Sigh. I’m not sure how to put here what I want to. But I’m sitting on something that feels heavy. I think part of the problem is that I expect this “art piece” to come out well formed to serve a purpose, when the purpose is simply to transmit honestly the experience as a process.

So last night I went to this event, sponsored by my hospital, that was a “Story Share” for physicians associated with residency programs in my metro area. It was at a brewery and it was kind of a swanky thing with hors d’oeuvres and craft beer, and I think it served its purpose well. They were at capacity and they had 20 readers. Self-care prizes included massage vouchers, coffee coupons, and a pre-paid cleaning service. We all do need a little help and those are sweet and thoughtful gifts. I didn’t read. I had thought about participating, but honestly it is a lot to share in general, and then the specific context of sharing with medical peers really changes things. I have a strong feeling towards speaking something truthful. And art has a purpose. In my case, I feel like my words speak in antagonism to the status quo, and so they generate discomfort for those invested in the system as it is. Which in this case, were the hosts of the event.

And I did speak with the Director of Academic Affairs (Dr. Rowan) from our hospital, who was involved in putting the event on. She knew, on some level, that I had something to say. She asked why I didn’t read. Well, I came to listen, I replied. But really I thought about it and it felt like too much to integrate my artistic purpose and my goal of completing residency. I don’t think that would have made any sense to her. But I do feel this kind of Venn diagram of my life. There is this physician role, which consumes my life, and that circle seems to be pulling away for the other. The artistic self. They can overlap more perhaps? I like to sit at the piano and sing with my guitar, but those activities get stripped thin when my energy is gone.

Some of the readings last night were heavy. An anxiety attack after day 2 on the MICU with some serious morbidity hovering around a completely fragile and humbling experience as a new doc. Dealing with a medical diagnosis of major depression as a medical student and how the time demands and the sleep sacrifice created bigger problems. One reader had collected vignettes of suicidal ideation from medical trainees at her institution where there had been 4 (FOUR!) suicides in her time as a student. 2 faculty members spoke, and their stories were personal, describing the damage they have taken on through their participation in this system. And now they have settled into positions that work for them it seems. But they were airing their grievances last night.

On one hand, what the fuck? I mean, I feel relatively “in the scoop” as far as physician depression/burnout/suicide go. But then, here we all are talking about it, and what does it amount to? This is a blow-off valve. Back to work we all go. We don’t know how to fix it. We don’t know how to address the systemic level problem that has made this profession so miserable. We do our jobs and we complain. Take the good and the bad. That’s where we are.

Perhaps my art can be more visionary. I could’ve read something about my plans. About my dreams. We need some dreams ya’ll. Signing a contract to eventually get out of debt ain’t it!

I called in sick to work today. It is a very hard thing to do as a resident. I was thinking about it last night and I was kind of gearing myself up for it. I woke up early today just to do it. I had to rehearse what I was going to say: “Hi Marge, I’m not feeling well today and I am going to use one of my sick days. I was scheduled for clinic in the am and pm. Thanks.” It is hard to say! I literally am afraid I will be somehow rejected and they will make me come in. That is not grounded, but I feel it.

So anyways, I call at 7:30 and it goes to voicemail, she is out of town and I am supposed to call her assistant. Ok. Repeat the rehearsal and then make another call. Same thing. Another voice mail with a message to contact the chiefs. Well fudge. I go to my computer to look up their schedules and send a text message to one of them, and then anxiously await the reply as minutes pass by. It’s creeping towards 7:50 and I’m thinking that my patients are literally getting checked in right now and nothing has happened. I call the front desk and of course am put on hold for a long bit before I talk to somebody who transfers me to someone else, who then wants to transfer me to Marge “hold on,” I call out. “I’ve already called Marge and she is out of town. I’ve called her assistant and she is out. I know you’re not the right person to contact, but don’t just transfer me to her voicemail.” So she says she will look into it and hangs up. I don’t even get her name. I decide to text the other chief. Now I am just anxious, and it’s getting to be 8:10 and I haven’t heard back from either of the chiefs. I looked at their schedules and one is supposed to be on study time at the clinic, the other is in our urgent care clinic.

So much for going back to bed. I am anxious and feeling guilty and not sure what to do with myself. I am physically laying in bed and letting the minutes click away. Finally, about 8:30 I hear back from the 2^nd chief that it’s okay, she’ll contact a 2^nd back-up admin staff person to let them know and take care of it. About 5 min later the other chief gets back to me with a similar message. Fine. Woo. I finally feel somewhat relieved. Now on to my morning.

I alternately feel guilty and validated. I have been dragging this week and I just am in a bad mood. I had clinic yesterday and I was frustrated with my MA, and I really felt overextended to be doing the basics of my job for patients. Today I was scheduled to see 16 more people. I thought about, and felt guilty about those people each either being rescheduled, or cancelled or whatever. But also, the clinic is responsible for making decisions about who needs to be seen urgently and who is appropriate to reschedule. And more importantly, if people are taking time to see the doctor, they deserve the attention of someone who is feeling better than I do. If I am fried, I am prone to taking shortcuts or not providing the best care. I want to provide the best care. Taking responsibility for 16 patient visits today when I am feeling fried is inappropriate. That’s what sick days are for. I am caring for myself.

In this (medical) world, you’ve got to take care of yourself. No one is doing it for you. They are just pushing, pushing, pushing. I am more sensitive in ways that do not get seen by this environment. I have to advocate for myself. And in the end, people deal with it. Others have called in before. When I am in clinic, and I know someone else has called in, I might have 2 thoughts about it, but then I get on with my day. That’s it.

And I am moving on. I am thinking about the beyond residency time. And I am thinking about medicine from this philosophical place. I lean towards outright rejecting the system as a whole. I think that is an emotional reaction and that the truth is not so black and white. There is a lot of good that happens through the system with the bad. Some are in better position than I am to be working with that good. But I think about this whole RVU game that the system is playing. Decisions are constantly made consciously, and subconsciously to play the RVU game. Patients deserve better than that. The RVU game serves the medical industry’s interests. I as a primary care doctor am stripped of any power, any agency when I am tied up in the RVU game. What kind of patient relationships can I have playing that game? They don’t feel like much to me.

I am reading this book by Henry Emmons “The Chemistry of Joy.” Part of what he is describing is an empowering model of delivering care that is based on education and not relying on pharmaceutical power. And I am reminded, that in the role that is set out for me, I am designated to prescribe a lot of medications. I am to “screen people for depression so they don’t miss out on the profound benefits of miracle drugs.” Well, it’s actually so much more complicated than that. When the SSRIs give people a little boost, so they have this story that “this is what normal feels like”, it’s actually a little trick to make them a bit elevated in the short term. It’s a fucking gimmick. They don’t work well in the long-term. And here we go, peddling them freely, often because we believe we are doing some good. And so my reaction, which is maybe also unhelpful, is so antagonistic in the other direction that it’s sometimes just like a grinding brake. I just want to stop everyone from taking medicines when actually in truth, some situations and some people benefit and they are used successfully and it’s not so black and white. It’s so hard to articulate why it is hard.

Last night I was on the phone with a friend (Raven) in Oregon with a natural health clinic and Adderall came up. She said she doesn’t use it, and that then people thank her. She made a comment about how it fucks you up and makes you less heart centered. I believe that. It puts us a little bit on overdrive. Ego. Confidence. SSRIs do that too (artificial calm). People get inflated chemically. Our world is so filled with exaggeration.

Our Department Chief gave a talk on coding and billing. RVUs. And also, as it turns out, contract and job information. Most jobs ask you to work 4.5 days/week and 44 weeks/year. Ok, so I saw 15.7 RVUs in one sample day, which would make 3108 RVUs for the year. Times 45 buckos, and that comes out to 139,887 for an “earned salary.” Hmmm. Well, primary care loses money I guess. You have to work very hard to make money. But salaries are more like 180K to 210K. He said the translation doesn’t exactly work out.

I had coffee with Dr. Williams. We stayed for like 3 hours. I felt like I was overstaying my time. But she didn’t complain. She thanked me. So, I guess it’s good. Our program has problems.

Welcome to the revolution. It starts with me and you taking care of ourselves. Woo. I’m feeling pretty good. I just got done a long clinic day and then I went to the Y and walked. I was cracking up coming up with good ideas. I plan to go on a medical/musical tour. I’m going to do the bit onstage about “I don’t have any merch, but I am a primary care doctor and I’m seeing patients tomorrow. $25. Bring your backaches, your earaches, your non-psychotic mood disorders, let solve some problems! I’ll have my tourmates do the typing on our medical typewriter. I don’t have to fill out of bunch of extra paperwork for any insurance companies. I just need to have some record if I get sued!

I was also thinking about how I am down most of the time, but people seem to think I’m doing a good job because that’s what I show outwardly. A lot of us are doing this. It’s nice that we are able to keep it up in some cases. And it’s okay that some people never are. We are all at different stages and that’s okay.

And I was thinking about my program. There were clear times as an intern where I felt that situations were unsafe for our patients. It is so inter-related to the culture of the program. It’s very hard to know if the problems that affect my program are really worse than they would be at another program. It can seem like it, but hardly anyone really has good perspective on that question. At one point when I was an intern I called an old friend from medical school who was a G3 at the time 2 states a way and was asking about some of the problem areas of my program. She sounded pretty surprised to hear I didn’t think I had enough supervision. I remember at the time wondering if I should think about switching programs in hopes of getting better training for my future career. I was worried that the foundations of my medical career had bad roots. That still may be true. But I don’t worry about it as much as I used to. There definitely is an effect of adjusting to your circumstances. And in the case of residency, we can normalize some pretty shitty conditions.

I know the new interns are going through some of the growing pains. I was talking with one about the difficulty of being an expert in such a broad array of fields, and how that is really counter-cultural in medicine. The mainstream gears towards specialization. Every medical problem has specific, sometimes technical answers. And if you are caring for the problem, the expectation is that you should be giving the best care. You can’t give the wrong antibiotic for a kid’s sore throat because you don’t see them very often. You shouldn’t undertreat a senior’s COPD because you aren’t up to date on the latest GOLD criteria guidelines. If your laboring mom meets pre-eclampsia criteria, you need to recognize it and induce her for delivery. If you know enough to get the consult, that’s all fine and good, but the danger zone is when you don’t recognize that you don’t know what you are doing. Anyways, primary care is a hard job. Even if some of our visits are easy. And the end of that conversation, she was pretty sure she needs to do a fellowship to narrow her scope so she can do a good job with it. That is a common sentiment in medical culture.

And so with our program’s culture, there are obvious problems. Some of them are BIG, some of them we are working on, and some of them WE ARE NOT. I recognized that I would be able to get through the training. I recognized that doing so would qualify me as a board certified family medicine doctor. I recognized that that doesn’t mean as much as I thought it did from the outset. The standard is sometimes lower than you might think (hope). People get through by sticking with it. That’s pretty much it. If you adapt to the system and keep going, you get there. I had had different expectations. The previous graduates of our program don’t meet those expectations. I don’t think I will meet those expectations when I graduate. I’m not getting the training I want.

Our program doesn’t do a lot of hand holding. I felt like there wasn’t a lot of hand holding in medical school. I have always wanted more explicit teaching. I have this golden image of what ideal teaching looks like. It involves expertise and attentiveness and patience, and creating the right level challenge for the learner so they are in their growth zone. Nu-uh. Not here. Here there are sick patients that you get to take care of. It’s high responsibility, low teaching. People should know that coming in. It’s not what I would have wanted. I don’t think it suits me. The intern process still intimidates me. Being a resident continues to be much the same. But actually, it does change. It’s weird, but I do get a sense of pride about it. It’s that odious “good old boy” thing. It’s this hard thing that feels good when you are done. I don’t know why it’s not considered hazing. Maybe it is. But it kind of feels good for me. From right here, right now when I’m close to done with it. I’m through the worst part for sure. And gosh darnit, I learned how to do it. I’m not completely done. But I’m through the hardest stage. And I’m going on to other hard stages. But it’s okay.

So after graduation, for a period I may go on a road trip. If I can charge 25$ a person to provide general medical care, that sounds like a dream. I’ll accept tips. And if I see 10 people, that’ll be a heck of a day. If I see 2, I can afford my meals and gas. It’s a hobo life. That what I want. I want to be a traveling doc. I don’t know how long it will last. I don’t know how long I’ll sit on my loans, with the interest festering. But fuck, this sounds fun.

And if I take a few urgent care gigs, that would be a real good skill set to get good at. That is close to what I will be doing. Urgent care, event medicine, travel medicine, lifestyle medicine. I can wear a lot of hats. I don’t want to do hospital work I don’t think. I can cover low acuity gaps. I can cover nights or something. I mean, I don’t want to run codes. But I could run codes. ??? I don’t know for sure. I can run a code. It’s a big deal, but I could do it.

I don’t want to be in an ER. But maybe I am fucking wrong? How do I know so little about myself? What the heck? Well… I have developed coping mechanisms that shut parts of myself down. One of those was a real stiffening in the ER. I was in survival mode and I was not thriving.

I have a lot to learn as a doctor. Residency is a phase. It sucks most of the time. It sucks more than most anyone can relate to or believe. But it is the route to a medical career. I have wondered along the way if I should just quit. It wasn’t wonder sometimes. It was just frank truth that I did not belong in medicine. I wasn’t interested in medicine. I didn’t care. But I kept going.

Holy shit. I went to this cookoff the other day and I cooked a pot of beans over an open fire. It took a long time. I gave up hope in the middle cause I didn’t think I had enough heat. The water wasn’t even boiling for the first 45 min. But eventually they were cooked. And at one point I had given up hope. But the beans didn’t care. It didn’t make one bit of difference to them what my attitude was. They were still on the fire, so they cooked. And they turned out. I missed the competition. They announced the awards while my beans were still cooking. I’m the beans!

So, my classmates are starting to sign contracts. It seems pretty common for conversations with my co-workers to quickly turn to the topic of: What’s Next? It is pretty common for me in that situation to start to slide towards thinking about doing the same thing. I get 10 or so emails a day from recruiters. I get text messages and voice mail daily. That is the experience of all Family Medicine senior residents. I know that those headhunters would take home a nice check if they get one of us to sign a contract, and I just don’t think that’s going to be the way I do it.

But the recurring questions in my head is still, what’s next? Right now, I think the answer is locums. Locums benefits me in a lot of ways, and it seems like it is the opportunity that is accessible to me through my training. I do think there are limitations or problems that I will run into, but maybe the cost/benefit ratio works out pretty good for me. I would say my #1 right off the bat is the possibility to take time off easily. I want a pretty big break. And it seems like working a few locums contracts spaced out would actually allow me a lot more freedom than just delaying a job start even 3-6 months. I do want to be working, I just don’t want to be contracted in to continue working. I want to keep my flexibility.

The other piece that is important to me is bridging the gap. I have this impression that the difference between being a resident and being an attending is overblown in my mind, and I am intimidated by the transition. In order to get over it, I think it’s best to dive in and see for myself rather than delay and worry. I also know I have a lot more to learn. The process of being a doctor is a continual growth curve. By visiting different smaller towns to work, I can hopefully encounter some of the good “teachers” who are untapped by residency programs or medical schools. As a mentor pointed out, I have good “teachability”, and if I show up eager to learn at a site, there are more seasoned docs who will take me under their wing. Not that I expect to be formally taught, but just that learning opportunities come up. I think I might get the most out of just showing up trying things out.

I have heard that a lot of locums contracts would actually be happy to turn in to permanent employment. I trust myself that I can say no, but I also know that that might be harder for me than it seems right now from here.

I’ve started reading about “the work” in Loving What Is and I am pumped about it. I feel like it applies to the struggles I have been having for so long about my profession. I have this feeling that I don’t like being a doctor, or that I don’t want to be a doctor. And yet here I am, nearly completely done with my training and apparently in position to begin my… “medical career.” What am I doing? This has been such a hard question for me and I feel I have simply dodged it for so long. Maybe it’s that I’m embarrassed of bringing it up with friends, or I just think that they wouldn’t understand. It’s too complicated, too nuanced. Well… that’s what this blog is for. Why don’t I like medicine, and what am I really doing here? Is it all momentum and no brakes?

I just finished streaming a board review course. I had a hard time focusing. I had made a priority to set the time aside, but I sat there with my headphones in and with my thumb on my twitter feed. I was watching news on the Kavanaugh story come in. But I’ve always been bored by medical articles. The AAFP articles just aren’t that interesting. Part of being a doctor is being able to slow down and interpret this boring stuff on behalf of my patients.

Why did I go in to medicine? I envisioned one-day spending time listening to my patients and help them to make decisions. They come in with a problem; I have training that helps me to help them with their problem. Now comes the curveball, through my training I have increasingly identified the pro-corporate-interests lean over the structures that rule my profession. The vision that I and many people hold on to of a caring physician developing a personal relationship with their patient and making decisions together in the patient’s best interest is now an illusion (from my perspective). I work in this system that supports the systems interests at the expensive of myself (the physician) and the patients (the real victims). I am afraid that this story I see has the power to end my career (paranoia) because in the competition of energy, the dark forces can see through me. My uncertainty leads to amplified and exaggerated fears.

But in publishing my thought here, I am spreading the word that things are not as they seem in the medical world, and that there are doctors who are figuring it out. I imagine a bridge, and I find it so difficult to be the bridge between worlds because the farther I go towards what I think to be the truth, the less comprehensible I am to my colleagues who I feel I am leaving behind. I think that by staying closer to the system, I am not going down the road towards the truth. I am speaking about the truth of myself. It’s the insight that comes through meditation. It’s about unpacking and dispelling the myths around self, and then what’s left.

I put a bracelet on my wrist and a bandana around my neck because I like them. That’s all. I would like to clean up my apartment and to sort through my belongings. It never seems to happen. I am going back to work tomorrow after a break. It was a nice break. Today (and yesterday) I was thinking of all the things I did not do, and was suffering with regret. I was also putting this pressure on myself that I still might do them. Laundry. Practice questions. Preparing for my group visits. Applying for my license. Hosting a bonfire in 1 week. On and on the list goes. How much brainspace has to go to that? The right amount. I get stuck though, and I think I wheel around for too long.

Coming back to what I’m doing in medicine. Right now, I’m getting through day by day. I hope to end up with a board certificate and then to be able to move on. I had the idea recently that I don’t need to decide for myself what my career looks like. It’s not just a dream I pick out of the sky and then try to create. It can come from the world too. I can just adapt to a space for other criteria.

So one step is learning to do locum tenens jobs. There’s a question. Can I work on and off as a locums tenens worker and feel okay about it? The system needs family medicine doctors. I have gotten the training. I can show up in a town and offer my skills for a short term. There are companies that will set the whole thing up. I can earn 90-125 dollars an hour. This is better than a carny or a coffee shop job. They talk about a minimum wage of 15 dollars an hour. If I double that. double it again. 6x minimum wage. Obviously the minimum wage isn’t even 15, the specific numbers aren’t important, but the idea is comforting to me that I have earned a certain privilege. This is at the same time uncomfortable because of the stories about inequity and I can feel guilt over my advantage. But, well, I do have the 270k loans to pay back. That is a significant burden that I’m not exactly dealing with. I estimated that I am generating about 17k in interest each year or 50$/day just for my education. That is currently growing, and that is after spending 8 years of my life working in ways that have been damaging to me. Whether you want to quantify it as more than 80 hours a week, or just believe my story that it has not been possible for me to engage in a healthy relationship during my training. That story makes me feel like a suffering-but-noble monk. Do I like that story? Yes. Is that story true? Maybe not.

I had a flash of a bigger story that I have been holding on to for a very long time. And it’s the one that MY STORY is important. That I matter. That as I toil away on my self-improvement exercises, whether that’s medical training, or music lessons or physical exercise, whatever, that this project is really so important. And what I just poked at in a way that felt new, was that: maybe not. Maybe my life isn’t special or meaningful in a way that I have held on to so tightly for so long. It’s part of the American story. It’s part of my parent’s story for me. But maybe for me, I can let that story go? Because it doesn’t end my life. It doesn’t make my life less meaningful. I can still do the same activities. I can still play the guitar and study medicine without telling myself the story that causes the suffering. What is the suffering? It’s in the separation between the story and the truth. There’s this mental energy that’s going to entertain the story. The story gets repeated and repeated. It takes on a life of it’s own. And pretty soon, it starts to block out the reality. Processing power gets bogged down.

And how much of a problem is it FOR ALL OF US, in the age of social media to feel that we need to speak up. That we need to have OUR WORDS, be heard? We are trying to shape the truth. We are trying to control. Does it do any good? Then look at the monks who sit in silence. Meditation is trying to untangle the mind. Observe the thoughts.

Again, in my future practice I want to “hold space” for people. Coincidentally, my friend Sarah just sent me a video from JP that seems to be satirizing the concept (https://www.youtube.com/watch?v=8aPsZaQcBs4). But I would like to practice that in earnest. I believe that it may actually be harmful or confusing when he is making light of a seriously useful concept. On the other hand, it is probably a good lesson in humility.

But what is my path? I don’t have to envision it from the clouds. But I can poke around. I want to hold space for people. I believe in that practice because people have emotional processing that they need to do, and good listening skills can help with that. He made a joke about “holding space” for the TV as a kid. It was a good one. And it is great that he can bring some levity to the topic. It’s also important to identify the real skill and it’s value. Sitting with awareness and being present has that value, and it doesn’t need to be defended. The truth doesn’t need to be defended. It just is. We may have a society that attacks the truth, but the truth persists.

So, in sitting with people, I “help” them come to breakthroughs. I help them to make medical decisions, to process medical information. I want to be an integrative provider. I want to be a holistic provider. I want to help with nutrition and exercise and social support and help to minimize the meds. I have said that over and over for ages. My job in the system doesn’t allow for that. I order the meds, write the notes and move on. So can I do the $90/hour job? Or will it feel like I am serving the wrong masters? And if I serve my patients directly, will I be able to make that work financially? Those are the questions I am sitting with.

That’s it. I am sitting with them. I don’t need to do anything more with them right now. Tonight, I need to go to bed. Tomorrow, I need to go to work. This week… I need to go to work. One thing at a time.