Control vs Connection: Deep Thoughts, Deep Breaths

As I was running over a long lunch break today, I tried to focus on one principle: Connection over control. This concept has been ringing in my thoughts since I listened to Brene Brown and Oprah talk about it on the Super Soul podcast. In Dr. Brown’s new book, Atlas of the Heart, she delves into emotions and language, and this was one example that I could immediately relate to in a dozen ways. She described a concept of “near enemies” and “far enemies,” said that the far enemy of connection was disconnection, which is obvious, but the “near enemy” of connection is control. It’s sneaky and dangerous, and I began to see it everywhere I looked.

People often have a hypersensitive radar for whenever “connection” energy creeps into “control” territory. Reflexively, with no conversation exchanged , the relationship shifts. Sometimes this is a mistake; it was only perceived attempts at control, which may have been rooted in pragmatism. Nevertheless, the relationship wobbles into adversarial territory.

Feeling every bit of the struggle of my out-of-shape legs and lungs carrying me past 2 miles, I began to think about my own struggles with perfectionism, anxiety, and shame. Shame was the atmosphere of my upbringing, and I shielded myself from it by strategically performing and connecting. To comply with expectations, I constantly wrestled to control myself. All that self-control helped me achieve every big goal I targeted–until it didn’t.

At 30 years old, in the middle of a tough surgical residency, my coping skills failed spectacularly. I would push myself intensely with self control, get overwhelmed with anxiety and start avoidance patterns, then make up for it with more intensity and self control, on and on the snowball grew. I had the profound experience of completely losing myself when ultimately, I flipped a switch from being self-controlling to self-disconnecting. The shift was palpable. I recognized it, and I was afraid. I was despondent, but also living with white-hot self-contempt. I did not know how I could endure this pain for the rest of my life.

Happily, with lots of work and help I came back to myself, but 6 years later I am still unpacking that experience. Today on the trail, thinking about Dr. Brown’s commentary, I focused hard on connection versus control in my workout. First of all, I was working out without internal coercion or guilt; I really felt like it! Nice day, big gap between cases, good steady energy level…getting started was no sweat. Since adolescence, I’ve struggled with streaks and guilt-ridden gaps in my fitness routines, so lately I’d been focusing on gentle consistency.

I tried to connect with my body, with the trail, with the breeze. On the way back, I was really tired and I focused on a spot in the distance and ran to it. Thinking back to the grueling workouts I’ve put myself through, the marathon I ran, the exam studying, the applications, the money I needed to save, the waist size I needed to maintain, on-and-on I thought of unbelievable amount of pressure I had put on myself to hit goal after goal.

I was thinking about self-discipline and self-control; they weren’t the same, right? If I wisely chose a goal, my self-discipline should create the consistent effort and ecosystem for me to achieve it. However, I had so often forced myself to persevere, despite inadequate skills, training, habits, routines, support, mentorship, etc. Yes, I got there most of the time, but at brutal costs. And a few times I failed; no wonder. I was emotionally and spiritually wounded. In fact, I literally had times when I was physically ill and wounded along that way. I looked at a marker post, and thought about all these things, and how there was a part of me that could sprint toward it and completely ignore my body’s signals. Instead of doing that, which I had done so many times before, I decided to walk, and show back up tomorrow knowing I would not dread it and I would not hurt myself.

Now that I have internalized this lesson, I see its repercussions in global health matters. How often does a humanitarian project veer from connection to control? How many humanitarian disasters sprout from the same dysfunctional tension? How do we ensure that our relationships with local stakeholders, patients, and donors, remain firmly in the “connection” realm?

If a project is stipulated on access to local resources, that’s control, not connection. If it’s a thinly disguised attempt to proselytize, that’s definitely control. And it won’t take much for that relationship to fall into disconnection, when projects get monopolized and the original purpose is totally lost. Anyone who has worked in charity or non-profit projects should be able to recall an example; the majority of projects are dysfunctional.

Honing the skills to recognize, and accurately communicate, when a relationship is one of true connection on a micro-level will help us solve macro-level problems. Recognizing when we are connected to ourselves, and our own values, is a pre-requisite to building authentic community, and doing no harm.

Tenwek Trip

I don’t know how it’s been two years since we finished training and moved from Minnesota to begin “real life.” During the arduous journey through school and training, Josh and I would chat about the first thing we wanted to do after training–that first goal or experience we’d been putting off since what felt like forever. We didn’t travel as much as our friends during those years, for various reasons, and so we both wanted to take a big family trip. I always wanted to see the French Alps. Josh wanted to go kayaking. We had a month off to move and travel, and we tried to pack in as much as possible.

Our plans hit a snag as Josh felt a compulsion to go to a well-known hospital in Kenya where one of his friends and former chief residents was working and living, Tenwek. For a little background on us, Josh and I both were raised as evangelicals, and had mission trip experiences in college that left us pretty cynical of that subject. Those trips probably had a lot to do with why we became doctors, because we were searching for a way to serve in a noble, pragmatic way. Now we were to that point where we’d finally arrived, and Josh was ready to try on this old goal of humanitarian missions once again.

I was not ready to give up my hedonistic vacation plans, and we had some pretty tense arguments about it. Then something pretty amazing happened. I sort of miraculously got back in touch with an old friend from Kenya, who I stayed with for several weeks in college, and she was planning a trip back home with her husband and children (they live in Europe) at the exact same time we would be traveling. So I relented–I could not give up this chance to see my dear friend again, have our families meet, stay with her Mum like old times. So, 15 years after we spoke for the last time, we were planning a joint trip. Amazing.

I dutifully followed through on the zillion details required for a multi-week international trip with two tiny kids (3 and <1 at the time). We got vaccines, passports, luggage, travel car seats, arranged secure transport from the airport, etc. We set up a little circuit of travel around Kenya that put us working at Tenwek for two weeks. Fortunately, they had a Trauma Surgery staff member who would be away at that time, so I got to plug right in to their team and fill that void. Josh’s Neurosurgeon friend was craving the company of a colleague and had plenty for them to do together. It shaped up to be a great trip, packed with community, family, work, and new experiences.

Tenwek is a model missionary hospital. It has grown and expanded into an exceptional referral center. Having just started their first Neurosurgery program, they were continuing to provide more and more top notch subspecialty care. The residents were and are simply outstanding, and they were hiring more and more of them back into the staff. Service lines were being turned over from white Westerners to Kenyan doctors and other providers, which is a good marker of sustainability.

Our time there didn’t feel rushed nor languishing. Two weeks felt right. We took in the experience, had a fairly harrowing journey home (flight out of Nairobi was simply cancelled a few hours before takeoff–that’s for another post or podcast), and I thought I would write this article fairly quickly. But then we moved in, started attending jobs, and got busy with little kids. I let the experience in Kenya just sort of settle and slowly tell me what I needed to learn. Josh and I talked about it a little bit but not much. I wasn’t sure if he would get that itch to go back soon, but after two years, it hasn’t happened. My feelings toward it are too complicated for one blog post; probably too complicated for even a series of blog posts. I’ve decided to just give this broad overview here, and then record some podcasts with Josh where we unpack it all, and just see where the conversation goes.

I will say that during this intervening time, I have sought out different opinions and voices on the topic of medical missions. No White Saviors has been a source of new ideas and challenging insights for which I am so grateful. Moving from a reading list on Effective Altruism to the White Savior Complex has been quite a mental and even spiritual migration, and after two years of introspection and seeking, I think I’m ready to start having this conversation, knowing I will have blind spots and will need recalibration and a good smacking or two by those with much more wisdom than I have. But I need to have the courage to be open to those critiques, so if you’re interested in this story, check out the podcast in the next few weeks.

And with that, I feel great for breaking the ice after two years of neglect for the Indie Docs project. I don’t know exactly where we’re going, but I think we’re moving in the right direction.

Suffering and Overwhelmed

On the PBS period drama, Poldark, the faithful village doctor, Dwight Enys, languishes as a prisoner of war. He scrapes together rags and crumbs to care for his wounded comrades. Their captors humiliate and torture the prisoners, finding ever crueler ways to break their spirits. They are starved, but Dr. Enys gives his bread crust to a patient with a septic wound who requires tending day and night. He establishes a practice and a pattern of caring for this patient, and gradually, after weeks, the man is convalescing as Dr. Enys gingerly cradles his head in his lap while conferring with a younger colleague prisoner. Laughter is heard from the direction of the officers, as a soldier snatches the patient to the floor and shoots him. Dr. Enys cries in agony. 

@DrJaimeFriedman recently expressed thanks to frontline healthcare workers, to which @MorningAnswer countered with “suffering and overwhelmed? Ha. What she means to say is ‘busy.’”

After 9 months of pandemic clinical practice, research, public health interventions, a lockdown and a reopening, a second wave tsunami appeared on the horizon. Calls to prepare were met by such mocking and protesting and denying, I watched my colleagues do the twitter version of pacing the floor, horrified and ruminating over how much different this could all be. 

At the height of the Spring chapter of the COVID19 pandemic, in one of the most prosperous cities in the history of the world, during peacetime on our shores, I provided critical care to COVID19 patients  in frankly substandard conditions. But we strove, we checklisted, we proned, we researched, we truly cared. Everyone on my team cared. Patients with COVID19 might code shortly after arrival, but more commonly, they smoldered for weeks. And then, very often, we lost them. At noon, there was free pizza. At 7 p.m. there was applause. The city mourned with us. 

Healthcare workers have been at this for months. Not just working in it, but living it. As predicted, the Second Wave has crashed over us. Instead of listening to the warnings of the wounded, society has collectively decided to resist caring. To call us sentimental snowflakes for being affected. Why was the dramatization of Dr. Enys’s heartbreak relatable? Because we do care that much. I can’t explain to someone why a human would be affected by the death of another human. Why 250,000 deaths might inflict morally injury on a healthcare force that can see out of this fishbowl to other nations who are getting it somewhat right. 

There’s another TV drama anecdote that I’ll never forget. Early in the Gray’s Anatomy series, George is asking why he should do CPR on a clearly deceased trauma patient, when Miranda Bailey’s tongue lashing smartly educates him: “So we can tell their family we did everything we could.” As a community, we cannot say we did everything to avoid the deaths of our neighbors. Shouldering on in such a reality is demoralizing. Being told we should thicken our skin and simply care less is the ultimate insult to our profession. 

We are overwhelmed by the vastness of a pandemic that has been allowed to spread rampantly through our cities and small towns. And yet, we are striving to convince leaders and civilians that WE are not the adversary. We are suffering the pain of loss and upended plans. We are not soldiers. We are not heroes. We are members of the communities we serve, and we may be suffering and overwhelmed. 

Open Letter from a NYC COVID19 ICU Physician Volunteer

I wanted to update everyone on my trip to New York to work in a surge intensive care unit (ICU) for COVID19 patients. First of all, I’m sorry it’s taken me a while to write this; life was moving fast and it took some time to reflect on the experience. I still have a little bit of writer’s block.

Thank you to everyone who encouraged me. I was overwhelmed, blown away, and humbled by all the messages. I had physician colleagues and friends reach out to offer housing, cars, food, moral support, and anything else I could possibly need in NYC. I even had a goodie bag waiting for me when I arrived at my hotel!

My first few days were hard. My set-up for organizing my personal protective equipment (PPE) and scrubs seemed cumbersome, and I felt like I kept messing up my “sterile technique” (as a surgeon this was very frustrating). I never fully unpacked, which was really out of character for me. The first day, work was disorganized and felt like a big noisy traffic jam. I just ran around doing procedures in an ICU where patients seemed to be near coding constantly. There was nowhere out of the way to stand or sit, so I felt like I was dodging traffic all day. Instinctively, I tried to learn the equipment and system quickly, and found a wonderful NP who had been there for a few days to show me the ropes. I tried to learn about the logistics and the realities of their environment in order to be effective. This was a situation unlike any we have experienced in our modern, developed healthcare system. Because of the chaos and sheer magnitude of the problems, I sincerely wondered if I would get to do anything worthwhile.

The “Morgue trucks” parked near my hospital entrance.

The next day they moved me and a team of other travelers to a new makeshift unit. It was a blank slate. Really blank. We had to scrounge for every wire, sensor, IV pole, and even beds. Somehow, we rigged up a fully functional, high quality ICU within a couple of days, and our clientele ranged from 6-8 patients (8 was a really tight fit). My colleagues were amazing, and everyone was 100% on their best game. We had some amazing saves; one patient coded on arrival and got 5 minutes of chest compressions before starting his long journey out of the abyss to extubation nearly 3 weeks later.

One of our amazing nurses running the quality checklist faithfully, which they did every day for every patient.

We spent 12 hours a shift covered in layers of PPE, ate snacks and meals together, talked about home, made jokes, solved problems…it was peak foxhole camaraderie experience. We even filmed a TikTok, one of many firsts for me.

Our amazing dietician who went to great lengths to set up a coffee station near our hot-zone ICU, even donating her own Keurig!

The equipment was intimidatingly retro and clunky. Every patient was supported by a transport LTV vent that I quickly had to learn how to use. Proning without a special bed, updating families over the phone through interpreters, trying to keep ET tubes clear without aerosalizing maneuvers–everything was new, different, and challenging. Little fires everywhere.

LTV vents hung from the ceiling like big bats, but faithfully kept our patients alive, sometimes for weeks on end.

The patients were shockingly ill. Every day a new challenge came up. Nearly everyone was maxed on vent settings with respiratory acidosis that bordered on “incompatible with life.” I read another ICU doctor’s essay on how the “game of inches” is won there, and it rang in my head when I felt like I wasn’t gaining any ground. We played the game of inches. We had checklists and followed every letter, responded to every actionable piece of data. In a few cases, we slowly won that game. Inch by inch.

“Loaner” says it all. This is what we called a “Christmas tree,” and most patients needed this many infusions.

We called families multiple times per day. I was prayed for in 4 different languages that I can recall. These phone calls were often a source of unexpected emotions. One time, I answered the phone in complete business-as-usual mode, started to update the family, and shared that their Dad was staying strong for the moment, despite our worry that he would pass away overnight. Their response was tears of joy and fervent encouragement, gratitude to our team for not giving up. Tears suddenly stung my eyes and a lump in my throat made responding physically impossible. I managed to squeak out, “It’s our privilege.” I pulled it together quickly, but my own emotional wobbliness surprised me.

In the evenings, I would schlep home in my Lyft and do my decontamination routine and shower. Then, I ritualistically face-timed my husband and kids. To be honest, this felt like a chore that I didn’t have much energy to perform. I didn’t feel like talking about my day at all, and the girls were too small to pay attention. So the conversation only lasted about 10 minutes before I would say goodnight and turn on Netflix. Then I took a melatonin and watched TV til I fell asleep, because I felt really lonely even thought I didn’t want to talk to anyone. I did this pretty much every night.

The two weeks went by slowly at first. Midway through my second week, I worried about who would take over for me. I received amazing news that another ICU physician volunteer was coming from LA, and I started plotting to go home the day after she arrived. Once I oriented her to the unit, I was confident that she didn’t need another cook in the kitchen, and I booked a Delta flight out for the next day. I left all my remaining PPE, disinfected absolutely everything, and headed back to the South. I got a COVID19 test on my way out of the hospital.

It wasn’t until this point in the journey that I considered not being able to return straight home. I talked over the risks of it with my husband, and we shared concerns over the safety of traveling home from New York. My COVID test returned negative, so that was a relief. I decided to self-isolate at my mom’s house in Nashville. We were very strict about physical distancing, but it was so nice to be with someone who loved me and took care of me. I rested, exercised, ate, and reflected for a few days. I got another COVD test that was also negative, and then headed home-home.

My kids fell into my arms and were so sweet. They stalked my every move like little shadows. I enjoyed a few days of quiet while I waited for yet another COVID test to be resulted negative so I could go back to work at my hospital.

I’ve had a fair amount of interest by folks at home in my trip. Several people have asked me for advice in how to use PPE, and decontamination routines as their work-places reopen. And from some very surprising people, I’ve heard comments like, “I had no idea you were a badass! Way to go girl!” These always catch me off-guard and make me laugh.

However, anytime someone wants to congratulate me on my trip, I immediately think of our colleagues permanently in the trenches in NYC and other COVID hotspots. It’s easy when there is an escape plan, but I just can’t imagine living in that situation for months on end (although this may be our situation everywhere soon). So, to all our frontline workers in NYC, please reach out. Let us know how we can help. Tell me your struggles, let me try to lift you up with exclamations that you’re a freakin’ badass, even if only a tiny jagged splinter of your brain lights up in belief and recognition of that fact. I know I did my best for you, but down to my core, I wish it were much, much more.

To change the world, you must first change a place like Mississippi

Nobel Prize winning Mississippi-native author William Faulkner famously said, “To understand the world, you must first understand a place like Mississippi.” Such a catchy quip, this sentence is printed on t-shirts and home decor objects all over my new hometown of Oxford, MS. As a lit-major in college, I was constantly reminded of this statement, and through the years it’s often bubbled up into my stream-of-consciousness.

At Rowan Oak
On display at Rowan Oak, home of William Faulkner in Oxford MS

When I left Mississippi at the age of 27 for greener pastures in the upper Midwest, I was relieved. It was nice to be in a place that was more politically diverse, less conflicted, more even-keel. New acquaintances would chide me about preparing for the brutal winter, and I responded that at least I no longer had to fear the venomous spiders, snakes, and fire ants of the South. I was only half joking.

Time came for the next transition, for my giant leap into professional life. I stepped back into this place where I am a native and feel like a stranger. Just about every day, people ask me where I am from, and they smile from tremendous relief when I say, “Jackson.” “Oh! I did realize you were a Mississippi girl!”

Mississippi has been decorated with many superlatives, most of which are negative. Poorest, most obese, worst infant mortality, and worst health disparities. “Black women in Mississippi are 60% more likely to die of breast cancer than white women.” It’s been called, “One of the riskiest places to be born in the developed world.

My first week here, I went to the post office. I had no big expectations of this mundane errand, so I was unprepared for the level of welcoming, genuine warmth that beamed from the postal worker. I left smiling. I went out to eat lunch, and my waiter put my food down and gushed, “Watcha know Hon? Ooooh that looks GOOD!” Never in my life have I ever felt so validated in my lunch order; I rode that high for the rest of the afternoon.

I’m raising two little girls in a two-surgeon household, and I have no doubt I could ask any of a dozen acquaintances and neighbors for ANYTHING and they would drop EVERYTHING to help. There are deep abiding roots of selflessness and generosity of the individuals in this community.

I was compelled to return by this idea that Mississippi is both the hardest and most tender of places. That going anywhere else was a cop-out. That if I want to fight for humanity, I need to meet on the mat here.

I’ve come to the conclusion that Faulkner was right. He wasn’t being optimistic; quite the contrary, I think he was saying no one will understand Mississippi, much less the world. I sure don’t feel like I can understand Mississippi.  But one thing I have come to understand is that change is hard. That feelings are more powerful than logic. That this community suffers from the wounds of the past and struggles to live in the present. I want the future to be brighter.

As I pondered my new life and decision to come here, and wrestled with whether I could handle it, a simpler statement came to my mind than the one Faulkner wrote. “To change the world, you first must change a place like Mississippi.” 

I’m not sure I’ll ever understand a place like this. I might understand it better than an outsider would. But I am bound and determined to change it, and that, I believe, we can do. And maybe all these places in the world that are considered the hardest, most complicated, most entrenched, most hurt, will change too.

Should We Reject the Moving Allowance: Contract Negotiations

As we close in on a pair of jobs, the nitty-gritty details of this complicated life-event are coming out. Today, I am focused on a line-item in our contract negotiations: the moving allowance.

This benefit has been a fixture of the recruitment package for young doctors for quite some time. I have observed many of my friends who signed contracts in previous years gleefully avoid the chore of moving their own stuff, and reassure us that we wouldn’t have to deal with the headaches, and backaches, of relocating all our stuff.

And then, in 2017, our congress passed the “Tax Cuts and Jobs Act.” This euphemistically named bill did many things, among them was to eliminate moving expenses as a deduction beginning in 2018.

In preparation for this post, I read through IRS Publication 521 , detailing the deductions allowed in past years. I thought that it was a very reasonable set of rules. Moving for a job is expensive, and these expenses aren’t things on which we would voluntarily spend our paycheck. Particularly for resident physicians completing government-subsidized training, and now looking to serve society as a major, essential, part of the healthcare industry, it would make sense that the expenses incurred in the process should be deducted from our taxable income, no?

The “Tax Cuts” architects declared that we don’t deserve a break for moving. Ok, maybe I can see their point. I could reduce the moving expenses if I were personally responsible. Should I get a bigger deduction for someone coming over and putting my cookbooks in a box, moving that box to a truck, driving that truck 800 miles, and then putting that box in my new garage, as opposed to me just doing it myself?

The other aspect to this change is that any relocation package that your employer gives to cover this mandatory and cheerless expense is now taxable income. I’ve seen a few contracts at this point, and all of them have offered a relocation package. For simplicity, let’s say that’s $1000. If I spend that $1000 to move, I have to pay taxes on that money. My box of cookbooks represents a quantifiable percentage of that budget; let’s say $1. That means that after taxes it cost $1.25 to move my box of cookbooks.

The question is not if the “Tax Cut” is justified; that’s way beyond my pay-grade. The question now is: Should I move the cookbooks?

Accepting a recruitment package with moving expenses seems rather pointless. I could just ask for a bigger salary or request the money as a sign-on bonus instead. Yes it will be taxable, but it would allow me to make some choices. I could choose not to move the cookbooks. Instead, I could choose to donate or recycle them, then take my taxable cash and either buy new ones, or not. The obvious additional benefit to this plan is that no one has to lift, handle, or haul the cookbooks 800 miles (or wherever, maybe it’s 80 miles. Not telling yet!). Seems like a win-win.

I recently had a consultation with a professional stager to prepare my house for the market. I’ve intentionally cut clutter and try to keep items in their places. I’m working through the Marie Kondo “Lessons,” and I’m particularly proud of my neat and organized closet. However, this lady destroyed me. It was brutal. I found myself struggling to keep up with her, scribbling away notes while simultaneously moving items to the ever growing “edit” pile in the floor and apologizing, “Oh, yeah, um sorry, bought that for our first apartment 12 years ago.” By the end of this appointment, the perimeter of my home looked adorable with sparse little vignettes and cozy furniture groupings, while the middle of the floor was a ransacked pile of shame.

So what should I do with this shame-pile? Should I pay taxes to move it? After this experience and in the context of the new “Tax Cuts,” I’m not only asking myself what sparks joy, but what is worth a 25% tax for the privilege of moving it. Should I pay taxes to move this 3-ring binder? That ill-fitting jacket? Our unread books–gasp?

Of course, I have to consider the cost of moving the item versus the cost of replacing it. If I have to re-purchase an item, obviously I’m going to pay taxes on the income used to purchase said item (~25%)+ sales taxes (~7%), so that would be more like 32%. So the mathematical equation becomes whether it will cost <7% of the replacement cost of the item to move it. And wow, writing it out like that makes me realize, in horror, that to buy something that costs $1, I have to make $1.32! This is why Mr. Money Mustache says, ” cutting your spending rate is much more powerful than increasing your income.” (Also see this classic MMM article).

I feel like this is a good step in the direction of paring down our stuff in case we ever want to make an international move, like the Copelands or the Duponts. It is certainly a good exercise in becoming more deliberate in how I spend my wealth (and yes, I do consider my pampered U.S. Citizen lifestyle wealthy, even on resident salaries). In the coming weeks, I will be exploring the concept of Effective Altruism, realizing that the mundane decisions regarding how we will conduct our move could have real implications on our impact for good in the world.

The bottom line is, I’m planning on letting the moving companies keep their fancy boxes and strong backs. I’ll hoard my Sunbasket boxes for a few months and only put the essentials in them. I’ll sell most of my furniture, and fit what will into another U-Haul trailer, load the dog, cat, and kids into the SUV, and haul what remains to the next home. There, I will make sure my house is a haven, and resist the urge to buy cookbooks.

How have you saved money on moving expenses? Have your contract negotiations been affected by the new tax laws? Please comment!

Why I hid my breast lump from my husband

We welcomed our sweet baby girl into our family in late September, and the fall was a busy and challenging season. The weeks of maternity leave passed in a blur, and then it was time for my follow-up appointment with OB. I was nursing my newborn when I palpated a firm, elongated lump. As a general surgeon, I had palpated similar masses in patients undergoing lumpectomies and was concerned enough to mention it to my doctor. She examined me and to my surprise found a second mass. She referred me or workup of both areas.

At this point, Josh was in his final months of a year long neurosurgery chief service assignment. He was exhausted and burned out. He left daily at 6 and came home around 8 to 10 pm each night. I was doing morning and evening routines with the girls alone most days, and he was heartbroken from missing out on this time with the girls. I tried to shield him from domestic stress with varying degrees of success. Some days I would throw my own pity party and fuss about how much was on my plate, but mostly I really tried to get the chores done and let him enjoy quality time with the girls. Nevertheless, he was maxed-out, and I just couldn’t bring myself to burden him with the news of my appointment in the Breast Clinic.

I had completed several rotations on the Breast Surgery service in residency, and it was surreal to sit as a patient in the waiting room. When my name was called and I was ushered into a room, I saw one of my former consultants down the hall. She smiled and waved, and then a flicker of inquisitiveness crossed her face. I smiled one of those acknowledging, pursed lipped grins and ducked into my exam room. The result of that appointment was a recommendation for an ultrasound the following week.

I debated telling him about my upcoming ultrasound, but I just couldn’t. I felt like it would be selfish to tell him, but I had never kept anything from him before. Since med school, we have lived, studied, and worked in the same building. We have the same groups of friends, the same gossip. No detail is too mundane for us to discuss together. But here I was omitting something rather major. On the other hand, maybe I was just being melodramatic; this notion was compounded in my mind by thoughts that I was going to need a biopsy, maybe had cancer, maybe would need chemotherapy and surgery, maybe wouldn’t be able to keep nursing my newborn, maybe wouldn’t be there for my girls as they grew up…I had to keep reigning in my imagination from these dark ramblings.

I didn’t tell him that week. I called my sister and my mom, venting my stress to them. I called my best friend and asked whether I was doing the right thing. I got various bits of advice from each of these trusted confidants, but I didn’t know what to do. That weekend, we had to drive 3 hours to South Dakota for my weekend locums assignment. I waited for Josh to get off work, and he didn’t get out until after 9 p.m. I picked him up and tried to gauge his mood…Not good. He quickly shared with me that he had made an uncharacteristic mental error that day; no one was hurt, but he was very shaken by it.

I felt a rush of adrenaline pump through my body and inwardly panicked thinking that I had nearly made a huge mistake. This was one of those profound, “Oh Shit!” moments in life. If I had told him about my breast lump the day before, if he had to donate a thought to the scenarios floating around in my mind, if he had to spend an ounce of energy on the stress of thinking through the possibilities, I would have thought that this mistake was MY fault. If someone had actually gotten hurt, I definitely would have felt responsible. This was a new reality of having a surgeon spouse that I had never before considered.

On the drive and throughout the entire weekend, Josh oscillated between ruminating over his error and trying to enjoy the long weekend being “just a Dad.” He took the girls for fun activities while I worked, and we enjoyed some family dinner dates. I never told him about the lump or my upcoming appointment.

My stress the following week compounded. I wasn’t sure that I had cancer, but I was sure that I would need a biopsy. I had other locums assignments coming up, and I was imagining trying to reconcile my schedule. I wondered how long it would take me to recover. I wondered if I would develop a milk fistula from a needle or surgical biopsy. I imagined being exposed in front of my mentors and resident colleagues. I had tremendous guilt over the hysterical idea that I wouldn’t be there for my husband and children. I vented more to my mom, sister, and friend. My impatience for the ultrasound appointment was almost unbearable.

Then, finally, the day came. I dropped off the toddler early at daycare and then trudged through the clinic carrying my newborn in her car seat. I changed into a gown, nursed the baby so that my ducts would not be dilated, and waited for my turn. She fell asleep in her car seat. I climbed onto an exam table and stared at the ceiling while the radiologist searched for the lumps. When she had finished her exam, she gave me the excellent news that she had a very low suspicion that these were dangerous; one was just a very dilated area of normal breast tissue and the other was what she called a “lactation adenoma,” which I had never heard of, probably because those never have to be surgically removed. She recommended 6 month follow-up ultrasound and released me from the appointment. I was elated.

Josh came home from work at a reasonable hour that evening in a good mood, and I had dinner ready. I told him then about the entire situation, quickly cutting to the point that the result was reassuring. He stared at me with wide eyes and a crestfallen expression. Then he looked worried and asked again if everything was ok. He couldn’t believe that I would hide it, but I explained it to him and he didn’t give me a hard time about keeping it from him.

So here we are, a married couple deeply in love, but who have to consider the safety of one another’s patients in the news we reveal to one another. This was a new facet to our relationship, but one I can’t deny is important. We have to calculate if the stress of concealing a difficult situation outweighs the risk of burdening one another with it. As a two surgeon family, the personal and professional lines do get blurred sometimes, and I can only imagine this will become even more true working in austere environments where we don’t have stacked teams of surgical colleagues to rely on for support in the OR.

Anyone who has a spouse dealing with burnout might relate to the precarious balance of being a life-partner while protecting them from stress. I’ve also learned how it feels to be the “homemaker,” while my husband finishes an all-consuming training program. Particularly back then, while I was still on maternity leave, I experienced for the first time the stresses of being a stay-at-home parent with an over-worked spouse. I have to say, anyone fulfilling that role for an extended period of time deserves praise for the amazing amount of work and mental energy that is required. It was a humbling experience for me.

At that point in time, we were definitely operating over the line of what was healthy for our family. As physicians, ww hear about the consequences of burnout routinely, but this scenario was one I had never before considered. When I recovered from my own burnout in 2015, I realized that not even having time for a dog was my personal red-flag that I was giving up too much for work/training, and so I coined the motto, “If I’m too busy for a dog, I’m too damn busy.” Well, that was a much cuter illustration of this principle. I discovered just how much training was requiring of us, and it was tremendously more that I had previously estimated. Still, if we reach that goal of being able to truly relieve the suffering of many others, is it not worth it?

What would you have done in this situation? How can we establish healthier boundaries professionally? I would love to hear your perspective in the comments section below.

A general surgeon and a neurosurgeon’s path to employment: The job search

I thought this was going to be the fun part. As my friends have graduated from residency and moved on into their grown-up jobs, I’ve wistfully wondered how amazing it must feel to be wooed and recruited to a glamorous physician practice. I’ve also observed with a degree of incredulousness as my friends have each complained about the anxiety of this process. I didn’t believe them. C’mon, man, you’re at the good part–the reward for all your hard work! You’re just being humble, right? It must feel great to be at the end.

But now I get it. Josh and I have spent something like 13 years (THIRTEEN! YEARS!) hammering away at this goal. Our pre-med requirements (2 years) deserve their own chapter in the tome that is our professional training, and then med school (4 years) was tough but of course a blast, and residency (7 years) has been a mixture of great and terrible, but generally complicated and incredibly tough. So here we are, ready for launch. All we have to do is pick a destination. But it’s been very, very, very difficult. Want to know why?

For starters, there are two of us. So we must each find a suitable job for ourselves and then check to see if there is a corresponding job for the other one. Once that is established, we delve deeper and even go interview, only to realize that the job might be great for one of us but not ideal for the other one. On and on the cycle goes.

Next, there is the fact that we have children. When we ranked Mayo #1 in our residency match lists, we were confident this was 100% where we wanted to be. With no kids, th move felt like an adventure. I knew we would miss our wonderful families, but I had no complicated feelings; it felt right. Now, we DO have complicated feelings about being away from Family. Our extended families are pretty great and would undoubtedly be a wonderful part of our girls’ childhoods. But, because of the situation in the previous paragraph, we have considered several jobs far away from family and we have found good opportunities here in the midwest. Nevertheless, being close to family is a weighty factor in this equation.

Next, there is the decision to make between private practice and academics. Many residents will clearly see themselves as one or the other, but Josh and I are both firmly on the fence on this one, Josh more-so than I. He has always pictured himself in an academic job, teaching residents, publishing papers, and doing more complex cases. As I’ve seen myself more as a trauma surgeon these past few years, I’ve also assumed I would be a part of an academic trauma/critical care practice. Additionally, at Mayo we are not exposed to the private practice world and know nothing about RVUs or running a business. The interview trail has been a crash-course in different practice models, and I’ve had to do quite a bit of reading about reimbursements, opportunities for buying into practices and surgery or imaging centers, etc. Josh and I don’t really love big cities (Rochester is about right for our level of excitement and tolerance for traffic), which really makes working in academics more difficult. So to find that perfect “big hospital in a small town” again, we’ve found mostly non-academic positions available, which has required a big shift in mindset for us.

We also want to select the right pair of jobs keeping our North Star in mind, which is that one day we want to be working on major global surgery projects. Whether that means moving overseas long-term or not is unclear right now. My thinking has been majorly influenced by the book Love Does by Bob Goff, specifically for the many examples within it of the merits of having a steady, good-paying income here in the U.S. and being able to invest in amazing, high-impact projects elsewhere. Josh keeps reiterating, “I just want to help a lot of poor people. That’s what I feel like the meaning of my life is.” So while we know that it’s necessary for us to work here in the U.S. a while, the bigger goal of wanting to be financially independent so that we have the freedom to pursue this humanitarian medicine path is constantly on our minds. We are trying to select positions that get us closer to this goal, but to be honest it feels like all of our options are only taking us farther from what we ultimately want to do.

Lastly, we have dealt with some serious disappointment from a practice that really sold us on a vision for both of us, and then my half of the deal completely fell through. This practice kinda had it all–location near family, a great group for Josh, opportunities in both trauma and critical care for me–but in the end the administration just couldn’t work it out. This situation was difficult to get over, and every job we have interviewed for since then has been compared to what was this original dream scenario.

As of now, we have essentially 3 choices. One of these choices is close to family. The other two are far away but have their own merits. When we’ve signed a contract, I’ll post more specifics about the positions, locations, and our decision making process.

One day, I hope to have some wisdom from the job-hunt to share with other young physicians. In the meantime, I would welcome any advice my readers my have for selecting a job. What do you wish you had known? What helped you make a great decision? What might you have overlooked in the process? Please leave a comment below.

Frivolous post: What is up with sock options?

I haven’t written a post in a while because I left town for a locums gig and came back with a stomach bug. I’ll try to get us back on regular posting schedule with a brief one on socks, and how they relate to my overall life goals.

I embraced the low-clutter lifestyle a few years ago. Before the Kon-Marie method became so popular, I read and re-read the book It’s All Too Much by Peter Walsh and really attempted to live by the principles. In my first big purge, I donated truckloads of unnecessary belongings and threw away an embarrassing amount of junk. Through the years I’ve had spurts of renewed enthusiasm for the clutter-free lifestyle and Kon-Marie’d my closet a couple of years ago.

Image result for its all too much book

Since I’ve gotten into the personal finance blogs and podcasts, I’ve become more intrigued by “essentialism” or “minimalism” as they pertain to not only stuff but also time and energy.  These disciplines are simply just a mindful way of spending money and living life, but ascribing to them has been quite liberating.

About a year ago, I had a rage attack while folding clothes. The inciting event was a basket full of unmatched socks that lived in the bottom of the clean laundry basket. Every few weeks I would painstakingly sort and match dozens of pairs of stupid socks. Most of them were white or gray, and had slight variations, but we had colored ones also. My husband just wore mismatched socks, but I couldn’t really stand doing that. By that time, I had been influenced by various personal lifestyle bloggers who discussed meaningful use of time, and I got fed up and just decided to quit.

I drove to Costco, bought myself two packs of black no-show socks (figured they’d last longer than white), and I threw away all of my socks. I offered to do the same for Josh, but he declined so I just threw his unmatched socks into his sock drawer for him to deal with.

Since doing this for myself, I have seen sock problems everywhere. You can’t shop for a pack of socks without getting six different styles of socks. Even most “white” socks will have a little thread in the toe or at the top that is pink, yellow, blue, green, teal, purple…WHY??? I don’t really know for a fact, but my conjecture is that the sock companies know most people want matched socks. Not everyone can be as wisely dismissive as my dear husband. So when we can’t find a sock’s mate, we consider that sock “out of commission.” We drop it in the bottom of some laundry basket and there it sits, in-prisoned until its match is found. But we never find all the matches, so then we are short pairs of socks. So we buy more socks. And on it goes. The more socks you have, the harder it is to find the other mate, as they are swept further apart in a sea of ever-so-slightly-different foot-mittens.

People aren’t shy when it comes to complaining about their consumable goods. Yet, in all my 34 years I have never heard anyone criticize their athletic socks, lamenting that if only there were a fuchsia thread near the toe they would be so much more exciting. Now, I’m all about the exciting sock trend with ironic, funny, sarcastic, and rebellious scenes and phrases; that is different. In fact, I would gladly still wear my “Kick this day in it’s sunshiny ass” sock if I could just find the other one. But most of these special socks are sold as single items, so if one design really spoke to you, you could purchase 7 pairs and just be done matching them forever.  Or if you just have one of those days, you can wear your obscene socks and snicker to yourself all day. This is a legitimate coping strategy.

My toddler is legitimately low on socks, so I decided maybe I would buy her some nice socks from Pacts Apparel or Bombas for Christmas. Here are the some options:

Pact’s toddler socks

Many more options for sock "packs" available...with a discount!
Bombas toddler socks

Not a SINGLE option to buy a pack of all matching socks or to buy them individually. Amazon was even more dramatic. I sifted through about 30 options for packs of “variety” socks until I found the one containing all white and matching pairs. I bought that one.

I might make fun of my husband wearing the one green and one blue sock, but  he’ll smile because he knows he’s above caring. But if I send my kid to daycare like that I’m a terrible mother (or at least struggling pathetically).

Ok so this is clearly an outrage and a conspiracy to make everyone buy more socks. Fine. But from a perspective that is more relevant to my life, hopefully yours, this is just one of those marketing tools that I was completely naive to for like THREE DECADES. How is it that I didn’t realize sooner all the hours and money I was wasting by letting the sock companies dictate that my purchase would be six pairs of slightly different socks? And how many more of these money and time wasting strategies am I falling for? Well the answer to that last question is, “Lots. Guaranteed.” and I’m hoping to do better by hunting them out and doing away with them ASAP.

No doubt we are wasting our precious time on other useless tasks. As medical professionals, much of the day spent on redundant documentation and butt-covering tasks will feel like matching a basket full of stupid socks. Over the arc of our careers, we might waste years of time on tasks that don’t contribute to our big goals. The potential is more than theoretical, it is the normal and expected narrative that ensnares the majority of us. I’ve heard countless times from late-career physicians, “I wish I had taken mission trips sooner,” “It was always what I wanted to do but I just didn’t do it for whatever reason.” Life is so busy, so cluttered, that our “urgent task” list never gets done, and so the big, optional goals never get prioritized.

My practical advice is: Be boring when it comes to socks. Get  a dozen identical pairs and throw them haphazardly into your sock drawer. Never match them, and yet always have matching socks. Or be like Josh and never match them and always have non-matching socks.  It’s kind of his thing.

Don’t let pesky little tasks steal your time and joy. Stand up and shake off these menial little traps, and don’t delay what’s important. If you want to do missions, make it happen. If you want to give more charitably, just do it. Find what’s holding you back and eliminate it.

I’m speaking to myself more than anyone else here. This year holds big decisions and little decisions that could alter our trajectory for decades down the road. I’m hoping that making a bunch of little improvements in how I spend my energy and money that make me 1% better now will result in a life that is 1000% more fulfilling.

What have you found to be holding you back, wasting your time, or stealing your joy? Comment below!


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?