, addiction to opiates has been a KNOWN side effect of treatment for over 100 years.

Rofecoxib and Opiates Kill People

Merck eventually settled its Vioxx (rofecoxib) liability for billions. Many states are suing Pharma Companies for misleading consumers and doctors about the safety profile of their drugs. Yet, doctors didn’t know about the heart disease risk when prescribing reofecoxib. However, doctors did know addiction and death were side effects of opiates at the time opiate treatment was increasing. Nonetheless, we kept on prescribing them.

Again: rofecoxib is a pain medicine killed up to 61,000 people over a 5 year period from heart attacks. Opiate pain medicines have killed many times that over a 5 year period and almost as many in 2017 ALONE. Rofecoxib was rapidly removed from the market to protect patients. Yet, ALL of the opiate pain drugs remain on the market. What explains this difference in reaction?

to americans, addiction is a vice, not a disease

The main difference in these two situations is our societal wide lack of compassion for people struggling with addiction. Don’t get me wrong, people in the throws of addiction are often very unpleasant people to care for.

Then again, many schizophrenics in the throws of their disease are very unpleasant to care for. However, we don’t blame their disease on their character. We recognize that they are sick and need treatment.

I can’t count how many times patient’s have said to me, “Well, those people aren’t using the medicine correctly,” when I am describing the risks of addiction and death. The implication is that I could never be one of those people because I have a stronger character, am more educated, am God-fearing, etc.

Guess what, people? Addiction can and does happen to anyone. You are not immune. Just like heart disease, some people are at higher risk (those with histories of sexual abuse, PTSD, depression, anxiety, etc). No one is immune.

addiction is a terrible disease

Moreover, I have cared for people with heart attacks and people with addiction. Heart attacks are scary. They can be personally devastating. Whenever someone dies, it is very, very sad.

However, heart attacks do not leave entire families broken and scattered. Babies, addicted to opiates from birth, are not struggling through withdrawals in NICUs around the country because of heart disease . Whole communities are not in a constant state of grief because of heart disease.

Yet, people with heart disease are treated as sick people and people with addiction are treated as bad people. This continues to happen everyday in this country.

when you find yourself at the bottom of a hole, the first thing to do is stop digging

It is time we stop digging. I am not proposing we ban the use of all opiates. Yet, as long as we are unaware of our biases toward the risks of addiction and treatment with opiates, we will be doomed to repeat the cycle.

An Introduction to Critical Access Hospital Doctoring Part 2

Doctoring on the High Lonesome

Hopefully, you read Part 1 of this series, or at least skimmed it (rural health policy isn’t for everyone) for some background. In this post, I will dig into why critical access doctoring is different.

rural family medicine vs critical access medicine

What is the difference between “critical access medicine” and “rural family medicine?” Traditionally, rural family medicine practice was the “does it all” local doctor. The doctor who saw patients in his/her own practice, admitted them to the hospital, took ED call, delivered babies, etc.

I currently don’t have a practice and am not a reliable presence in the communities in which I work. I have no longitudinal relationship with patients. As such, I don’t really feel like I am doing “rural family medicine” in my current arrangement.

The bulk of what I do now is low acuity emergency medicine. Larger EDs label this kind of care “Fastrack.” However, I also have the occasional heart attack, stroke, sepsis, and trauma thrown in for sphincter training. In certain locations, I see the occasional primary care patient or urgent care patient in clinic. I also take care of low acuity acute inpatients. On top of all that, there is the bag of worms known as “swing bed” in Critical Access Hospitals (CAH).

The biggest difference between critical access doctoring and being an urgent care doctor, hospitalist, primary care doctor, or emergency room doctor is that I am often juggling all of these responsibilities at once. This demands a kind of mental flexibility and strategic thinking different from what I have experienced in more specialized settings. Moreover, you are almost always doing something at the limits of your comfort zone. You can call for advice (but rarely backup). At times, I am the only doctor in an area the size of Rhode Island.

swing bed programs

Swing bed programs are designed to allow CAHs to “swing” some of their unused beds into post-acute care skilled nursing facility (SNF) beds. CAHs most often use these for post-stroke, acute illness, or surgical rehabilitation services. These services include: physical therapy, occupational therapy, speech therapy. Occasionally, patients who require long term treatments such as IV antibiotics are swing bed patients.

The purpose of these programs is to allow CAHs another revenue stream to help them maintain their critical access mission. The reimbursement for this is again “cost based.” No hospital will be able to make a profit with swing bed services. However, they can get a lot of the costs covered that a hospital incurs from having nurses, techs, doctors on call or on the payroll just to have a basic level of service.

why can’t people just stay in the hospital?

Normally, swing bed patients are fairly easy to care for. The acute care hospital (ACH) addressed their acute issues and it should be fairly simple from that point on. In fact, the doctor only has to see them every 7 days, because they are not supposed to need acute care. However, it is not rare for the transferring acute care hospital to present the situation in the rosiest light possible.

These patients are often chronically ill and debilitated and on government insurance such as Medicaid and Medicare. These plans pay based on DRGs (diagnosis related groups). Meaning, for a given diagnosis, CMS pays an amount based on the average cost of providing care for the diagnosis.

So, once the ACH has dealt with their acute diagnoses, these patients are costing them money. Especially if they are short of staffed-beds and having to turn away other acute care patients. They want them gone.

swing bed can be a solution

In the past, these patients might just be sent home or out onto the street by some of the more profit-hungry hospital systems. If they came back, no worry, CMS paid them for the second hospitalization as well. Now, hospitals are getting penalized for 30-day readmissions.

Due to these new punishments, acute care hospitals want to get patients out of their hospital, but to somewhere from which they are unlikely to bounce-back – SNFs(skilled nursing facilities), LTACs (long term acute care), LTCFs (nursing homes, assisted living, etc). Basically, swing bed programs allow CAHs to function both as an acute care hospital and as a SNF.

This financial pressure on acute care hospitals means that sometimes the transferring hospital buffs the chart to make the patient seem less sick than they are. It definitely happens where a patient arrived at the CAH, spent 1-2 nights, and quickly return to the ACH because of their illness acuity.

trials and tribulations of a swing bed patient

Specifically, I can think of a patient who had back surgery, was in the surgical hospital for 3 nights, then sent home. She presented to our ED with worsening pain and inability to care for herself at home. Due to her first hospitalization, she qualified for swing bed. I admitted her to swing bed as there was no obvious acute diagnosis at the time.

Her pain worsened, she developed a fever, which in the end turned out to be secondary to a wound infection. She returned to the acute care hospital for a washout and antibiotic treatment. She was sent back to our facility for IV antibiotics and physical therapy. 3 days later, her wound was gushing with fluid again. Back she went to the acute care hospital for another washout and treatment, after which the acute care hospital transferred her to an LTAC.

critical access doctoring

I spent a disproportionate amount of time on swing bed care because it is a type of medical care that really only exists in CAHs. It is definitely NOT what I spent the majority of my time doing, but it is something that I had never encountered before working in a CAH. It took me a while to wrap my head around it. I have even hospitals that utilize swing beds often poorly understand it. I hope that the discussion was useful for anyone who is trying to figure it out.

Finally, I hope this paints a basic picture of critical access medicine. At its foundation, it is a commitment to meeting patients where they are, in a literal and geographic sense. The challenge is that there is almost no routine and you are frequently reinventing the wheel. This necessitates lower volumes as you have to think things over more carefully and can’t rely on muscle memory and reflex. If you can handle those constraints, the benefits are more time with patients and more variety than almost any other practice environment.

An Introduction to Critical Access Hospital Doctoring – Part 1

Critical Access Hospitals (CAH)

I thought I would take some time to introduce the concept of the Critical Access Hospital and the kind of doctoring that is done in these facilities. Likely, relatively few of you are familiar with them.

how do you define rural?

The relative obscurity of the CAH is natural, only about 19% of US population lives in rural areas. Even fewer, about 3%, live in counties designated as “frontier.” WTF does “frontier” mean, you ask? I am glad you did, because it is one of my favorite little arcane facts about rural life.

In 1890, the US Census Bureau determined that the American Frontier had reached a population of about 6 people/square mile. This, they decided, was a dense enough population to declare the frontier closed. As noted above, 3% of the US population still lives in counties with a population density <6 people/square mile. Thus is born the designation of frontier county, which is used in rural policy circles to denote a qualitative difference in the kind of rural life that exists in these places.

okay, but what is a cah?

CAH is a designation that can be earned from the Centers for Medicare and Medicaid Services(CMS). It is primarily based on distance from other services(generally 35 miles from the next closest hospital) and a few other a criteria, such as 25 or fewer beds, 24/7 emergency services, <96 hour average length of stay for acute care inpatients.

These facilities can range from having general and orthopedic surgery, internal medicine hospital, dedicated ED doctors and obstetricians to facilities that effectively have a clinic, and small 2 bed emergency department, and a few inpatient beds. I tend to practice in the latter group.

Why would a facility want this designation?

Medicare cost-based reimbursement. What does that mean? For any inpatient treatments provided to medicare patients, medicare will reimburse critical access hospital 101% of the cost of providing those services. This often includes costs associated with maintaining a hospital that often has empty beds. It helps keep these low volume facilities, which are often located in poor areas, afloat so that they can maintain “critical access” to healthcare in rural areas.

why pay to keep these facilities open?

There is a moral argument that access to healthcare is important. I tend to agree with that argument, but that isn’t really the reason why we continue support these facilities. The real reason is that rural areas have a disproportionate say in national politics.

Let’s take the Senate for example. There are currently 270,202 registered voters in Wyoming, that’s right, in the entire state. In California, that number is 18,980,481, but California still only gets TWO senators. So, if I were a registered voter who voted in the last election and lived in WY, every time a senator voted in the Senate, 0.0000037 of that vote could be attributed to me. A Californian on the other hand, can only be attributed 0.00000005 of his senator’s vote. That is 74 times more representative power in the Senate for an active voter in Wyoming compared to California. The difference is less in the House, but still significant.

Let me be clear, I am not saying that I am opposed to these programs or that I oppose money being directed to rural areas for healthcare, education, or other social programs – my income currently depends on it, as a matter of fact. I think these are interesting facts and realities about the macroeconomic forces at play in rural healthcare that are worth knowing.

But what about the doctoring?

In Part 2 of this series, I will discuss the actual doctoring that goes on in these facilities and what it is like to practice in these facilities.