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!

It feels important to recognize that I am sometimes miserable. Sometimes, people go into a tailspin of misery because they expect to not be miserable, and so there is then a second insult to the first problem. But there is a way out for me when I realize that being miserable during the week is part of it.

I get in to a string of feeling like I have no control. I get to clinic just in time in the morning and all of those tasks line up. And then maybe I have to drive to the hospital and work with a specialist. They may be kind enough, but it’s a somewhat superficial experience. On my end, I truly don’t want to be there, but feel compelled to pretend otherwise. There’s just this general untruth to it. I choose to avoid the complications that would come from frank honesty. And so I try to fit in. I think I am doing a fine job of it, but it takes a toll.

Someday, the goal is obviously to practice with integrity. This means I get to be myself in clinic. Myself is completely blocked out by the processes of the day, which take charge. I have to identify what the complaint is, which of the medical problems are relevant, to check on things like their health maintenance, their immunizations and screenings, and come up with a plan for the day. And then repeat again and again. It is too much. “I” back out. I recede into just getting the tasks done. I call the Spanish interpreter. I ask the questions, I order the meds, I check the boxes.

I had a session with my therapist today. I need to take better care of myself. I can. I get into becoming a victim instead of helping myself get out. I can be more in control of my energy rather than being so reactionary to the system. You know how these things work. Move your self. Get the work done. Take better care.

It feels very unlikely that I will be practicing clinical medicine after I finish residency. I can sense that this doesn’t make sense to some, but more importantly, I have been too unhappy for too long. It’s not a good fit for me. It’s unfortunately true that it doesn’t seem to be a good fit for almost anyone. That said, there are some who are still doing it. I want to learn what I can from them. But I don’t see myself filling those shoes.

I went into medicine to better understand the human condition. I am a poet. I am an over-sensitive artist type. This whole training process has been brutal on me and it is important to acknowledge that honestly. It is hard on anyone. It is hard on everyone. I’m not interested in playing the game of being the biggest victim.

I want patients to have good medical care. I don’t feel that I provide that. It means patience and good listening. But it also means confidence and medical knowledge. I have something of an error in how I process information. I don’t understand it, but it feels accurate to say that I have too much soul to work according to algorithms. A medical presentation to an attending is supposed to fit into a box, and I do not. I am supposed to click certain boxes saying I have reviewed the allergies and the medications and I do not. I am as overwhelmed by our shitty system as our patients are. I don’t believe they should be on statins or blood pressure pills, but I prescribe them. The whole thing feels meaningless. I am so bored of blood pressure. I don’t like anti-coagulation. I don’t like industrial primary care. I want to practice human medicine.

I want to play bass. I want to cry. I want to care about my patients and I want to live in a healthy community. Sometimes I feel like I am supposed to solve all of the world’s problems. That is not a healthy outlook. But I was so glad to hear the perspective of a Family Medicine hospitalist who finished his residency about 5 years ago say that he, like me was going through this spiritual process while he was completing his residency. He had this feeling that he was the only one “woke” to how awful the system is and how that at the time, on top of the tremendous load that is medical residency, this feeling added to the already overwhelming expectations that he put on himself. What a trip! How familiar?

I want patients to feel good. I want them to know about the benefits of a plant-based diet. I want to rant about of the over prescription of psychotropic pharmaceuticals. But perhaps that is a better realm for the people who have been in that fight personally? I can speak up, but I don’t need to go on a crusade against the institution of psychiatric medicine as an outsider with no skin in the game. It’s important, but it is not my life’s mission.

I do feel for the way our society lets the artists down.

I started residency as a kind of a 1000-day Vipassana (insight meditation) journey. This is what this feels like. It has been hard. I have been down. I have been mad, sad, angry. I continue one day at a time. Today came with its bruises. Tomorrow has more in store I am sure. I don’t do a meditation sit everyday, but in the last 2.5 years I have sat 463 times according to the insight timer. 43% of days. 110 hours and 22 minutes. I do get a little ego hit of pride from that. I remember telling a teacher at a free introductory meditation class that I wanted to be a meditator. Here I am I guess.

My sits don’t feel revolutionary. My mind wanders and I lose track of my breath. But despite my low opinion of how I do as a meditator, I do believe in meditation. I actually believe it is a kind of key to my worldview, an access point of sorts to the truth of how things work. How the mind works. We are all part of this ever-unfolding moment. There is no ego “I” self at the center of this identity that’s any different from the “I” that is at the center of everything. We can look at each other as brothers and sisters in this way and that’s it.

I want to teach people about meditation as a way to deal with suffering, not prescribe antidepressants. I don’t like the role of western physician. A western physician is supposed to give a PHQ-9 and then according to some guideline treat mental health concerns with medications.

Our system has been rearranged to serve the interests of the pharmaceutical companies and I feel my job, in the service of my patient’s best interest, is to say so. In my role as a physician working in the conventional system I get so lost in the day-to-day busyness that I lose sight of the overall rot.

On the weekends I am reading Deepak Chopra’s “Quantum Healing” and Lewis Mehl-Madrona’s “Narrative Medicine.” I like to keep up on the “Mad in America” website that regularly critiques modern psychiatry. I’m trying to do too much. I have a headache and I’m not sleeping well. I have notes to catch up on from clinic and assignments due this week.

I finished a “regular” week of clinic, and I found my self totally exhausted in a way that is routine. I had hoped to possibly visit home this weekend to see a couple of old friends and reconnect to that sense of community that has been harder to find in a new city with all the demands on my time as a resident. It would have been a short trip. I know seeing old friends would have energized me, but the road seemed too long for a short weekend. I could not transition from a day in clinic to a night on the road. I was tired.

A silver lining is that I found a sweet little house concert instead. There was a pair of earthy, singer-songwriter types on their way from East to West who shared their music after a little potluck dinner. The scene was complete with a dog and a breastfeeding mama. This kind of space feels so familiar and refreshing to me, though it is so different from my day to day in the hospital and clinic. There was an air of respect and quiet as the 25 or so packed in on mismatched furniture and a blanket on the floor. Christmas lights, a salt rock lamp, and loads of houseplants made a fitting backdrop for the living room stage.

To be on the road… it is events like this that remind how accessible and sweet it is. You show up in a new town with maybe 1 connection, but then you are welcomed in, and you share something that helps others to open up. It’s a lovely night. On the next day, you are back on the road again. I spoke with the musicians afterwards and one reflected on how nice it is to have music as that vehicle for connection while traveling. She went on about how she funds her art projects by working in the service industry. She has considered indiegogo or kickstarter, but she feels it is important to be supporting herself.

In my case, I have something a little different up my sleeve. A year from now when I finish my residency training, I plan to clean out my apartment, load up my car, and adventure west. I would be happy to follow in the example of the musicians I saw last night. But on my tour, I imagine connecting with the hostages of our broken medical system over the topic of how to break free. I’ll meet with burned out students, residents, attendings who want out, and hopefully some of the ones who are already finding their way. Medical Liberation Tour!

I had the morning off yesterday to work on “research”, which meant I had to be physically present in the workroom so an administrative person who wanders through could check off that I was there. I was running late and wanted to get breakfast and coffee anyways because nothing really needed to be done, but I got a message from one of the chief residents letting me know the Program Coordinator (Marge) was looking for me. Well, shit. So I skipped the coffee run, and a few minutes later I was unpacking my things in the workroom. There was no sense in going to look for her, I took the message to be more of an FYI than like a “page” on behalf of the Coordinator. I was feeling like shit from just generally not sleeping enough and not having coffee. I had old clinic notes to write and my in-basket to clear out, but I just cannot bring myself to those kinds of tasks when I feel lousy.

I sat around for about 30 minutes and finally decided to go to the nurse’s workroom to at least get some calories from the vending machine and some of their coffee. It seems hypocritical, but I have totally accepted that I don’t get to follow my own best advice about diet, exercise, sleep as a resident. No guilt. I ate a pop-tart. Marge, who seemed to be coming to the workroom as I was leaving, didn’t say anything to me and I imagine she checked some box noting that I was first seen around 9am.

Back in the room, I never got around to completing any work. I wandered over to Kevin MD, and then to studentdoctor.net where I opened a couple tabs about doing locum tenens work. One of my post-residency ideas has been to travel in my car, doing short jobs at rural hospitals. I think (hope) that the training I am getting is suited or adequate to prepare me for those kinds of experiences. Where there is a lot of need, as a family medicine doctor I am supposed to have the broad set of skills to “do it all.” That’s what I used to think, but as graduation nears, it is clear to me how many of those situations might still be so uncomfortable to me. I hate to be in a position where I feel like a patient is not getting the best care, and it feels like it’s my fault. I think there is enough material on inadequacy or “imposter syndrome” for a whole other post. But thinking about being in a rural hospital without supervision managing problems I would refer to specialists throughout my training sounds like a bigger task than I am looking for right now.

One of the bloggers spoke very positively about doing mostly urgent care work. She apparently eventually found a job site through that work that led to a permanent position, and she now has benefits and a contract for 10 shifts a month and still does plenty of locums work in between. Her attitude, which is classic for the profession, is that when she is on a site she wants to work as much as possible. No sense in wasting her time in the hotel when she on site to make money. Another thread from the website had a medical student asking about salaries in family medicine and the older docs that replied commented about “earning potential” rather than starting salary, because they had the traditional view that we should be working harder, seeing more patients, generating more revenue. That is a tidy little worldview. It is compatible with the system. The administrators are happy, and to the world, you look like a heroic, hard working doc. My problem is that seeing patients is exhausting, and seeing more of them sounds worse.

Today I heard one of my classmates (Doug) ranting about how he liked working in the toxicology department for an elective with the Emergency docs because he likes “real problems”. He is frustrated in clinic with so many patients who “feel bad.” He doesn’t like taking care of patients who “feel bad,” he likes taking care of patients with a problem he can fix. And I understand his sentiment. In that moment I thought of how he will do just fine in an urgent care if he wants, churning them through, assigning diagnoses, prescribing antibiotics or NSAIDS or antidepressants, and generating plenty of revenue. There are patients who do want that kind of medicine. Unfortunately for me, the medicine I’m interested in doesn’t fit into this system so well.

Hello. This is a space I am creating to explore my own thoughts about health, healing, medical training, our medical system and what I am up to in this world. I am working as a resident in a family medicine program at an underserved hospital and I am just about to begin my 3^rd and final year.

As a new class of interns begins work, I see the same cycle from a new lens. I hated internship year, but I didn’t understand why. There must be a thousand reasons, but one is that I felt so uncomfortable all day long with the atmosphere in our workroom. And now I watch as my peers and faculty continue to perpetuate this same sick culture. I empathize with these new trainees, but I can’t fix it. I want our attitude towards them to be nurturing. I want to put attention into creating support for them as they learn the basic skills of doctoring. Instead, chaos reins and these poor interns feel helpless and trapped. The cause for these problems is hard to figure out, and hard to describe. I could attribute it to ego and insecurity, but the problems really are so many and so nuanced that I can’t sum it up neatly. That is partly what this blog is for, to create space to pick apart some of the reasons that make my residency (or perhaps medical residency in general) such a soul crusher.

I don’t know what I am doing here. I am interested in my own spiritual growth. I want to heal myself and heal my patients. I believe that plant-based nutrition, regular exercise, social support and mindfulness are the important aspects of wellness that I can address with patients. In my day-to-day work, the patients I see have such complicated problems that often include homelessness, substance abuse, traumatic relationships, and violence. Their medical visits often don’t have a clear medical complaint or a real medical solution. Of course there are the medical emergencies too, which is the technical reason for their admissions to the hospital. Congestive Heart Failure, Pneumonia, Wound infections and Sepsis, out of control Diabetes (DKA), COPD, Heart attacks etc. I am willing to order the diuretics, xrays, antibiotics, insulin, breathing treatments, blood thinners and such when they help patients. But I don’t want to spend my life in a hospital. This job is for someone else. I want to be striking closer to the root of the problem. I don’t know what that means yet.

When I have completed my training, I am hopeful I will be able to exit from this system. I have plenty of dreams, but I am avoiding “a plan.” Like so many medical trainees, I have accumulated a mountain of debt. It is growing as I make minimal payments during this residency phase. As an intern I plugged about $10K towards the debt to try to limit the relentless growth of compounding interest. As a second year, I changed strategies and put another $10K into savings for my escape route. My plan (ok, I guess there is a little one) is to create space for myself after graduation to travel and slow down. I figure I can continue making minimal payments on my loans and streamline my budget to live for 6-12 months before I need to work again. I am anticipating opportunities will come to me in that time so that I never have to sign a contract with Corporate Medicine. We’ll see!