Category: Motivation

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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.

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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

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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.

 

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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.

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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!

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Is Financial Independence the Key to a Global Medicine Career?

If I had to point to one single resource that has motivated and inspired me like no other these past few months, it must be the “FI” community, particularly the Choose FI podcast.

I am a complete newbie to this world. In fact, I got connected to “Physicians on FIRE” on facebook (through my Physician Moms Group), and I did not know that FIRE was an acronym for Financial-Independence-Retire-Early. So for anyone out there as clueless as me, FI stands for Financial Independence, and it’s propounded “Fye.”

At first encounter, this seems like a fairly narrow focus. I was peripherally aware of some nuts who wanted to retire by age 30 and did all sorts of weird financial acrobatics to accomplish this, but I did not consider any of that relevant to me. I finally listened to one of the Choose FI podcast as I was exploring options for accomplishing the Indie Docs lifestyle (although I did not have that term for it at the time). Josh and I kept discussing the best plan for funding our dream of being humanitarian physicians, and without charity funding it seemed that achieving financial independence was essentially mandatory. Otherwise, debt obligations alone would be prohibitive to traveling and working for little-to-no pay. While religiously affiliated programs and some fellowships exist that can fund 1-2 year projects or even longer missionary careers (topic for another post), we ultimately decided to leverage our income potential to control our own destiny. Hence, my portal into the Financial Independence world.

I quickly discovered that FI is so much more than extreme budgeting, saving, and investing. Mr. Money Mustache was for me, as for many people, the gateway to a whole new mindfulness toward how I should spend my attention and time in addition to money. He calls out many ridiculous notions of consumerism in a compelling and entertaining way, and at this point I’m practically inhaling 2-3 of his archived posts every day. On a very practical level, he convinced me to ride my bike regularly to work and for errands around town, and this has been a very enjoyable, economical, and healthy transition. His post “What do you mean ‘You Don’t Have a Bike’?!” is what first intrigued me–Click the hyperlink to judge for yourself!

Saturday grocery trip. Hauled a full load of groceries in the bike trailer with Eddy. Workout-check.

While riding my bike, I’ve listened to several more episodes of the ChooseFI podcasts, and discovered resources like Get Rich Slowly, Raptitude, Frugalwoods, Making Sense of Cents, and many other blogs. I explored the travel rewards section of the Choose FI website and listened to the Travel Rewards podcast episode. This topic also deserves an entire post in it’s own right. The obvious practical implications of finding a way to travel at a huge discount would be a total game-changer for humanitarian physicians. I realized that I had done a very mini-version of their travel hacking by opening the Chase Sapphire credit card years ago and using the miles for airline tickets and recently a sweet deal on a rental car, and subsequently opening two Delta cards between myself and my husband to qualify for bonus miles and free companion tickets. So in the past 6 years we have played this game 3 times, but not in a super-savvy way and totally unaware that there was a whole busy and geeked-out world of travel hacking teeming below the surface.

Yesterday, I listened to the Choose FI podcast episode 48, which featured Jeff from The Happy Philosopher, a radiologist who experienced severe burnout and found a path to professional fulfillment and happiness again as he pursued financial independence. The episode gets fairly deep into a discussion about burnout and it’s effect on all aspects of life, and practical approaches to emerge from this crisis. I myself have experience full-fledged burnout and will definitely devote a post to this topic, and I was again amazed at how relevant the FI discussion is to so many of life’s complex emotional problems.

On the most basic level, achieving FI will open up possibilities to spend our time and money on the projects we are most passionate about. One of the earliest steps in the path to FI is becoming debt-free, and this is a particularly large hurdle for many physicians. It seems that the college and med school tuition and student loan structure are practically designed to keep us working as many hours for as long as possible just to pay back this obligation. When we get past residency and find a “real job,” our work schedules are optimized for billing, and many physicians would find it impossible to spend a significant amount of time pursuing humanitarian projects; in fact, I personally know several wonderful physicians who devote over half their vacation time to short term projects. In addition to paying back the loans, we need to make up for a decade of lost time funding retirement accounts and other funds, such as kids’ college.

However, if you can imagine that suddenly you are financially independent, the game changes drastically. You can insist on a part time schedule, find a work-share situation with another physician, or simply walk away forever. Even if you have a full time physician job that you love, it frees up your financial obligations to make a huge impact on your passion projects rather than paying back the bank.

Josh and I have just started investigated new strategies to start our FI journey. I love the easy equation that comes up often on the Choose FI podcast that (Money Made) – (Expenses) = Your Gap, and the Gap is what you invest to achieve FI. Our income is relatively fixed as two residents, but I do supplement with teaching courses and plan to do Locums this year for some bigger boosts. The big category I’m fired up about now is minimizing expenses to maximize our Gap. I’ve started taking my lunch to work, riding my bike to work, really cut dining out. (I truly enjoy my PB&J, which is super charged with rich omega-3 supplemented peanut butter, rhubarb and strawberry jam, and gourmet whole grain bread).

Packed lunch for the playground, pretty identical to work lunch except more “snacks” for Eddy.

I bring my coffee to work every morning; I don’t have a coffee thermos that I can toss into my backpack, so I rigged one using a mason jar and a breast-milk insulated carrier from my diaper bag (see photo), and I have no plans to upgrade as it works great. We have always used cloth diapers at home (day care requires disposable), and it is a huge money saver that is so easy I have no idea how all families don’t at least have a hybrid cloth/disposable diaper system.

After July, we will no longer employ an au pair, and I will be able to cut out a smart phone line and cable and sell a car (saving money on the insurance also). At that point, I’ll look into budget smart phone carriers to try to find something cheaper than Verizon (have a feeling that will be pretty easy). We have a few low-interest debts that I will look into paying off, but we are in a debate as to whether it’s wise to use part of our emergency fund to do this when we are only a year away from both having full-time attending jobs and can reasonably float these small loans a little bit longer. I think we are paying too much for house and auto insurance, so I’ll look into switching that in the next few months. I have to take my general surgery boards in July, so some of these items will have to wait until that task is complete.

We will revisit FI again and again on Indie Docs, as well as explore other ways of funding a humanitarian medicine career. For now, enjoy visiting the amazing resources available through the hyperlinks above. Please leave comments with your favorite financial blogs, websites, or podcasts, as well as any practical tips and tricks you have for maximizing The Gap.