Whoa, I’m feeling good. There’s a lot to put down here, and I’m going to start at the end. I’ll try to unwind some of the thoughts I had on the walk, but I wish I could have captured them in the moment. Anyways. Part of the end is being on the road and showing up in a town and giving a talk, playing a show, and then seeing patients. Stay around for a week or so. Hang out in a coffee shop. Meet people and explore. Try things out. But start with a connection to a doctor friend if possible. I could post on FB: “So I don’t have merch, but uh, I’m a primary care doctor and I’m seeing patients tomorrow. If you’re having trouble with your blood pressure, feel depressed, or dealing with low back pain hmu.” And charging like $25 for 15 min appts. Just line ‘em up and knock ‘em down. 8am til noon and 1pm til 5pm. If it’s busy, make 800 bucks. They can wait to see the doc. If I see 8, I make 200 and that’s cool. A good day’s work. It’s super affordable for people. It’s accessible. People will connect. It will be rad. And then I just hop to the next town. Boulder, Fort Collins, Durango, Eugene, Klamath Falls, Vancouver, Olympia, Port Townsend, and on and on. Go, go go.

So I have been feeling upbeat lately. I have a vacation coming up and I am looking forward to being done with residency. I know this is all in flux, but what I see right now is probably doing some locums. I have a hunch that I won’t really like locums. But I will be a board certified family medicine doc and I will be qualified. I will make some money. I will have some flexibility. It can give a framework to my travels. Or it can fit into the framework of my travels. I will practice my skills, gain skills. I will learn and earn money. And, ultimately, maybe I will have tried it out enough to feel okay giving it up. That can be part of the process. I don’t have a STRONG need to do locums at all, but I do think it will be part of it.

The other part is the dream clinic part. I struggle to describe the dream, but writing about it is part of the practice. I want patients to value my time. I want to spend time with them in a meaningful way, and I want them to pay me for it. I think there is a kind of breakthrough that happens when I have convinced myself that my time is valuable, that I bring something valuable to my patients when I am present for them, and that they are willing to pay for it. It empowers me to leave the system behind. It allows me to travel more easily and set up shop again. I can work with the flexibility of letting myself and the patients define the practice.

And I can tinker with it. If I want to see more patients, charge less. At the beginning, I can charge rock-bottom rates and not even make money and just get practice. Just learn how to do the thing. And be grateful for my patients, and offer them exceptional value, and then, after having some experience and some success, THEN scaling up. Like shifting from 25 dollar appointments to 150 dollar appointments. That can happen. It will be almost a different phase. And eventually, in maybe 5 years or 10 years, if things go extremely well, then I’ll have new problems, but the sky will be the limit. If people really adore what I do, and they can’t find it anywhere else, and people are lined up for months, the sky is really the limit. They want what I got, and I only got such a little amount of it. I can charge 400 dollars, or a 1000 dollars and I can be full. I don’t see any reason to really charge 1000 dollars, but I do believe it is true that I could be in such demand that people would pay it and I couldn’t see them all.

That is somewhat pie in the sky dreaming. That is if things really, really, really take off and the kinks are ironed out, and I have a book and I am somewhat known for my work etc. etc. etc. And I might not want to go there. I might not want to be there. But it could happen, and at that point, if I like seeing patients one on one, I can just find the right price, and the right volume and enjoy my life. Do my hobbies. Take my time off and support myself with a career I enjoy. But, maybe if I don’t like it quite so much, or it doesn’t feel just right, or if my interest leads me this way, I might get into training community health workers to replicate my work, to expand my work. I might work with other doctors to do similar work. I might do coaching or I might do consulting. I could make bigger money doing this… but again, what for? I really don’t think I’ll need the money, so just do what is interesting.

So anyways, again, the first step might be doing locums and traveling, or the first step might be opening my clinic right here. I could stick my name on it for just a few months, and then hit the road. Get out of town for the winter. In those first months, just try to see patients. Keep it cheap. Work somewhat hard. But have a deadline and then move on. Have a 1^st and a 2^nd locums contract lined up. Do a lot of stuff early and then take a break. Make the transition first and then relax. It’s somewhat opposite from my earlier thinking, which was that the in-between is the right interval to take a break. And I thought so because for most people, you get into the cycle of work and you never get out again. But for me, because I’m doing things so differently, I aim to always keep that element of break, of rest. And I just don’t want to be in that usual position of procrastinating at the easy time. Then it gets hard to get restarted. Because the thing that comes next, you don’t even know how to do. Break the ice, THEN take a break. It’s better.  July, Aug, Sept, Oct… 4 months of a clinic. Many would say it’s hard to make anything happen in such a short time. But I’m aiming for a pop-up. I want to see SOME patients. I can set goals. I don’t expect, or need to make much money. But try this thing. Get some experience before you leave town. Then maybe spend November, Dec, Jan, Feb either on the road, traveling, or at some point starting a locums contract somewhere. Maybe even the rest of the year (Until July again). And then you can re-sort. Reset. You can decide from there to reopen the clinic. You can keep doing locums. You can open a clinic back home. Or you can move on to doing the pop-up clinics in Colorado, Washington, and Oregon like you said.

These things all sound so sexy. Play music. Make art. Give talks on health. Exercise and take care of yourself. Protect some free time. Eat well and meditate. Date and build relationships. Support parents and friends.

Some day, how about a retreat center with your partner? Maybe. I could do that. It might make sense for the children phase. A farm commune somewhere. Maybe still be on the road to make money. And people can visit you if they want.

I think I am still open to the long legs of love. I’m not done yet.

I have some big level confusion about what I am doing with my life. Though I complain about medicine, I am here. I completed medical school. I am in the final year of residency training. I really haven’t much enjoyed almost any medical experience so far. I don’t like the medical model. I came because I started off inclined towards the authority as truth. I believed that science and western medical thinking was simply objective.

I come home from work and I fall asleep. I listened to a lecture tonight from a psychiatrist on trauma. I read a blog from an “intuitive doctor”. I dabbled around on my musical instruments. I did a meditation and I am trying to wind down for bed. As I was sitting, I was thinking about asking for help from one of my colleagues who appears to be navigating residency well.

I am unhappy. I have been unhappy through medical residency. I am afraid I will be unhappy after residency. It may be because residency was not the right fit for me. Some people are meant to be doctors. I don’t exactly know what I am “meant to be.” I think it can be anything. I believe in art. Art is important to me. I believe it matters in the world and that it is is a valid occupation. I mean, a valid career. I think of work as how one spends one’s energy. Time. And I think how putting my energy into medicine isn’t working for me. That’s a message I am picking up. This is the wrong place for me. I have been learning to persist, because that feels like an option to me. I am able to persist. But I do not thrive in the medical field. I am shut down. This is a confusion for me, and I think there are many wrong places to go with this. There are medical peers, or non-medical peers. Many people in my life, but most of them are the wrong people to go to. That is why I write. Because I just need this space to be honest. To explore. To dig. And I want to do this same work with songwriting, but it is not accessible right now. I have said that plainly before, but other times, I still beat myself up about it.

I am an artist in recovery. I am a human in recovery. I have spent a long time in a field that has been traumatic to me. What’s important to me is waking up to what I feel. Meditation is an important practice. Proper diet is an important practice. I want that not to be too rigid. By proper diet, I mean learning to cook a plant-based diet. I mean enjoying cutting the foods. Bringing presence to the process of cooking. Exercise is an important tool. I want to talk with people about their exercise regiments. I want to be a health counselor. I forget what I have said before, that the medical training was the long route to what I really wanted. It may have been the wrong route. But here I am. I don’t think what I will be doing is exactly practicing medicine. It will be a lifestyle clinic. I am not good at the analytic side of medicine. I am not good with the physical exam. It’s not technological, assembly line medicine I don’t like, it’s the paradigm of understanding problems as reductionist, material science. I am not a “scientism-ist.” I am an intellectual and a critic of “scientism,” the world view that is practiced as a religion of understanding our experience through scientific means. I am a spiritualist. Meaning I believe spiritual practices have value. I believe in god as a metaphor that is helpful for understanding the true nature of things.

So before I completely get off here, I would like to practice a healing modality that involves listening to my client. I would like to be sincere in my intention to help them with my recommendations. I am interested in mostly working on lifestyle as the mechanism to address “medical problems.” I believe this is a scientific process. I plan to use scientific evidence to help people.

On the other hand, is the residency’s coordinated care clinic. Which is where we meet very many real people, who have very many real problems and limited trust or faith in the system. The patients are dealing with drug abuse and trauma history and badness. And they need a doctor, and they sometimes show up. My clinic is trying to help. That is good work. But it is not my work. I think I can show up to the homeless camp and connect with people. Maybe I am wrong. Maybe that is idealism from when I was younger.

I also want to recommend integrative modalities to help with day-to-day issues. Like Tieraona Low Dog’s book. I feel like I’m just behind on life. Because I’m 31 and still in this holding phase. Still frozen. Still traumatized. I have felt that it is too hard to make a relationship work.

But what is it I want? That I haven’t figured out. It could be that I want to find a partner to raise a family with. I am searching for the ideal partner to parent with. That is definitely something I believed in at one point. And now, I feel interested, curious about exploring the beyond that. I feel bored with monogamy. Bored with marriage. I don’t want to fit that pattern. I want to be a more radical being. I want to at least explore that. What it means. I think it means being more open to significant relationships. But instead, at this time, I find myself more isolated than ever. Back home, there is this community sense that I could feel a part of. Now that I am away, I don’t exactly. I remember I had to kind of edge my way in. And because I was there, that was good enough for me. But I am dealing with isolation. I have acquaintances, but no WOEs. I’m borrowing that term from Emergent Strategy (Working On Excellence. Life accountability partners.) I want people in my life that I am working on life with. People I can talk to about stuff that’s going on with my ex. People I can talk with about wanting to be a musician. People I can talk with about meditation. What do I need in a WOE? Is meditation the key? Art? Empathy? Who is it I am looking up to? Who are my role models?

Some random bit of inspiration from the other day was remembering that I was sort of destined to break out of the system. Dr Williams, as one example, knows that I’m going to do something… different. And I think part of it is recognizing that I’m not 100% rejecting the system. What I am claiming is “I do not fit in the system.” It is not the right way for me to be spending my time. I have tried it; it doesn’t fit, so I am getting rid of it. That doesn’t have to be true for everyone else. I feel like the medical system is a bad parent to me. It leaves me feeling uncared for, underdeveloped.

And so I am piecing together my way out.

I think starting from a place of taking a job, any job, is not going to work. It may be part of my path forward. But I think the more I carve out for myself, the better.

So my dream is, I spend time with people and they pay me for it. We talk about the kinds of problems I can help them with. I want to leave the medical model behind. I want to not practice medicine. I want to have the perspective to help people avoid the medical system. Is what I am doing medicine or not? Maybe it is okay that this question isn’t answered yet. I plan to get a medical license. I plan to be certified by the Board of Family Physicians. But I do not plan to be hired by a recruiter looking for a family physician. It’s not a contradiction, but it is confusing. That why I need pages and pages of writing. Dig, dig, dig. I believe this is in the right direction. I really don’t know how accessible this is to the reader. I think… not very. I am not aiming this at the reader. It’s closer to “art as therapy” than “art as entertainment.” I’m not selling; I’m sharing. I am also confused about art and it’s relationship to those 2 directions. Worth exploring with artists…

Well, I finally shared the address with a couple friends, so now someone has read these words. I am feeling pretty high about my plan for now. I’m caught up on notes and my in-basket looks good. I have many tasks for tomorrow, but I’ll get through them. I have moved on from the 12 months off idea. Right now I am thinking of opening my clinic right away. I think I have learned enough about this city that I kind of will know how to promote myself. And it is a kind of trail run. I could be leaving for the road in the future, but it makes sense to test things out before I go. And so my idea is to give myself that first 12 months to try things out before I settle into a “job” job.

The point of my clinic is just one on one conversation. I don’t think I need hardly any equipment. I guess they can be house calls, why not? But I wouldn’t mind having my own space. Because I have such little needs, I think I could find something for free or very cheap. If I could have a piano there, that would be excellent. But what I’m doing in my clinic is listening to my patients. It’s not “primary care” as defined by insurance companies and the AAFP. It’s more like medical therapy. It’s like paying to spend time with a massage therapist or with an astrologist. I bring my background and training, and we sit and I listen to the patient’s stories. They pay me for this. I can help create a treatment plan. I can write prescriptions. But that’s not really the main point. I am mostly being paid to listen. And to offer my opinion.

And I guess one of the therapies that I really believe in is the whole foods, plant based diet. So we can talk about that, and how that can reduce the need for blood pressure medicine, or diabetes medicine, or anti-cholesterol medicine. We can talk about exercise. I can show you some exercises and we can write an exercise prescription plan together. We can talk about meditation or other stress relief techniques. I want to use and promote mind-body skills. People can find other places to learn this, but some will get a real kick out of hearing it from an MD. Who am I to complain?

And so I have the idea to charge for my time. My first idea was 170 for an hour and 100 for 30 min. But then I was thinking of the cost of living of this city, and am willing to bump it to 230 and 150. I believe the service I offer is valuable, and will be appreciated. I think people investing in our relationship helps them to invest in the changes that we talk about. And also, importantly, is I don’t have a huge capacity to do this work. To spend an hour with a person, really getting to know them and giving them my best energy, this is not something I can repeat all day long. I can do it maybe 2-4 times a day. I think I can do it 3 days a week. ~ish. At first I will be excited and maybe want to do more. Okay. But I think in the long term, setting a limit so that I am seeing 4 patients, 3 days a week. This is from a whole other world than traditional family medicine. It almost doesn’t seem to make sense. But then it does. If I see these 12 patients a week, my goal is that that will sustain me. That that will provide a comfortable enough salary that I will be able to meet my needs, AND pay down on my student loans effectively. If I am earning “enough”, then all the extra space in my life is mine.

The point isn’t to rush through those 12 hours of work. It’s 12 hours of performance. It’s actually a lot of work. To be really engaged with it. But also, to be really engaged with my whole life. Taking good care of myself is a full time job. I will be cooking. I will be exercising. I will be involved in the community. I hope to be writing and giving talks (?) IDK. I have hobbies! I want to have a band.

So I have this sweet life. I mean, I’m not trying to brag, but what I’m describing sounds awesome. And then I can travel. I can just not schedule patients for a week or 2 and go do what I want. The idea is this skill I’m learning allows me to make money easily, anywhere. I’m not a traveling musician, I’m a traveling doctor. My skill set is in my head. (My heart?) And so I can pop-up in my hometown for a couple months and see folks. I can work 5 days a week for a bit if that’s what I want. I can work intensively for stretches, and I can work lighter for stretches.

Part of this is that my intervention happens in the room. I am not a surgeon, but I am performing an operation. People are engaged and in the moment with me. We talk about reducing their meds. I’m trying to wean them from healthcare. So we have our appointment or appointments, and then we each move on. You’re welcome! It’s not this chronic disease management thing. Go to your “doctor” for that. I’m here to talk about it. I can help you to understand your medical problems. I want to empower you to eliminate them. And if we are successful, then you’re done, you graduated. Congratulations. Money well spent I hope. And if it’s not working, then maybe this model wasn’t for you. Thanks for trying. Thanks for giving it a go.

And so, on I go. And then what’s the next step? And the next step? Those will come with time. Who knows? I can’t see them yet, because I am still months away from these first steps.

But having this cool plan feels so empowering to be getting through residency. My peers/faculty have no idea what I’m really up to. I’ve tried telling them about it, but it’s just like there’s no starting with them. I can’t get past “Solo clinic” and they have a thousand questions to shut me down. So on with it. Just do the thing. And who knows, they may have some sense that I was up to some alternative thing, but they probably won’t get it even when I’m doing it. So anyways, just do it. Do the thing.

So I co-hosted a little event on the topic of wholistic medicine yesterday. A few said that it was a rich and necessary environment for them. That is wonderful, AND, it wasn’t that for me. I am always grappling with how to express myself and even figuring out what my own opinions are. Why am I in the medical field? I would like to help people heal. But I am also a musician and a meditator. I want to deeply listen to people. I overwhelm myself thinking about becoming an expert in integrative health ON TOP OF traditional medical care where I generally feel inadequate. It’s this expectation I have for myself to go above and beyond when I’m actually not quite meeting the standard. I could do better.

But I also have this attitude that my self-care takes over my life. I indulge in having the weekend slow time. I am not able to exercise or write as much as I would like. I am still in residency. I have neglected a few obligations recently, and that very well may bite me in the ass.

I want to be childish. It’s my inner artist that is calling out. I do not want to be this stuffy expert. I don’t want to control it all. I may be a family medicine doctor, but I don’t have the answers on how to fix the system. I don’t get it all. I am interested in facilitating. I am interested in community building. I am interested in deep listening and empowering.

I have this vision for my clinic, but I am not able to really describe it yet. I tried telling a friend about it yesterday, and it just seemed to fall so flat. Let me try again. I want to open a clinic in this city. I would like to rent a space that I have access to on a part time basis for very limited cost. I would like to have a piano there. I would like to initially set up one off consultations. The rates I imagined the other day were $170 for a 1-hour appointment, and $100 for a 30 min follow up. Then I thought about the cost of living in the city, and boosted it to 230 and 150. The previous rates were town rates. They are respectable, but also accessible for the people who value what I do.

What do I do? So this is the part that has been hard to define. I know it looks different than my current role at residency clinic. I am currently delivering medical care as part of a very large system. A big part of my current role is connecting patients with the other parts of the system that can help them. In my future role, I won’t be able to easily refer people for colonoscopies and mammograms and behavioral health consults and social workers, and so on. I’m not planning to perform spirometry or manage very much medical complexity. That is not my strength, and it is not my interest. I am interested in a “lifestyle approach” to health care. I want to simply create space to help people with their health behaviors by listening deeply. I want to have a core set of practices that I promote, but also have flexibility to customize and personalize the treatment for each patient/client/person. I want people to bring me information and ideas that I haven’t heard about it. I want to look it up and explore it together. I want to share my honest opinion. I want to listen to people talk about their mental health. I want to support them in coming off of their medications. I want them to choose another provider if I am not what they are looking for.

I want to be heart-centered. I want to love my patients and all people. I want to deepen my spiritual practice. I believe creating my own space will facilitate doing that.

So when I open up, I might schedule 1 person. It will be slow and deliberate. I might see up to 4 people on a busier day if there is demand. I guess seeing 8 people seems like an upper limit, and I wouldn’t choose that for myself. I want to respect that the kind of presence I want to offer works best when I am seeing 1-4 people a day. 1 sounds puny. But I am doing work in other areas. I am reading. I am writing. I am involved in the community. I am playing music and going to zine fest. I am getting myself outdoors and I am cooking. I am taking good care of myself.

And I am creating an experiment to deliver “good health” care. I am interested in using the word radical to describe what I do. Radical means “getting at the root of things.” That is my focus. And my personal view is not so biomedically focused. I want to simply be authentic. I’ll just have to tell my patients when they need to go see a “medicalogist” for concerns beyond my expertise (interest).

What am I doing in medicine? That is a big part of what this blog is supposed to be for. Most conversations on the topic lead to a superficial answer. I’m exploring the real answer for myself. Part of it is circumstance of course. I mean, I can look back at the times I made decisions that led me in this direction.

Yesterday I was seeing patients in clinic and staffing with one of my favorite preceptors. An absolute role model if there ever was one. She’s caring, thorough, thoughtful, patient, and she has also shared that she’s burned out and she knows there must be a better way of practicing than through our current system. But anyways, there we are. I had already seen 5 patients, and one or two of them had already significantly delayed me, or somehow thrown my mojo off to the point that I was looking to get in and out of those last 2 rooms. I was trying to do what I believe our system encourages us to do which is to put patients into boxes, label the diagnosis and prescribe a medication. Intellectually I’m a critic of this process, but practically I work in this system so sometimes it’s best to resign myself to the process.

So I had this gentleman who was in is 50s there to establish care. He’d been trying to lose weight and was interested in trying a medication that a friend had recommended, phentermine. He has been having outbreaks of herpes and needed a medication refill. He had a rash on his shoulder that I peeked at and believed a steroid might help. After trying to cram his complaints into the little boxes I stepped out of the room to precept and I went to this favored preceptor for the first time that day. And as I told her the story, she had more specific questions that I didn’t have answers to. How often did he have herpes outbreaks (should he be on a daily vs as needed medication)? What else had he been trying to do for weight loss? And maybe I could do a little more reading on the drug and get back to him. What were the other symptoms of the rash? Was he using any new products that could be responsible? (Is he having a contact allergy?)

These are good questions and she is a good doctor. These are questions I am capable of asking, but ones that I did not. I am (still (always))learning, and I am glad to have this great preceptor pushing me a bit. Many times my experience “precepting” is just whizzing through the story and it’s like a check off process, no learning, just a formality. But at this moment I was getting so much feedback that I was feeling demoralized. I was recognizing that I don’t like providing medical care. I don’t like asking so many questions and being so thorough. Even though it’s the right medical care, I felt like the wrong person for the job. I just wanted to get through my day and get myself home.

And so it comes back to “Why am I on this medical route?” I plan to continue on for another 10 months and end up with a board certificate in family medicine. But I don’t actually want to be a family medicine provider. I do not want to work in primary care.

One practical part of the answer is loans. I borrowed a lot of money, and I’ve yet to put a dent in that debt. I have had this idea, one that I haven’t shared too much, which is that part of the value in being “highly trained” is the capacity to earn a high wage. My goal is not to have a huge income, but to have a flexible life. By earning a higher wage, I have thought that I could work fewer hours. The logic of this is simple, but the practicalities of working less in the field of medicine are not so easy. Part of that is the medical culture. Many employers are looking for full timers, and they want you to take call and on and on. There are exceptions of course, and I will likely end up exploring those exceptions. Like locums for example…

I still believe that I AM in the right place when all is said and done. Residency is hard. The modern medical system stinks and primary care is dysfunctional. But primary care is also necessary. And so that creates this position where I am getting the skills to do this broken job, and I want my work to be in the direction of making it better. I value meaningful work, and the fact that my day-to-day duties often feel to be a means to an end is just one of the many reasons why this route is so difficult.

I have this interest in what I have been thinking of as “radical medicine”. By radical, I mean “striking at the root of things.” And in this view, I do start to wander from mainstream medicine into alternative. Because in my view, the roots are behavior patterns and psychological processes. In my dream clinic, I aim to empower. The work I aim to be doing is partially intellectual in processing the available evidence, and it is partially compassionate or empathetic “work.” It is spending time with people with presence. And I think to do this work I need to build a new model. A 99213 code sent to an insurance company is a box that it’s time to break out of.

I have been feeling miserable at work lately. I had a full day of clinic yesterday that included 10 (urgent care style) visits in the am and 7 full visits in the afternoon. My mood was foul. I woke up and dragged my sorry ass to work. I thought of calling in for a “mental health day”, whatever that is. I just didn’t want to go to work. I dreaded seeing patients. And here they came, one after another. I don’t like my job. I feel like the most suffering person in the clinic. Is that so? Does the MA feel less of this evil spirit? Does the nurse?

Part of it is dissatisfied patients. I had this young woman who has been having abnormal uterine bleeding. She wanted to have answers today, and when I set the expectation that that might not be possible, that was the end. She became mad at me and just wanted to leave before we even had the chance to connect, for me to hear her story. She needs to have an ultrasound, but she is not willing to work with this system, to set up the separate appointment, and then show up for it. I wish I had been able to help her, but I also understand that sometimes the problem isn’t accessible to me in my role.

What else? I’m not sure. I’m not sure what I’m trying to say. But my mood was in the gutter. I had my afternoon and I came home and sat around. I was depressed. I’m trying to get some tasks done today. I have 5 days worth of notes to catch up on. Lord. I’m supposed to go to this wedding today and I’m not looking forward to it. Okay.

I want to have a lifestyle clinic. I want to open up my shop in an arts building or a bookstore. I want to have a “pop-up” medical clinic. I want to talk about my medical views which are not unscientific, but which point to the value of lifestyle in risk reduction instead of pharmaceutical management. But I also want to explore my unscientific views about energy healing or whatever the fuck. I’m not even sure what it is. I want to meditate and I want to make art. I want to be more free.

I want to cook and have a good life. I want to be undepressed. I want to unfuck my life. Get out of the medical industrial system!