Are student loans being exploited to limit physicians’ practice choices?

We are in the thick of the job hunt, and it seems like every time I feel like we are inching closer to having a couple of jobs locked down, some new variable comes up. We’ve interviewed at small private practice groups, large private practice groups, academic and “priva-demic” groups located in the southeast and midwest.  The more I learn about these different job configurations, the more I realize I don’t know. However, along the way we have discovered a few morsels of information, and I’ve been struck by some aspects of the evolving healthcare climate that I wanted to share.

First, there is a noticeable migration of surgical practices toward hospital-employed rather than private practice. In my limited sampling on the interview trail, the practices have either just become hospital-employed, or are doggedly fighting to resist the gravitational pull of becoming hospital employed (and discussing this situation openly). Coming from my academic institution, at first this did not strike me as noteworthy, and I felt like the physician-employed model was essentially more convenient and equitable.

I was pretty close-minded regarded going into private practice, and definitely didn’t  consider full-time locums as a viable option until I started listening to Nii Darko’s podcast Docs Outside the Box. I’m sure it was somewhere in the dozen episodes I’ve listened to where I first heard the phrase, “No one will pay you more than you will pay yourself.” Such a simple statement, but it got me thinking about this situation with physicians voluntarily giving up control of their practices, and to a large extent, their paychecks. My experience matches the published statistics on the AMA website that as of 2016, less then half of physicians own their own practices, and the statistics are more dramatic for younger physicians, with 59% of physicians under 40-years being employed.

The second issue that has come up more and more frequently is that of the federal program for Public Service Loan Forgiveness. I first heard of this program in med school, roughly ten years ago, and at the time it was described as a program that may or may not ever come to fruition but has the potential to wipe out your loans after ten years. I was quite skeptical at the description, and honestly I assumed that it would never work out. I kept my loans on the standard repayment plan, even though it was a bit difficult at times to keep paying them on that schedule through residency. Then I refinanced near the end of residency (I should have done this sooner) with SoFi. However, I have many friends and colleagues who bought into the program, made the minimum payments to stay eligible (opting for the income-driven repayment plan), and consequently ran up piles of interest, graduating with larger balances than they entered residency with. THEN, they are limited in choice of employer to these “not for profit” entities, and now are facing the frightening possibility that they still won’t ever see the loans forgiven. (Note: I don’t mean to incite panic or add to any melodrama. The White Coat Investor has some good advice for anyone worried about this issue). Whether or not this program was written with the intention of limiting physicians’ practice options in order to encourage the employed model is questionable, but it has certainly had this effect. (Here’s link to .gov site for direct info).

Taking into account the principle that “No one will pay you more than you will pay yourself,” these physicians have:  #1. Taken out massive amounts of loans, #2. Had interest payments balloon through residency thanks to income-driven repayment plans that don’t touch the principle, #3 signed up for jobs that will likely pay less and prevent them from taking control over their practices. This situation seems like an ideal formula to take a tremendous amount of power and earning potential away from physicians and transfer it to administrators.

Now, I’m personally not against taking an employed position. As a trauma + critical care surgeon, I think this is probably a much more common scenario for my field considering many tasks we are responsible for are non-RVU based and located in larger hospital trauma centers. Nevertheless, I’ve been amazed at how many neurosurgery practices have been bought by hospital systems, and the main reason cited is complexities of billing.

At the risk of sounding glib, I’d like to point out that this same evolution happened in the record industry, did it not? We ended up with a bunch of simple, formulaic, boring bands and cheesy music genres. Same thing happened with beer; remember before craft brewing was a thing and all that was on the shelves was weak, smelly water with clever ad campaigns?  Fortunately, these two industries, among many others, have benefited from an awakening of independent artists and craftsman, and there is now a flourishing variety of creative music and micro-brews for us to enjoy. Maybe the same thing can happen with healthcare, but that there are much stronger influencers including lobbyists, politicians, and that infamous army-of-middle-men standing in the way. However, if it’s best for patients and best for physicians, we can keep the indie spirit alive in healthcare as well. The Frugal Physician has just written an excellent post about this very idea, expanding on the idea that in order to take back control of medical practices we have to control the finances, starting with our personal finances (i.e. student loans).

This idea of finances being the key to engineering the practices, and lives, that we want has been coming up again and again lately. Personally, we have little choice but to pay off our debts and achieve some measure of financial independence if we really want to pursue careers in humanitarian medicine. But for those outside of this field, ignoring finances has the analogous consequence of limiting the type of practice, and ultimately life, that one can have. It’s likely no coincidence that these changes are correlating with the burnout epidemic. I’m not the expert, and I don’t have the answers. I’m merely the naive young doctor observing and asking the question: Is it too late for physicians to take their practices back? Who is really benefiting by keeping us out of practice ownership?

Guest Post: A Day-in-the-Life of a Surgeon Mom

I am pleased to share this post detailing a day in Dr. Jessica Schnur’s life. She is a general surgeon with a subspecialty in minimally invasive surgery at Stony Brook University Hospital. Despite her humor and talent for writing, I’m sure it will be quite apparent that her job and career require astounding commitment and sacrifice. While I have heard it said that the average person underestimates his/her free time, this statement couldn’t be further from the truth for dedicated physicians like Dr. Schnur. We are all searching for the balance that will allow us to do the jobs we love and use our talents to help our patients while loving our families the best way we can.

The last 6 weeks for me has been complete madness, between work and family I feel I have barely been able to stay afloat. I wrote this as a compilation of the combination of things that happen simultaneously every day. The amount of emotional and intellectual energy one must dedicate to taking care of your patients, your family and your friends is at times exhausting. We all became physicians because we want to help people, but the risk of burnout is real and while I have read many articles advocating for remedies to it I have yet to see anything significant be done about it. Dr. Jessica Schnur

My alarm goes off, it’s 4:40am. I flail around trying to turn it off so I don’t wake up my husband. Find it! I close my eyes for a second and pass out instantly, open my eyes to find that 15 precious minutes have passed. I debate whether I have enough time to exercise and still leave for work on time. I have an hour and 15 minutes. I can do it. It’s never happened before, but today it’s going to. I go downstairs, take my coffee and sit on the couch in the dark to enjoy my few minutes of peace for the day. My mind wanders until my phone goes off. Ping ping! I look over, my junior colleague was on call last night, he is letting me know there are a few new patients for today, two gallbladders. Maybe three.  Also a patient with a decubitus ulcer.  He is leaving town now for a “conference,” would I mind taking care of all that? Of course, I write, my freakin pleasure. I start to feel some unrest in my bowels, a combination of the rocket-fuel grade coffee I made and rage against my lazy co-worker. It’s been ten minutes and I need to get ready to work out. I go back into the kitchen to wash the dishes from dinner last night. I didn’t cook, so I do the dishes. Can I do this in 30 seconds? 100% More unrest from my bowels, I abandon my dishwashing and run to the bathroom. I finally get my workout in, inhale breakfast and jump in the shower. When I get out I see I have 11 minutes before I have to leave the house. Plenty of time. I look in the mirror at the pale bloated face looking back at me, pimples and wrinkles that need covering, significantly greying hair that needs to be blow-dried so I don’t look like Albert Einstein. Various creams, concealers, highlighters, blush… check the clock again. One minute left. Mascara flies on, blow dry my hair for 60 seconds, good enough. Compression stockings, scrubs, find a sweatshirt that doesn’t have too much dog drool and marker on it. Ready to go! Should have left the house 15 minutes ago but what else is new.

I arrive at work, tires squealing in the parking lot like I’m running from the cops. My phone rings, it’s my chief resident.  We have an intraoperative consult from GYN, they have run into some difficult adhesions and are requesting help, can I meet her there?  Ummmm, I’m not even in the building yet but sure.  Run up to my office and try to find somewhere to throw my stuff. It looks like a tornado hit, papers everywhere, dirty scrubs in piles on the chairs, multiple empty water bottles. I sort through the madness and am about to head down to the Operating Room when I realize I am wearing slippers. This is disappointing, but there is nothing to be done.

About an hour later we are finishing up the first case and my phone starts going off again. Ping Ping! Ping! Ping Ping Ping! It’s my husband, my little one peed all over her bed. He’s annoyed. The text message is multiple screens long and involves some talk about how we are going to sleep train her. After a few paragraphs, “Where are you?” I write back a frowny face. I have to round, still have four cases to do. I come out of the OR and find my intern and PA to start rounding. My intern is pale, sweating, looks like he might be in heart failure. I try to console him, it’s ok buddy, we will get through this day. He actually might not, but we must move on.

We go see a patient I operated on a few days ago, “Hello, sir! How are you feeling?” He’s a very nice elderly man, looks like he’s doing well. “I want to eat!” Fantastic! “That’s great! You can eat!” He looks thrilled, asks me if I can tell his doctor he can eat. I debate whether to point out to him that I am his doctor, decide to go for it. This may have been a mistake, he stares at me wide eyed, speechless. Was it the slippers? It is best to leave at this point. “See you later!” I say cheerily.

I battle my way through the rest of rounds, some more consults and admissions, a few cases. I get my phone to dictate my last case and there are multiple missed text messages and a missed call from my daughter’s school. I panic momentarily about the school phone call but it is just a robot announcement. We have told the school as well as any other place our children or dog goes to call my husband with issues because he stays at home but they still call me. Every. Single. Time. The texts are from two of my friends and my husband again. One friend wants to know if we can get together for a playdate tomorrow afternoon at 3, which is Friday. I say I will ask my husband if he can bring the kids over and then lose the motivation to relay this information to him. The next is from another friend who is seeing the latest greatest nutritionist among the other moms who magically helps you become thin and fit and full of energy. He had sent off a panel of blood work and told her she may have a gallbladder issue. She sends me three pages of lab results and asks me what I think. I think I really can’t look at this right now. Finally my husband. He is unhappy with the light fixture in our younger daughter’s room, it is apparently flickering, which may or may not be true. He is debating on how to rewire the fixture and switch to fix this. He is not an electrician and refuses to call one. I only ask that he not burn the house down while the kids are home.

At some point I realize I’m starving. It’s 5pm and I forgot to eat lunch. Or drink water. I don’t think I’ve peed since I left the house this morning. I go to the recovery room to get some water and graham crackers, but there are no cups. Or crackers. I ask one of the staff for a cup, he points out the cups really are supposed to be for the patients, reluctantly shows me where they are hidden. I apologize profusely for being a human being and take my water.

One more consult to see. Ping Ping! Husband again, apparently my younger daughter is “very angry” at me because she misses me and wants to know when I’m coming home. I’m on till 6, but things are looking good. Just one more patient to see, I tell him. We go to the ED to see a middle aged man that was suspected of having a bowel obstruction. He is there with his wife and mother, all look extremely concerned. He has been constipated for a week, very bloated. I listen intently to the tale of his failed attempts to poop this week. We look at his labs, imaging, he has no bowel obstruction, he is simply constipated. We recommend some laxatives and stool softeners, fiber, etc but his family catches us as we are leaving and wants to talk more about constipation. It is now well after 6. I have received a video from my husband of my four year old angrily telling me I have to come home and she is very mad. I extract myself from the ED and head back to my office to gather my things to leave.

I get home around 7:30, dinner has been had, my husband tells me he gave the kids a bath, but they washed themselves. He is proud of them. I’m concerned about their hygiene but too tired to look into it. He tells me to eat dinner quickly before we put the kids to bed but at this point my priority is the glass of wine that I am going to pound before story time. Teeth get brushed, stories read, I lie down next to my 4 year old to rub her head while she goes to sleep and pass out before she does. I wake up because she is kicking me in the face. I get up and look at my watch, 12:30 am. I crawl into my own bed and prepare for another day of complete insanity.

Designing our “Best Life” with help from Montana Money Adventures Mentoring Questions

One of the biggest “Aha!” moments for me came from finding Jillian from Montana Money Adventures, initially while listening to her podcast on ChooseFI and then reading her article “Big Family Minimalism,” on Cait Flander’s website. I signed up for her email list in order to gain access to her awesome Resource Library, which contains mentoring questions and “Let’s Chat Worksheets.” These are pages of guided discussion and questions that can really challenge us to address what our true goals and passions are, instead of simply following the path of least resistance and hoping we end up somewhere decent.

This idea of intentionally designing the life I want started during my 3rd year of training when I realized that I wasn’t doing ANY of the stuff I enjoyed and was suffering from severe burnout as a result. After a few years of pondering these topics on my own, I was ecstatic to find Jillian’s excellent guidance. Answering these questions is HARD! Josh and I have been working through them together, and we can only do a few questions at a time before we are a little worn out mentally, and it takes us a few days to complete a worksheet. Nevertheless, going through the worksheets together has been a wonderful exercise for our relationship; it has gotten us communicating about these ambitious big goals and deeper motivations, and it has definitely helped us understand one another better. We will often be mulling over the same question and, lo and behold, come up with the same answers. It’s also amazing to hear him come up with a totally different answer than mine, as I then have something entirely new to consider. I definitely recommend these resources to any individual or couple who is interested in mindfully constructing their lives and purposely cultivating relationships, careers, possessions, time-management skills, etc.

I contacted Jillian by email to ask her permission to post the worksheets completed with our answers, and she graciously agreed. If you find value in these posts, please head over to her website  and sign up for her email list, so that you can have access to her entire resource library. She never sends emails that aren’t very insightful and beneficial.

We decided to start our mentoring questions with the worksheet titled, “Highlight Reel.” The following is our completed worksheet…
What were the most significant moments from the last year?

Joy graduating general surgery residency.

Esmé being born.

Starting our website and podcast.

Starting research year.

Joy taking time to spend with the girls, having a real maternity leave with this one.

Finding FI information

Interviewing for jobs together.

What are our best memories from the last 10 years?

Eddy being born.

Esme being born.

Trip to Big Sur.

Matching at Mayo.

Music festivals together.

10 year anniversary

Choosing our sub-specialties—being liberated from pressure of doing cardiac/peds neurosurgery

Family vacation to smoky mountains

Family get-togethers in Nashville

Watching Archer on maternity leave with Eddy (seriously one of the most fun memories I have. We watched two episodes every night and laughed our heads off).

Camping trips

Duluth trip

Joy-trip to Ukraine and Guatemala

Joy-trip to ACS 2017 meeting global surgery sessions

What do we wish we would have done in the last 10 years?

Travel more for global health projects

Gotten an MPH or MBA during residency

Been more active in global surgery world instead of putting it on hold for training

Gone on more family vacations

Decided to do trauma earlier, let cardiac go earlier, not let myself become burned out

More date nights

What are our most significant achievements? What are we most proud of?

Beautiful girls. Toddler who is very sweet, affectionate, and confident.

Breastfeeding for 2.5 years.

Strong marriage through all of education and training challenges and parenting. Staying best friends and supporting one another.

Couples matching at Mayo.

Both of us succeeding through specialty training.

Living below our means during training despite needing SO MUCH childcare.

What would be amazing to see happen in the NEXT five or ten years?

Significant involvement in high-impact global surgery projects focused on alleviating suffering.

Network of folks working toward the same goal.

Girls traveling with us frequently and understanding our mission.

Spending down time near our extended families (hopefully moving closer to home)

Financial independence with funds for early mini-retirement.

Indie Docs having regular post and reaching anyone who might find it helpful (easily visible).

Financial highlights:

What are a few money goals we would love to hit? In five years? Ten years? Twenty years?

5-years: Debts paid, Financial independence with enough $$ for mini-retirement, couple of investment properties to maintain income while overseas, kids college funds fully-funded.

10-years: Enough money to give away generously to projects we believe in, passive income to sustain personal finances and giving and Indie Docs ventures.

20-years: Solidly funded full-retirement accounts, high-impact projects that are self-sustaining and more projects that we are investing in.

Do we have a net-worth goal?

Sorta. Arbitrary “fat-FIRE goal” of $3-3.5 million. Highly subject to change.

Passive income goal?

$3000/month or enough to just tread water when we are out of the country or not working (don’t really know about this number specifically )

Is our goal to pay off our home?

Yes

Certain amount or percentage donated or in a donor-advised fun?

Would like to eventually be able to donate all income.

Certain size inheritance to pass on?

Enough to fund kids retirement so they are able to pursue whatever career they are most passionate about.

Lifestyle Highlights

Any health/physical highlights that seem exciting to you?

Staying healthy and energetic, being able to do certain body weight exercises like pull-ups and pistol squats, and increasing flexibility to stay injury-free (for Joy).

General fitness, daily exercise would be a win (for Josh). 

Any relationship highlights you want to add?

We want to be more intentional about doing fun and exciting things together, being more affectionate, having deeper conversations.

Get to work together on passion projects.

Travel goals?

Definitely want to be traveling regularly to sites of our global surgery projects.

Also would like some fun adventure travel to unplug and recharge.

Work highlights you would love to hit? Certain position/rank/awards/contribution?

Become confident and experienced surgeons.

Don’t care about rank or position.

Would like our practices to be impactful for local community.

If I’m running a private practice, would like to be maximizing impact and using smart financial strategies and tax strategies to run the business successfully.

It would be a huge bonus to be able to get back into academic medicine within the sphere of global health so we can be 100% into global neurosurgery and global trauma surgery AND teach residents AND publish high-impact projects that lead to real progress in these areas.

What would a highlight in your schedule be? In 10 years, about what would you like to be able to look back and say, “We always made time for…”

Time for family and each other. Want to have time to indulge in play activities in the evenings, take our time with meals and housework without feeling like we are rushing through the daily routine. Time to travel. Time for birthdays and special occasions with cousins.

Are there any highlights you want to create from your hobbies?

Start white-water kayaking and more “glamping” adventures in the mountains, time outdoors. 

Impact Highlights?

What kind of impact do we want to leave in the world?

Alleviate suffering for a lot of people permanently, sustainably.

Create some new trauma systems where there aren’t any currently.

Improve the resilience of current trauma systems in settings of disasters.

Happy and generous, empathetic kids and grandkids

Create some training programs for neurosurgery, trauma and general surgery.

How would we finish these sentences?

The world is better because I…

Used my training to impact communities.

Paid attention to what people need.

Used my income to help people.

Told the stories of hard-working humanitarians.

Tried to help.

People around me are better because I …

Worked on my weaknesses.

Tried to become kinder, more thoughtful, and generous.

Don’t allow myself to become over-extended and grouchy, not exist in “survival mode” which makes us just try to make it through the day and through interactions with others. Make sure each interaction is dealt with thoughtfully and mindfully paying attention to that person. Treat people as people and not a task on the list.

When my time on this earth is done, how do I want each of these people to describe my contribution: Spouse, kids, extended family, coworkers, community members, customers, friends?

This section is pretty personal and unique for each individual, so I just left this set of questions here for you to ponder on your own. 

For Conversation:

What’s your “most important” and what is “the rest”?

(Joy) My most important is having a happy marriage, making sure Josh feels loved and cherished, loving my two girls and keeping them safe and healthy, and having a career that feels like a calling. For me, “the rest” is academic prestige, stuff like cars and a fancy house, yuppy vacations.

(Josh) Most important: Caring for the poor. If I get to the end of my life and haven’t done that, I’ll think I haven’t done the thing that was really important.

What kinds of things do you want on your highlight reel?

Joyful and hard work that made a lot of people’s lives better. Generous giving of our time, money, and energy.

By creating more financial freedom, what would that make possible?

The main thing that having financial freedom would make possible would be control over our schedule so that we can travel and work overseas. We would also be able to choose any job or assignment that was a good fit for us, and we would be able to give generously to causes that we were passionate about.

What a neurosurgeon can learn from a beer brewer: The dangers of playing it safe.

It’s odd the places you find concepts that bring your life and goals into focus.  I never thought the founder of Sam Adams —Jim Koch—a guy whose name I didn’t even know, would say something that changed my perception of what’s at stake in choosing a career path (full disclosure: I am biased against Sam Adams because I don’t like their beer much, and if there’s one thing I have impeccable taste in, it’s beer). I came across the story as told by Jim Koch in the podcast, How I Built This with Guy Raz. 

Jim tells the story of how he finished business and law school and got a great job at a firm called Boston Consulting Group (BCG). The pay was high and he flew first class to important meetings with important people, but he came to the realization that he did not want to do the job the rest of his life, and if he didn’t want to do it the rest of his life, then why do it tomorrow? So he quit that job and decided to…brew beer?!

His reason for leaving that great job is fascinating, he says:

I left it because staying there was very risky. Leaving it was not risky. And it’s the difference in life between things that are scary and things that are dangerous. And there are plenty of things that are scary but aren’t dangerous, and there are things that are dangerous, but not scary. And those are the things that get you.

He goes on to give an analogy in climbing. Rappelling down a rock wall is scary because you are jumping down a huge cliff, but it’s not dangerous because you are held by strong ropes and a harness. On the other hand, walking down the side of a mountain on a sunny day with blue skies around you is dangerous, but not scary. It’s prime weather for an avalanche that could easily kill you, but the beauty of the day lulls you into a sense of security. He elucidates further about his great job:

Staying at BCG, was dangerous but not scary, and the danger there, the risk of it, was continuing to do something that didn’t make me happy, and getting to, you know, 65 and looking back and going, “Oh my God, I wasted my life.” That is risk. That is danger.

As I look for a job after residency, I think a lot about this idea, that there are things that are perilous, but do not raise alarm. The job choice all residents face out of residency is private vs academic. I won’t go into the differences, as I’m sure most of you reading this know,  but I’ve always leaned academic.

I have been fortunate to train at a great neurosurgery program with wonderful mentors who have excelled in academia and are master surgeons. The thing about mentors is they make you want to follow in their footsteps, to do what they did because they are inspiring people. I like the academic side of medicine. But it’s a regimented path that requires discipline, dedication, and persistence to be successful. It doesn’t leave a lot of room for other pursuits. 

I don’t have any illusions that if I decided to pursue academic neurosurgery I would eventually be the chair of a renowned department or the president of one of the neurosurgical societies. Heck, right now, I’ve applied to more than a couple of academic positions and I can’t even get an interview. But academic neurosurgery is a clear path to pursue with well-defined goals and milestones. It doesn’t seem scary at all to me.

Pursuing a career in global health, on the other hand, seems quite the opposite. I worry about how Joy and I will raise our daughters in a different country (how will they be educated? what risks will they be exposed to?), how will our finances work out (where will our funding come from? our retirement?), what if we fail (what will job prospects look like then?), and many, many other things from dying from some strange virus to not having access to good beer (it’s the little things after all). 

But when I sit in the quiet moments, late at night when I am honest with myself, it’s taking the defined path, the one that doesn’t FEEL risky, that I am terrified of looking back on and saying “Oh my God, I wasted my life.” 

Trying to think about my life from the perspective of my 65 year old self is an insightful exercise. I imagine myself at the end of a career at a major academic neurosurgery program, I’ve mentored a lot of young surgeons, done interesting cases, I spend my day mostly doing the surgeries I like, and writing the papers I want to write, etc. When I think about that, I still find this nagging part of me that feels, well, unfulfilled. I don’t mean to disparage people who do this; I have benefitted immensely from people who found this was the right path for them. I also acknowledge that there are inspiring people in academics who have successfully pursued global neurosurgery projects (Dr. Haglund at Duke comes first to mind), but something in me just seems to say it’s not the right path for me. I also worry I could be diverted or distracted or not be able to devote enough time to my main goal.

When I think about dedicating my career to trying to improve neurosurgical care and education, as well as learning how people are already providing this care around the globe in resource-strapped settings, I get excited with the kind of feeling you get when you are clicking up the first hill of a roll-a-coaster held down by a harness. It feels scary, but people are there doing it with you and others have done it before you. When my 65-year-old-self thinks about looking back on that life, he has a deep satisfaction and peace.

I can’t say completely why dedicating a career to improving care in resource-limited settings has become my version of a life well-lived. I think it’s partly because I was raised in a Christian home, and the aspect of that upbringing that rang truest to me was that a life well-lived is one in which you gave up some comfort of your own to provide comfort for others less fortunate than you. That principle has stuck with me when a lot of other parts have faded.  And I’ve come to realize I’m not really choosing a career between private practice and academics; I’m choosing between the defined and undefined, the well-trodden path versus my own unique one. 

When it comes down to it, the things I worry about in working in global health are mainly logistical, not dangerous. Lots of missionaries have raised and educated kids across the globe. There are ways around the financial concerns. Strange viruses could pop up anywhere. And I can always home-brew. But the chance to pursue a career that you feel lines up with a truth you intrinsically and inexplicably hold regarding what gives your life purpose and meaning, you only have one lifetime to make that happen. The more I think about that, passing on it, or pursuing it only half-way, is the real danger. 

~ Josh

What are we waiting for? Holding-back vs. casting-off into the global surgery world

We are overdue for a “state-of-the-union” post. Part of the reason is because I started this blog in a big state-of-transition; I was at the end of residency and then at the end of pregnancy, so any post about where we are would have been instantly obsolete.

I can do a brief recap of the past 6 months or so (a more full audio version of a lot of this is in our first podcast episode).  I had just decided to take a research position here in Rochester so that I could take maternity leave and care for the girls during Josh’s chief year (sans au pair), and Josh and I were starting to interview for real jobs. This job-hunt prompted the serious discussions about how we still wanted to do global surgery, and so I started researching the topic obsessively, and getting overwhelmed by all the information and options regarding huge, life-altering decisions. So I started the website and blog, wrote a few posts, graduated, started the podcast, and had a baby.

As we will emphasize time and again, we started this project because we needed a way to organize the information we were finding and because we wanted to tell the stories of inspiring humanitarian health providers. We are not the stars of this show; we are the naive amateurs trying to join the bigger leagues.

Despite that awareness about ourselves and vision for Indie Docs, I had a conversation last night with Josh that made me a little sad. He expressed regret for not “doing more” in residency. Back in 2005, his motivation for taking his very first college-level science class (Basic Chem 101) was to become a doctor and do global health work (after reading Mountains Beyond Mountains). That goal wove it’s way into countless conversations regarding specialty choice and long-term plans beyond residency. Josh spent a month in Uganda as a 4th year elective in med school (while I was on another away-rotation) with the Cure hospital, and he had a fantastic experience. Mayo has generous funding for short humanitarian surgery electives but no formal program for long engagements during residency; I enjoyed two such trips, one to Ukraine and another to to Guatemala, but Josh hasn’t travelled for a medical trip since Uganda.

My response to Josh was to list all the reasons for us not traveling more. In 2012 we became a two-resident household, both in surgical specialties, and I was proud of us for just keeping it together through training and the birth of our first child. We needed lots of help, from our au pair and day care and one another, and I honestly didn’t feel like galavanting around the globe was a huge priority. I didn’t have any doubts about humanitarian work as a long-term goal that felt like a road-test was needed.  Honestly, before I became a chief resident I wasn’t super useful on medical trips, which is a bad feeling after taking all the effort to go. This is the same sentiment I had back in college and I was teaching math and English in Nairobi when I decided to become a doctor; I wanted to do something concrete and unequivocally helpful (education IS definitely important, but there were plenty of local educators who needed the work, and it didn’t quite feel like my purpose in life). In another sense, I felt like Josh and I took somewhat of a mental break from the subject of global surgery, and if we were really meant to do it I thought we would return to that goal. And we did. So in short, I supposed I felt like we were biding our time, doing the necessary hard work of getting excellent training, and enjoying some aspects of life in the meantime (namely starting our family).

Despite these points, I don’t want to dismiss Josh’s feelings. It is entirely possible that the above paragraph is nothing but a pile of excuses and we absolutely should have done more. We could have gone for MPH degrees during training, adopted a passion project overseas, made a serious effort to travel together, been more generous with our money, volunteered more here in town, etc. Like Dr. Dupont discussed in his podcast episode, we could have foregone buying a house, gotten more serious about slashing our debts, and maybe set ourselves up to travel sooner. I will absolutely admit there is more that we could have done.

So why didn’t we? Like I alluded to earlier, being so busy and stretched so thin probably had a lot to do with it. There is a buzzy word that I think applies here: that of the “scarcity mindset.” We never had enough time to spend together. Our money was relatively tight and I’m a big saver; it’s hard for me to spend money on travel. With the birth of our first daughter, I was worried about having enough in the budget to cover 80 hours per week of childcare (we definitely dipped into our savings those two years). Additionally, I simply didn’t have the bandwidth to pay much attention to this idea.

In a way, Josh’s regrets represent the real and present danger we are in professionally. If we slacked off and made excuses during residency, how much more likely will those mistakes be as we acquire more responsibility. Josh often refers to a statement by Sam Adams founder Jim Koch that some things are scary but not dangerous and others are dangerous but not scary (paraphrasing, he will have a full-post about this up soon); I think this situation falls under that latter category. It doesn’t feel scary to grind out an over-loaded daily life, but we might look around a decade later and realize we haven’t accomplished our goals and haven’t found our greater purpose (or get majorly burned out).

So whatever the reasons, legitimate or not, that we’ve had for inaction in the past, the time is here for transformation. We are beginning to plan for our first humanitarian trip together as a family; I will write about our destination, financial strategy, and timing in upcoming posts. I was recently challenged by Episode 1 of the So Money Podcast (hosted by Farnoosh Torabi) with Tony Robbins, in which he says that being generous helps us to avoid the scarcity mindset by convincing our subconscious that we have enough to give, and if we don’t give when we have a little money, we certainly won’t give when we have a lot of money (paraphrasing again). So we will also establish some causes to support on a regular basis rather than just the helter-skelter giving we’ve been doing until this point. And of course, we will continue to make a big effort to post useful content on this website and tell the stories of inspiring humanitarians making the difference with their hard work.

One thing I must address briefly at this point is the reason that we won’t be moving to a medical mission immediately out of training. I will do a complete post on this topic soon, but suffice it to say that it doesn’t make sense from a financial or professional standpoint. We have debts, namely student loans, and very little savings.  At the same time, we have the potential to make what is frankly a huge income between the two of us, and I feel like there’s no way I could justify asking for charitable donations when we could essentially be self-funded in a few short years. We’ve determined that achieving financial independence is really the only pathway that makes a lot of sense for us. And, although we both were raised in Christian homes and are heavily influenced by many Christian ideals, we wouldn’t meet the standards to qualify for the same funding programs as our evangelical friends. Additionally, Josh needs to take neurosurgery boards in a couple of years, and we would both like to get some good experience as full-fledged surgeons before jumping out on our own in a low-resource setting. 

The project of creating Indie Docs has jolted us with motivation, and accountability, to push ourselves to learn more and do more. Establishing our plan of action with clear intentions and wisdom is requiring intense effort, but one that I hope will pay off not only for us, but also for other physicians struggling to find the best way to make this life-goal a sustainable reality.

 

Burnout, Recovery, and a Better Life

Trigger warning: This post contains references to burnout, depression, and a brief and non-specific account of my friend’s suicide. 

I was reluctant to write this post, but I can’t get past it to write others until this one is out there. I’ve been mentally ruminating on what I should say for weeks. I’m convinced this topic, although widely discussed and written about by physicians, is still in the stage where sharing our personal experiences might be what helps someone else fend off their own struggle with burnout and depression, as there are few institutionalized solutions or strategies for dealing with it. And perhaps for myself, sharing without shame is a form of therapy.

2010, residency interview trail.  In my smart gray suit and burgundy blouse, I focused on maintaining eye contact and a slight smile as I introduced myself to my interviewer, a heavy-set man with a bushy mustache and friendly face, somewhere in the Southeast. First question, “So I’ve looked through your CV, and I have to ask you…what are you doing here? You and I both know you’re not going to rank this program.” Well, actually I’m couples matching with a neurosurgery candidate, so I’ll be ranking all programs and your program has a good cardiac surgery department and research capabilities, so…awkward.  Ok next question. “You are like the medical version of a gym-rat. You like never leave the hospital. Don’t you know you’re going to burn out?”

I was adamant that I was doing what I liked. Of course I was not going to burn out, thank you very much.

2014, 3rd year of general surgery training. I was edging ever closer to entering the integrated cardiac surgery track I had committed to during my 4th-year med school away-rotation. The advice from my wonderfully supportive mentor, Dr. S, back home echoed in my mind, “If you go up there to do this, you have to follow through. Don’t punk out. Don’t be one of those women who gets washed out.” The problem was, I was conflicted about cardiac vs. trauma in med school, and I remained so those first few years in residency. I reasoned that in the worst-case scenario, I could just do the integrated cardiac training and then be a trauma surgeon; it’s just an extra year of training, that’s doable, right? In any case, I was not going to quit.

I have had a few other instances in life of not knowing when to quit. In the first grade, my teacher gave explicit and strict instructions to not interrupt her lesson for any reason; I’m pretty sure she gave the example of not even for the bathroom. And then I had to go really bad. But I said nothing, and her lesson seemed like it yawned toward eternity, and of course, I ended up sitting in a HUGE puddle of urine as my neighbor silently laughed his head off. I was quite confused when my mother and my teacher both admonished me to simply raise my hand and ask to leave next time I had to go that bad.

To get a discount on my prom dress, I posed as a “human mannequin” in the mall. I could go hours without moving a muscle. Teenage boys would try to get me to move or smile, and I was so determined that I would have tears rolling down my face from dry eyes before I gave in. I was also undefeated in staring contests; I still do not know my upper limit of standing still.

3rd year of med school, Dr. S informed me that there were no residents on his service that week, so if I showed up I could scrub all day every day and be 1st assistant. Needless to say I was PUMPED. By the end of the week, I was taking 600 mg of ibuprofen before every case to deal with the neck pain, but having a blast. We had a case that was going great, and so true to routine he ordered for the room to be warmed up in preparation to come off pump, but then we weren’t actually able to come off pump for quite a while. The surgeon ran through various maneuvers and waited patiently for the right constellation of labs and monitor feedback. Minutes stretched into hours, and I could feel beads of perspiration dripping down my shirt and legs. The room was over 80 degrees. I started to feel faint, and so I held a valsalva maneuver to get my blood pressure up; that helped. I tightened my leg muscles, shifted back and forth, flexed my calves, and kept myself from passing out at the table. This went on for another couple of hours. If I relaxed, I got light-headed and the room would start going dark, so I’d tighten everything back up. Finally, at a point where I was starting to hear that high-pitched screech that comes right before you really pass out, the surgeon told me to go scrub out and take a little break, since it was obvious it would be another 30 minutes. I went to the locker room, collapsed on a bench and ripped off my dripping wet scrubs. I looked down at my legs and saw that they were covered in petechia up to my thighs. I put on fresh scrubs, guzzled a glass of water, and went back in to finish the case.

There are other examples, but I’ll wrap up this digression by saying that I might be one of those few people that Angela Duckworth references in Grit who really doesn’t know when to quit.

So back to 3rd year, I was flying high after coming off of one of the hardest but most enjoyable rotations in residency, where I was the senior resident with one of our most respected and demanding surgeons in the program. I had also just returned from my trip to Ukraine with Novick Cardiac Alliance, where I learned how much potential there is for advanced-level surgery care in lower-resource settings.

OR in Ukraine, with a viewing theatre in the ceiling.

Having wanted a career exactly like Dr. Bill Novick’s since med school (He founded cardiac programs in low-resource countries all over the world), I should have been sure of my direction, but small doubts were persistent as to whether cardiac was the right field for me. I was more interested in the bombings on the Ukrainian border a short drive away from our site than in our pediatric cardiac cases. I couldn’t deny that I was a little bored with cardiac, which was a very troubling concept, but one that I shoved aside. I couldn’t quit.

I felt great going into my thoracic surgery rotation, which was a big test for whether the integrated cardio-thoracic spot would officially be mine. Only a couple of days into the rotation, I felt myself faltering. After a couple of weeks, I was drowning. Nothing I did was right, nothing I said was right, I was never where I was supposed to be when I was supposed to be there, and I felt like my brain was 10 steps behind me at all times. I confided in trusted mentors that I didn’t know why I was failing so miserably. I didn’t get it and I was frustrated and terrified of failure.

One of the fellows, T, knew Dr. S from back home. He gave me compliments every day, telling me how highly Dr. S thought of me and all the nice things he would still tell people about me. T was a meticulous clinician, and shared with me his routine for rounding, which was truly exceptional. I tried to emulate him. He was probably the nicest person I’ve ever met, especially within the hospital, and his encouragement kept me going.

At our program, we have chief conferences for every rotation, where we go to the fancy auditorium, get onstage in our suits, present our cases from the rotation, and field questions from the staff. It’s a nerve-wracking event for all the senior residents, and we spend hours and hours preparing. I met with multiple staff to go over my case list. I studied for 15 hours one Saturday that I wasn’t working because I needed to make up for my poor performance on the rotation. I kept trying to meet with one particular staff member who would be leading the questioning for my conference, and who always met with residents regarding the conference in the past. She rescheduled with me no less than 10 times, even rescheduling a phone-call with me, and always at the last minute. Finally, the day of the conference she sat down with me, looked at my list, said it looked good with a finality in her voice that did not invite further discussion. I left that meeting knowing that I was about to get massacred; it was just obvious. Sure enough, despite my preparation, I fielded a rapid-fire of questions on controversial topics, and my brain was stuck in red-alarm mode. I could see the paper sitting in my bag discussing how there was no professional consensus on a certain topic, but my mouth just couldn’t say the words that demonstrated what I knew.

The next morning, my typically formal, reserved and always gentle attending greeted me with the words, “I was so PISSED last night! That was BEYOND inappropriate.” I had cried my eyes out after the conference, but I felt responsible for it all. I should have been able to do better. I should have done lots of things better. I took the blame despite more admonishing that it wasn’t fair to me. What’s fair got to do with it?

The remainder of that year was a downward spiral mentally. I had never outright failed professionally before. I continued to force myself to fight for something I didn’t really want. I relived all the moments of shame and humiliation over and over again, all day every day. I became irritable and would pick fights with my husband. During a car ride, I even heard myself say, “I am yelling at you because you’re the only person I can yell at that will listen.” Things had gotten very dark for me.

I was at my workstation getting vital signs one morning when I got a page. Our friend T was missing; he hadn’t shown up for work. So uncharacteristic and worrisome. I paged my other friend on a rotation with T to find out what was going on. I got another page, returned it, was told to sit down.  Two days after supper club and movie night where we had a great time, laughed and joked, where I consciously perceived that his presence was like a port in the storm for me, T took his own life. I wailed in the workroom, felt sick, then felt numb. I rounded. Cried, felt numb. Scrubbed into my first case, cried at the sink, went numb. Did the case. My attending asked what was up. I told him, cried, went numb again. Did another case, actually thankful for the distraction. My group of friends stayed in close contact all that week, tried to get together as much as possible. We were all scared, although we could say exactly why or what we thought would happen to us at this point. I couldn’t understand how such a kind and gentle person could…it’s still too painful to write.

I slipped further into a dark, heavy, and bleak state. I functioned at work, had rebounded to some level of good performance, but every day I felt like I couldn’t keep up with all the tasks on my to-do list. My mind frantically begged for a pause button. Weekends off weren’t enough to recharge; vacation time didn’t help either. Every day started with a panic over how much needed to get done and seemed to end almost instantly, with nothing but shame on my part for not getting to this or that. My life felt like it was careening forward at breakneck speed, and I couldn’t slow it down, keep up, or catch up.

I had no emotional reserve. I received feedback that I seemed miserable from my intern, but I felt like I was doing all I could to simply function at work. My marriage suffered.

Then, my elderly, cancer-ridden, sweet greyhound, Pfeiffer, died. We knew it was coming for months. But this tipped me over from what was probably severe burnout to full-blown depression.

One of my trauma mentors, Dr. M., had talked to me a few times over the years about a particularly hard rotation he had in residency, and he described his emotional state during that time as “suicidal-enough.” He didn’t have a plan, but said if his car happened to run off the road or something like that, he wouldn’t have been disappointed. That’s also how I started feeling. But I also became convinced that my husband would be better off without me, my friends were only friends because they felt sorry for me and were nice people, and although my parents loved me they would actually be better off without me too. I had intrusive thoughts about my car running off the road every time I drove. I thought, maybe with some measure of hope (if that’s what we can call it), that perhaps I would develop a terminal illness.

I also felt trapped. My fate as a cardiac surgeon was still unclear, or at least for the integrated spot. I wasn’t ready to quit because I didn’t want to be a quitter. I agreed to go back to thoracic for another audition rotation. I did fine but not stellar. Whatever, I didn’t care.

I recognized my symptoms of depression and was acutely aware of the danger I was in, especially after my friend, who was much kinder and gentler than me, had recently succumbed to it’s pain. I took an online questionnaire that pegged me as “severely depressed,” and instructed me to seek medical attention. I shared this information with my mother and told her I needed advice but I didn’t want to go to the doctor. Could we just talk it through? I thought her wisdom and love could pull me out of it. I didn’t want “depression” in my medical record, and I didn’t want to tick that box on professional forms in the future.

I researched strategies to combat depression. I exercised regularly, tried to get outside on every sunny day, eat healthy, connect with friends, talk about it with my mom, Josh, and my best girl-friend.

I longed for some canine companionship and so decided to volunteer to walk dogs with the local greyhound rescue group. I met up with them and instantly connected with a big yellow staghound. I picked him up on the first 50-degree Saturday of the year, and we went to a hiking trail.

My first hike with Ramble, when the sun literally and figuratively came out for me.

There was still a nice covering of snow on the ground that sparkled in the warm sunshine. It was a glorious day.  I smiled and my face literally hurt because I couldn’t stop smiling and laughing as we clumsily jogged up and down the rutted out, snowy trails.

We stopped at a bridge and just sat together, and the dog literally hugged me, draping his giant neck over my head and just resting there long enough for me to snap a selfie.

Staghound hugs are healing.

Ramble had a gift for making everyone feel important. Indeed, he convinced everyone that they were important with his confident affection. I thought about many things sitting on that bridge, including what my options were in life. I could do so many things still… I could learn a foreign language, write creatively, read some books, adopt this dog! I could be a trauma surgeon if I wanted. Suddenly, there were a dozen sunny paths before me instead of the claustrophobic walls of a dark dungeon.

Of course I got the dog, and named him Ramble. I created the life-motto of, “If I’m too busy for a dog, I’m too busy.” I decided I would never cross that line again; it was too dangerous. I made room for all the things mentioned above. I apologized to my husband and started doing fun things with him, like seeing as many indie-rock shows as humanly possible. It was a blast.

I sat through the meeting where I was told I did not get the integrated cardiac spot. One loud thought started flashing across my brain…I’m going to start a family! So we did. And I went all-in on trauma/critical care, and that felt so, so good. Trauma is just more fun, and I loved every day of my fellowship year. And  thus, What-is-More-Fun finally became a guiding light.

What actually changed for me that day with Ramble? Only one thing: Perspective. All of those possibilities in life were always there, but I couldn’t see any of them. I went from trapped to in-charge. It was a sudden revolution, but one that I’ll never forget.

I made some mistakes on this journey. I got lucky that I made it through; but not seeking medical help was a huge risk that is not worth taking. I know of residents with the most stellar reputations, who have won the biggest campus-wide leadership and teaching awards possible, who are open about being on anti-depressants. Anyone with symptoms of depression should seek professional help. One other excuse that I made was that my symptoms hadn’t been going on that long, so I couldn’t really be depressed, it was all situational, blah blah blah. Again, I urge anyone who recognizes these symptoms in themselves or a friend or relative, seek and encourage others to seek professional help. It’s just too important, you are too important, to settle for less.

I hope that I am able to spot the symptoms of burnout among my future residents. With my performance level dropping, seeming tired and overwhelmed by the schedule, even after asking for help and understanding from my staff, the signs were fairly apparent. Yet, I had only one single attending ask me during the course of the year whether I might be depressed after I confided that I felt overwhelmed with my to-do list every day (and at that point I summarily denied it). It seems that this is a common experience during 3rd year of general surgery, but it can happen at any time. I hope that by sharing openly about this issue, that someone feels less alone, and less trapped. The biggest lesson to overcome burnout for me was that I was in charge of my life. No one else could be expected to carry me to my desired destination, but I absolutely had the freedom, and responsibility, to make it happen. I learned the importance of knowing oneself and being honest about what I really want rather than what is expected of me.

Another concept from Dr. Angela Duckworth’s Grit is that having an overarching purpose in life helps one have grit, because even if you fail at something specific along the way, you will just find another way to continue the long arc of achieving your greater purpose. I’ve always wanted to do humanitarian medical missions. Indie Docs is about intentionally, methodically, making it happen. Several studies and sources have published that humanitarian medicine can combat burnout among physicians, and the reasons are fairly obvious. By helping those with less resources, we get that “givers high” and feel like we have an awesome purpose, and I truly believe there is nothing better in life than that.

There are many other great posts and discussions on burnout, but the one that really got my attention several months ago was the ChooseFI podcast with guest The Happy Philosopher, where he talked about his burnout and recovery; this got me reading his blog, and there are numerous fantastic posts about purpose, meaning, and his own story about burnout. This is a great resource to start with if you are struggling with it. I hope that my little contribution to the subject might connect with someone and help you know that you’re not alone, you’re not weird for feeling this way (over half of physicians have symptoms of burnout!), you’re human, you’re the boss, and you can make your life into a fantastic story that you’ll be happy and proud to live out.

Feel free to email me at joy@indiedocs if you’re struggling or just want to share your experience, or share your own story in comments below. If you have thoughts of self-harm, please call the  Suicide Prevention Lifeline at 1-800-273-8255 or seek help at your local emergency department. 

 

Being true to our younger selves

My alarm beeped at 5:00 a.m., and I was instantly awake. I roused my sister, and we donned our jeans and rubber boots before heading outside in the dark. Gravel from our driveway crunched underfoot as we hurried to the barn, banged on the wall to encourage the rats to hide, and flung open the wooden door to retrieve the feed and hay for our mares. We sat on the steps waiting for them to finish their breakfast, anticipating the joys of our daily trail ride. The air was already warm and thick with humidity in the Mississippi summer, and if we didn’t get the horses on the trail with the sunrise, it would be too hot. Tack on, we mounted and sauntered down the road, taking an easy pace for the first hour through Mr. Buddy Crawford’s pastures to the beautiful old pine forrest trails. The mystical beauty of the morning and perfect harmony with my horse, Naomi, filled me with joy every day of the summer. As we emerged from the woods, a long straight stretch of unused cornfield made for the perfect runway, and my sister and I raced our horses across. Naomi responded to my voice command, “GO!” with unbridled enthusiasm, and the thrill of galloping across the flat grass course was like no other. At the end of the ride, I could tell she was just as happy as I was. This horse was my soul-mate; she came when I called, sensed my moods, and would follow me anywhere. She was easily spooked, but I knew all of her quirks. We returned to the barn and went about our day, watching the antics of our goats, dogs, and cats, and always looking for more adventure.

At this phase of life, around age 8-10 years old, I simply knew who I was, what I wanted, and what I liked. Shortly thereafter, around middle-school, my self-consciousness soared while I became thoroughly confused about what I liked and wanted. Unfortunately, that “phase” of life continued through high school and in some form through college, and young adult life. I made decent decisions for majors, friends, career, life-partner (ok an astonishingly fantastic decision on that one!), but I didn’t have that effortlessly pure, distilled sense of who I was. I also didn’t realize that this was the case, until I faced my own big monstrous burn-out during residency. This topic deserves it’s own post, which I will eventually write, but for now suffice it to say that it took months for me to work through the challenges associated with it, and when I was finally emerging from those doldrums I had a burning question constantly on my mind: What would my 10-year old self think of me now?

It was hardly a rhetorical question, and I had lots of answers. First of all, I would have been appalled at the lack of book-reading happening. As a child, I devoured stacks of fiction-book series. I read in my room, in the car, in the yard, in trees, at night, first thing in the morning, on the bus…I was a bookaholic. If I recall correctly, I was into several equestrian stories, maybe had just finished all the Boxcar Children, Baby-sitters Club, Chronicles of Narnia, and Saddle Club books. Anyway, at the point of my burn-out recovery in residency, i hadn’t read a novel since 4th year of medical school, when I read one chapter each night of War and Peace to help me fall asleep; it took me about a year to finish (short chapters) but I loved the ritual.

I also would have been perplexed as to why I didn’t write more. I always enjoyed journaling and writing stories, and even through high-school and college I nurtured the interest and skill in writing. I took AP English and was an English major in college; I wrote all the time. Even as a math (double) major, I wrote an honors thesis (on Non-Euclidean Geometry), which is just to say, I worked in writing at every opportunity. As a med student and resident, I never wrote anything except daily notes and H&Ps.

The next one was even more painful to admit to that little girl of my past…I had grown up into a woman who was too busy for a dog. This was a profoundly sad realization, and was decidedly the catalyst for springing me free of the burnout and depression because I made his resolution: “If I’m too busy for a dog, I’m just too damn busy and something has to give.” I decided then that this would be one of the barometers of my life to keep things in balance. And I adopted, and got adopted by, my soul-mate dog Ramble. (If you want some insight into how low I felt at this point in life, listen to the song, “Too weak to Ramble,” by Dr. Dog, which inspired his name.)

My first hike with Ramble, when the sun literally and figuratively came out for me.

Maybe one last big one would have been participating in humanitarian work and travel, essentially being connected to current events. I had picked cardiac surgery as a specialty and was pretty determined to not fall back on what I felt was a commitment to that field, but increasingly I felt that trauma surgery was so much more intricately connected to the community and current affairs, which I was very interested in. I did go on a trip with a cardiac surgery group (Novick Cardiac Alliance, which is a fantastic organization I will write more about in future posts) to Ukraine, and learned a lot there about delivering superb quality, highly advanced surgical care in a developing country, but I was much more interested in what was going on with the folks being bombed at the border than with the cardiac stuff. I hadn’t really made being an activitist in global health topics a priority with my time and efforts to that point; I was just trying to “get through” training.

Me in Kharkov, Ukraine, with a tiny patient in the ICU awaiting her procedure. We had to hold/bounce/jiggle her to keep sats up before surgery.

Ramble and I went for hikes every weekend that I was free from work that spring, summer, and fall. His influence on my life was profound, and taught me to be open to sharing my time and energy with the right people (and creatures). I also wrote a couple of articles for a local independent journalism group. I picked up some good books to read. I started the first Global Surgery Journal Club at Mayo Clinic in Rochester, and networked with some awesome surgeons and residents who had similar interests. I’ve never had a recurrence of burnout or depression. 

So many people go through similar growing pains in their early 30s, it’s almost a cliché. But the transformation was real, and was about taking back my life in small ways, and stopping that utter neglect of all the things that made me “Me.” But where am I going with this long,  long post? What’s it got to do with Indie Docs, or Global Medicine?

Learning about myself, what I genuinely like, how I truly want to spend my time, has been a challenge and has developed some skills of insight. It almost feels like a muscle that started out pretty weak those few years ago. It can be quite stressful to trust myself to step off the prescribed path of daily routine or academic medicine, and even more-so for choosing a really unusual career narrative.

Josh and I have discussed the subject, “What do we want our lives to look like in 5 years,” countless times, and we are still discovering the answer.

Fortunately, through her interview on the ChooseFI podcast, I discovered Jillian from Montana Money Adventures. I started working through her mentoring worksheets, and I was blown away by the insight they provided me. I asked her permission to use the worksheets as topics for discussion here, to which she has graciously agreed. So in upcoming posts and maybe on some podcast episodes, Josh and I will use her mentoring worksheets to answer the questions of how we are purposely designing our lives, engineering our time and finances, and thinking about the future in order to be true to our most quintessential goals (doing humanitarian medicine!)

I gave birth to a beautiful baby girl this past week. I’ve designed my year so that I get lots of time at home by taking a research position rather than an attending job. I’ll be doing some locums assignments as well to keep my skills sharp and gain experience, but doing this “off-year” was one decision I made that may have been different than what most surgeons would think is the right way to spend my first year out of training. With our unique circumstances, and how much fun I am having with my girls AND with stretching my skills as a researcher, and I’m secure in knowing that I made the best decision for us.

The ability to answer these simple questions of what we really want in life will be central to making sure we make the right decisions about what jobs to take this year, particularly in order to facilitate our bigger goals of making humanitarian medicine a major part of our lives. The decision could enable us to have the freedom to pursue many global surgery projects, or strap us to confining responsibilities.

There are trade-offs to every scenario, pros and cons to weigh, futures to consider (the girls’ in addition to ours), and plain old money questions. But all of those specifics take a back-seat to the simply being able to know and do what will make us happiest and give us the deepest sense of purpose.

With the help of some great mentors this year (stay tuned for that!), I am certain that we will find the right path.

Indie Docs: The Podcast!

Our first podcast recording.

Joy has really been the catalyst behind getting this website site started. On a drive home from Minneapolis one day, she started talking about an idea for a blog that could serve as a resource for people interested in global healthcare. She had done a lot of research, figured out how to obtain the domain name, start the website, etc, but she couldn’t figure out what to call it.

She was so excited about the concept; honestly, I didn’t think one thing or the other about it. I liked the idea, but didn’t intend to get involved much. But because I could tell it was important to her, I participated in brainstorming names, trying to help her dig-in to what was driving this desire in her to make a website and blog. Eventually, we came to Indie Docs, combining the thought of indie music (the liberated, do-it-yourself attitude that has changed the music industry over the past few decades and resulted in many of our favorite bands and tunes), and, of course, the concept we are hoping to achieve of being free to pursue global health projects. Like I said though, I thought of this website as her passion project, not mine, or even ours.

Part of my–dare I say it–disinterest, stemmed from the fact that at this time I had commenced my final and toughest year of training as a chief resident. Combine that with the fact that we have a little girl, and at the time, another on the way (who is now here as of September 24th!), and trying to find a job, I didn’t have much mental energy for other things. But Joy’s enthusiasm is infectious and, within the seed of her idea, I started to see the many possibilities in it.

I’ve always been a big fan of talk radio, mostly NPR shows like This American Life, Fresh Air, and Radiolab; eventually I have found my way to podcasts, of course, and I devoured Serial, S-Town, Malcom Gladwell’s Revisionist HistoryMissing Richard Simmons, and many, many others. It’s such a populist art form and a brilliant way to tell stories, share ideas, and explore all the little nooks and crannies that exist in our world. I mean, 15 years ago, would anyone ever have produced a radio show about figuring out why Richard Simmons has disappeared from public life? Or spend a whole series on telling the life-story of an eccentric paranoid genius in Sh**town, Alabama?

Stories have always influenced the direction I think I want to take in life. When I was young and watched Karate Kid, I wanted to take karate. When I saw Top Gun, I wanted to be a pilot. I abandoned both pursuits eventually (made if further in karate than in becoming a pilot). Maybe growing up is choosing a story that inspires you, and sticking with it. It was the story of Paul Farmer as told by Tracy Kidder in Mountain Beyond Mountains that led me to become a doctor. It’s the stories we were both raised on of Jesus physically ministering to the poorest, least powerful, least cared-for that I think serve as the bedrock for why we want to work in global healthcare.

Truthfully, we are just now figuring out how to enact both of these sensibilities and, other than becoming doctors, we haven’t done that much in the way of caring for the poor other than a couple of short-term trips, relief efforts from afar, small amounts of charitable giving, etc. We’ve been trying to get through school and training, but now that we are finishing up with that part, we are starting to look at each other as we enter our mid-to-late thirties and say, If not now, when? And  beyond that, How do we start?

I don’t know how or when the idea of doing a podcast for the site came to my mind. There was no inciting event, or thunderbolt from the sky. I’ve always tried to learn the stories of people working in global neurosurgery. When I was a medical student, I went to the CURE hospital in Uganda, and learned about Dr. Ben Warf, who was the first neurosurgeon I came across that showed me neurosurgery was not only possible, but could thrive in an low-resource setting.  When I go to national neurosurgery meetings, they almost always have a session on international neurosurgery efforts, and I am amazed during the presentations by the intelligence and effort of people like Drs. Kee Park, Dilan Ellegala, and Michael Haglund who are changing the paradigm of global neurosurgery. My former senior resident, Will Copeland,  made the decision to go right out of residency to live and work in Kenya (with his wife and six kids!), and has shown me it’s really possible.  Joy and I think these stories, and stories of people like them, hold the key to figuring out how we are going to achieve our ambitions of joining the global health community.

And so the past few weeks, I’ve learned about microphones and pop-filters, Garage Band and Zencaster, how to use the Seriously Simple Podcasting app for Word Press (how to use Word Press at all really), how to register a podcast with Apple, make a logo, and on and on. I’ve also learned that I am as passionate about this as Joy is, that it is our project. We set out together to become physicians, and eventually a neurosurgeon and trauma surgeon, so we could gain skills we enjoy and that would be useful in global healthcare. Now we are setting out to discover how to employ them, and as part of that, finding, sharing, and learning the stories of people who are already doing just that in a variety of ways.

The podcast will include episodes in which Joy and I tell our story as it unfolds, interview others about their experiences, and reflect on how these interviews are shaping our thinking about what we are going to do next. We have several great interviews lined up already, starting with Sean Dupont, a general surgeon who Joy did residency with, who is just getting started working in Niger,  as well as Will Copeland and Kee Park, both of whom I mentioned above. We will talk about how they manage their lives and families, finances and careers, and what inspires them to do the work. Stay tuned!

~ Josh

 

 

When it hurts to rescue: perspective from the other side

In college I had a list of things I wanted to do before I got married or graduated. One of them was to be a counselor at one of those fun outdoorsy mountain camps. I got my chance right before my senior year, and I was really pumped about hiking to Blue Ridge peaks, making camp-friends, and mentoring youngsters. The pay wasn’t great, but they offered an extra $15 per week for life-guards, so I signed up for their Wilderness Lifeguard Certification course. I knew that the requirements included an initial test of a 500-yard swim, so I conditioned ahead of time at the local YMCA where I was a spinning instructor. I arrived for training to our lovely mountain lake in late May. The waters were frigid. They were so cold, we were told to get out of the water every ten minutes to let our core temperatures warm up to avoid hypothermia. The time came for the 500-yard test, and I confidently lept in the water and stretched out for freestyle swimming. As my face broke the surface of the frigid lake, my respiratory muscles immediately spasming so that I snorted icy water into my nose and mouth. I lifted my face out of the water while trying to maintain my stroke and choked out a mouthful of water and heaved in a very brief, shallow breath before the spasm made me cough again. With a bit of grace from the instructor, I was allowed to gain my composure before proceeding with the test, and with all my willpower and concentration focused on breathing between the chest spasms I managed to finish. Further challenges included deep lake dives to the bottom for a “sweep,” that resulted in one of the other trainees bursting an eardrum, and my first personal experience with true, all-consuming claustrophobia and vertigo in the pitch-black lake bottom. If I had known how to quit, I would have. I struggled on the final to haul a guy 100 pounds bigger than me out of the lake, but I passed my certification.

A few weeks later, I reluctantly led a bunch of little girls on a white-water tubing trip along with 5 other lifeguards. There were about 30 campers, from 6 to 17 years old. My reluctance was due to what I considered unsafe river conditions; heavy rains had increased all rapids by 2 classes, and the river was so swollen with torrential currents, and I didn’t think the little girls and weak swimmers could handle it. Alas, my strong opinions were over-ridden by the other guards, who suggested that we have a system where I “tested” the tubing route as the front lifeguard and then made the decision. I struggled to traverse a rapid as my foot got caught between two large rocks, and looked back to try to wave off the other lifeguards to indicate that I was right, we shouldn’t be in the water! But the wall of campers in inner-tubes coming towards me confirmed that it was too late. I had to abandon my float to rescue one girl who flipped out, and another got passed me. She was swept beyond the deep pool that should have been the exit point on the brief tubing course. I caught up to her and we slipped down a small set of rapids to the next deep pool and I hauled her out. At this point, I was pretty mad, but out of sight of the group. I planned to march up the bank with her and demand everyone get out of the river. I was rehearsing my speech when I heard calls of help from the far side of the river.

What happened next inside my brain is completely inexplicable to me. My conscious thoughts were loudly in denial: They cannot be our campers; they are boys; they do not belong with our group; I do not have to get back in that freezing water. But they were our campers and I found my body moving, first toward my safe camper on the bank asking her to run and get help, and then into the water. The river bank was covered in softball size smooth, slippery rocks. Every step I took, I stumbled. I finally got to water deep enough for me to crawl like a salamander toward them, and I was horrified as they crossed my horizon from left to right. I struggled and crawled and pushed, and finally caught the current. They were gone. I desperately swam down the river, crashed over a rapid, and looked for them. It was another set of rapids before I caught them. Each time I slid over the rocks and crashed down the drop, it hurt. It hurt my feet, my back, my knees, and my legs. I caught the girls and hung on to both of their tubes; somehow they had stayed together. I remembered in our white-water training we were supposed to keep our feet up so that they wouldn’t get stuck between riverbed stones and result in our ankles getting snapped as our bodies got jack-knifed by the current, but I was completely powerless to stop myself from trying to put my feet down to slow us. We met rapid after rapid, and each time I was holding onto the tubes and skidded down the rocks on my back with my head forced down under the tubes and water surface; I braced myself for a blow to the head that I was sure to come.

In the midst of all the turmoil, my brain still somehow made room for thoughts of blame and disbelief, and I was filled with a furious rage like I had never known before. I was angry at the pain and the fearful thought racing across my mind of, “THIS is how people die on rivers. We could all 3 die. THIS is how it happens.” I tried to steer us back to our bank, but made no progress. As I got a brief respite from skidding over the rocks, I looked far down-river, and I’ll never forget what I saw: 100% whitewater. All of the wide-open river in front of us was a churning and rocky field of rapids. I panicked and kicked as hard as I could toward the far bank. One of the girls got pummeled on the back by a large rock and almost popped out of her tube. I held her and her tube and the other tube, and kicked. We landed in an eddy. It all stopped.

I trained my eyes to the water for campers, expecting more victims to be floating down. My rage grew. Beaten up, we hiked barefoot a mile or so downriver, across a bridge, back to our group, and I expected panicked colleagues and a hero’s welcome. Heck, I half-expected some helicopters to be canvasing the river looking for us–it felt like we were gone for hours! What greeted us instead was disinterested blank stares and the phrase, “Oh, we didn’t realize you were gone.” Needless to say, I lost it. I must have said something fairly scary, because within a few minutes, everyone was out of the river, headcount was done, and we were in the vans. I fumed. How could they not even know we were missing?

It took me a while to get over my anger and to stop ruminating about the close-call, but what I ultimately learned was a really profound lesson. As uncomfortable, and frankly horrible, as that experience was, I realized in discussing what had happened with the other lifeguards that I would not have wanted to trade places with anybody.  If someone else had made the rescue instead of me, I would have been crazy jealous. Of course I wish it had never happened, but that’s not reality. It did happen, and in some form or fashion it will happen again. At this point I was heading toward med school, and I decided then and there that I wanted to go after those people that I would encounter throughout life that need rescuing. As a trauma surgeon, in a literal sense “rescuer” has become my chosen vocation.

Residency was at times pretty uncomfortable. Med school, too. I never reached the level of acute suffering, and certainly not personal endangerment, I felt on the river, but I remembered that experience and was emboldened to persevere. My medical missions experiences have also been uncomfortable at times, like when I got norovirus 15 weeks pregnant in Guatemala and needed 5 liters of normal saline before I stopped feeling dizzy. Or sleeping on army cots, working in heat, and failing to fix everybody. My experiences are a mere pittance compared to what our colleagues in war zones and refugee camps endure as they risk everything to rescue as many as possible.

Advocating for a cause is also frequently uncomfortable. Sometimes I still feel like I’m yelling into the abyss of disinterested blank faces trying to convince people that we should be doing something different. Especially in situations that I feel are dangerous or risky, this can be frustrating and draining. In the global health world, the need for advocacy is infinite and immediate. I think this may be among the main stressors of the field. Many worthy causes, and our passion projects, will suffer from lack of attention and support, but it will be up to us to make a strong case for why people should care about what we do. Indeed, people’s lives depend on it.

I suspect the “rescuer trait” is common among humanitarian medicine providers. However, I have also encountered many people who are unprepared for the discomfort and the pain that come with this lifestyle, and it shows in grumpy attitudes, intolerance to local culture, slow progress, and early burnout. I have to admit that I myself was not prepared for the discomfort involved in a river rescue, or even in being a lifeguard at all. We need to carefully prepare ourselves for reality rather than just hoping the mountaintop experiences to put enough wind in our sails needed to fuel the mission. We need to be mindful of our inner conflicts as we encounter difficulty, and support one another as we process new challenges. We need to work to recognize when a colleague needs to talk about it, and lend a sympathetic ear.

My little adventure in the beautiful Blue Ridge Mountain planted this seed in my mind, and I hope that as my professional ambitions take me through some arduous experiences I keep the perspective that it is my privilege to be the one jumping into the river.

Change is always bad, until it gets good: Lessons from the Quality Academy at Mayo Clinic

I am spending a year as the Trauma, Critical Care, General Surgery Research Fellow at Mayo. I have time to focus full-time on projects that will hopefully make a difference, expand knowledge, and really help our patients. I have aspirations of completing a couple of Quality Improvement projects, which is a very particular type of research with roots in sophisticated industries that have developed complex strategies for minimizing risk and errors. I have attempted a project before and essentially got nowhere, as I didn’t even know where to begin. So I signed up for the Quality Academy, which in true Mayo fashion, was an efficient, information packed, slick course that gave us all the tools we needed to get going on our projects. We covered a broad range of topics, and I was inspired by many of the thought processes and exercises presented there, but non stood out to me as more profound that the so-called “Change Despair Curve.” It looks something like this:

Image result for change despair curve

(Credit: https://betterleadership.wordpress.com/2010/02/05/the-valley-of-despair/).

 

Now this was not the exact curve in our presentation, but it’s essentially the same. The curriculum stated that any change, whether personal or institutional, small or large, is accompanied by this same terrible transition by all involved parties. Even if the change is obviously positive and gets unanimous support at the beginning, there is a valley where everyone is bummed.

The reason I thought this was so profound is that I have seen it play out in my toddler’s reaction to 100% of suggestions I have made to her in the past 6 months or so. That’s not an exaggeration. I say, “Banana?” and she gives me a tortured expression and says, ‘NO DON”T WANNA NaNeeeI!!!” before her face softens and she holds out her hand for the gift. Every transition, change in our momentum, new idea, or suggestion of any change in the current activity and state of affairs is met with initial resistance. So of course I smugly thought, “Ah motherhood, giving me yet another edge in the professional world,” and gave myself a mental high-five.

This curve  represents the challenges we will all face as we try to do good in the world by changing the status quo. All stakeholders will eventually get sore with us and with our ideas. We will get depressed about our projects and moving and traveling and starting new ventures. We will have to convince ourselves and colleagues that the change is worth it, over and over again. With perseverance, what is there on the other side of the difficulty is higher quality projects and a life of more purpose and impact.

I encourage every professional interested in global health to get acquainted with the principles of Quality Improvement, as we should be held accountable for proving the quality of any new endeavor or change we implement. We need to show that the change and resources required are justified, and having the right tools to do this analysis is part of the job description of a humanitarian physician. If your institution does not have resources available to get you started, email me at joy@indiedocs.org and I will send you everything I can to help.

What life-lessons have you learned from something like “Quality Improvement?” How important do you think quality research projects are to the field of global medicine? Please leave comments below!