On Endings and Beginnings

Hello....hello....hello. 

Wow. Um. Not really sure where to start.

I quit my job. I am no longer a rural GP-Surgeon. So, there's that. I moved. Enrolled in a Dermatology Diploma through Cardiff University, got a new full time job, a part-time locum. Oh and a full time LIFE again.

I bought a new house, adopted a second dog, moved. Is that everything? I guess that is the big stuff.

It's awkward as I have so much back tracking and so many half written half cocked stories and posts and its overwhelming. And were does one pick up the thread?

I will start by saying that physician burnout is a real thing. I read somewhere recently that around 80% of physicians in their first year of practice report feelings of burnout. It made me feel reassured. I haven't really sat down and dissected the past 15 months since finishing to see if the diagnosis would be burnout but I can certainly see that there were moments, really long moments that lasted weeks or months at a time where the over arching theme could be described as "burnout". Sure.

And I cycled through the emotions of feeling guilty for being overwhelmed when I should have actually felt good that I was acknowledging that too much was being asked of me. Feeling I was weak instead of seeing that the load was too heavy, and all of that.

So now I'm staring at all these books in my basement. Do I get rid of the stacks of emergency medicine books? ECG guides, Operative Obstetrics, Mastery of Surgery, Palliative Medicine? I have Care of the Newborn and PALS guides strewn beside Colorectal Disease atlases and AIME study manuals. It's nearly comical. I am letting go of some of my skills, some of my training but I am weirdly clinging onto these books. I am not a nostalgic person. Ever since I Marie Kondo'ed the shit out of my house 2 moves ago I have paired down and donated, sold, and dumped a lot of my belongings. These books feel like haunting reminders of the person I thought I wanted to be or the person I thought I'd become.

When people would ask me, "How are you?" at work my response was always "living the dream!" And this was an intentional response (for me) even though it may have sounded flippant. I said that because if you go back, all the way back to even before this blog started, I wanted to be a rural physician. A rural emerg or rural gp-surgeon or full scope rural GP. I turned my life upside down. I left my house in the mountains, all my friends, all my family. I left my financial security and traded it for crushing debt. I left the freedom to chose where I got to live. I left my hobbies, my boyfriend, my favourite recreation. I left my country! I traded all of that in to become a doctor. I came back to Canada and was lucky enough to land a residency in a fantastic rural program. Then landed another residency in enhanced surgical skills. Then I was offered a full time job in a full scope GP service practice in a place that I had spent 6 months as a resident. And everything was just finally lining up perfectly and I was reaching the end goal of 8 years of moving, studying, exam writing, wondering, hoping, and guessing.

And my "dream" finally came true.

And then it all went to shit.

So I purposefully reminded myself every single time someone asked me how I was doing, that I was in fact, living my dream. It's so easy to remain in this goal oriented, delayed gratification, head down, life will be great when....mentality. "At the coal face" as my husband describes it. You are in survival mode, you don't look up you just grind grind grind. You will one day live your dream, you tell yourself.

Then you arrive and the unicorns aren't sliding down rainbows to greet you. I can't even go back and read the post I wrote when I finished medical school because I may actually punch myself if I do. I was taught this lesson before but I suppose I never learned it.

I wanted to remind myself so I could stay in the moment. So I could find that thing and see the beauty in where I was even when it felt like it was crushing me. Something had drawn me to this exact place in the world so I had find those rewards and acknowledge them. Even when it felt really really hard.

I'm sure there are many, many people who chase certain goals in medicine, and achieve those goals and the rainbows and unicorns are there to greet them when they do. And to those I say, "you're so lucky". But to anyone reading this who felt weird and sad and stressed and unfulfilled when you finally got to live your dream I say, "you are not alone, dude".

So I finally gathered up the courage to admit all these things to myself and those around me. And here I am. Trying to focus on how I am going to make this whole medicine thing work for me, instead of the other way around.

To be continued.

Only in the Prairies

My patient, sitting there heavy with pregnancy is looking dismayed at the thought of having to be induced now that she is post-dates.

I ask her what is up.

She tells me her garden isn't done.

Then she asks me if she can come 30 mins later than the scheduled time so she'll be able to milk her cows.

Later in the same clinic I had another woman who had come in for a possible abscess. She informs me that her mother in law gave her some ointment they use on the animals when they get infections. She was using it all weekend.

Evidently it worked. 

I love my prenatal patients on the prairies. 

Rural Doc Realities

Even though alcohol is legal and I don't have an unhealthy relationship with it, I always feel a little awkward about stocking up on wine and beer in my local liquor store. I have this irrational fear that I will see a patient and they will think it's inappropriate that their doctor drinks Chelada's or American reds. I hated buying booze as a resident because I always looked so haggard and forlorn I was convinced people would assume it was the alcohol that made me that way and not the fact that I'd been up for 44 hrs on a surgical "bender".

As an attending I hardly drink as I'm on call 1:2 (or 1:3 at best). Alcohol has become a treat because it also means my phone can be off and I can shower without having a "get to the hospital in 5 minutes" outfit laid out on the bathroom floor.

So I go to the (one and only) liquor store the other day in the hopes of maintaining a low profile. I do my sweep while trying to eye out the selection. It's pretty disappointing, as I expected it would be. But, in a way I'm glad it's no Wine Cellar* because it would be too hard to stick to my new $100/month budget if I had their glorious products to choose from. When Barefoot and Yellowtail are rounding out the options it makes splurging on a Rodney Strong or a Layer Cake seem indulgent.

I'm perusing the boxed wines and wondering how rapidly I would descend into alcoholism if I started drinking Copper Moon by the box when I hear "DR. BLACKBEAR!! DR. BLACKBEAR! How ARE YOU??" My eyes have still not quite adjusted from the sunlight outside so I look around, trying to locate the voice while half-hiding behind the Pilsner stand. People are milling about and looking in my direction. A staff member is waving wildly at me and smiling. I think I recognize her from the clinic...? The ED...? I don't think I've delivered her baby recently...did I ?

Hi.

Hiiiiiiiii!!!! ARE YOU ON CALL TODAY?

Yes. (I can't lie, dammit. I was on call. What if she ended up going into the hospital that night with an appendicitis and they called me in to see her? Then it would seem even sketchier that I'd lied about it. I wasn't planning to drink the booze THAT night, I just knew I wouldn't have time to get there any other day this week. Besides, I am on call all week anyway!)

OH MAN YOU WORK SOOOO MUCH! THEY REALLY WORK YOU GUYS TO THE BONE!

Yes. (Now people are staring at me, they are judging me not only for my choices in alcohol but the fact that I am a doctor and buying it during the day, when I'm on call!!)

ARE YOU TAKING PATIENTS YET?

No...erm...I am doing so much call and covering the surgical program right now so I am not really in the clinic that much and I ...... (I'm mumbling, trailing off, and deciding if I should just pull the pin on this whole endeavor and leave without buying anything. But I feel like I am committed and really, my husband would come and buy just one bottle of Malbec then try and convince me I liked it in the past).

WELL I DON'T HAVE A FAMILY DOCTOR!!!

I think I then sputtered something about continuity of care and resources and some apologies while going to the farthest till away and hoping things would peter out from there.

A lady with tight permed curls and a wrist brace starts ringing in my order. She keeps her eyes locked in mine as I fumble with my wallet and hit the automatic start on my key ring.

What is your name? Says wrist brace without looking away.

Albino. 

No, what is your DOCTOR name?

The other people behind me in line lean in slightly.

Dr. Blackbear (WHY WHY WHYYYYYYY)

Hmpf. Well I don't have a family doctor EITHER. 

So, so sorry to hear that I think there are a few doctors at the clinic taking patients....byyyyyeeee thank youuuuuuuuuu.........!

I grab my bag and head for the door. My initial greeter yells, BYE DR. BLACKBEAR SEE YOU LATER HOPE YOU GET A BREAK SOON!!!

You and me both, honey, you and me both.

--

*I was not paid to put that endorsement there. The Wine Cellar and 124st St Liquor Store were my two favorite places to go when I lived in Edmonton and was discovering the world of wine. The staff were super knowledgeable, the selections were varied and interesting, and I never felt intimidated about asking questions. I loved pretending I knew anything about wine and pretending I could afford the good stuff. And look how far I've come in the past 15 years, now I know even less about it all and can still only afford the cheap stuff!



 

Education Debt IS Bad Debt

I was recently given some bad advice.

I am deeply, profoundly, eye-wateringly in debt thanks to four years of international medical student tuition and a penchant for expensive wines, perfumes, and restaurants.

I come by it honestly. It stemmed, initially, from being a medical student and spending a thousand euros a week on tuition, for four years. Why would I buy a 10 euro bottle of wine instead of a 20 euro bottle of wine? That ten euro difference was not even a drop in the volume of money I was hemorrhaging at the time.

Then it morphed into an easy justification. I had no life as a resident. I worked, slept a little, ate when I could, peed when I could and I was going to have that cashmere sweater from Club Monaco dammit because I had nothing else in my life at the time….nothing!

I could say that I had made so many many sacrifices; my income, my freedom, my country, my relationships, my RRSP’s, my whimsy. Didn’t I deserve that stay at the Fairmont? That 7 course meal at Quattro? That bottle of Veuve demi sec? HECK YES I DID.

So, now I am finished residency. I am actually an attending physician, making more a month than most people do all year. Yet I am broke. Why? Well. That begins with one’s definition of “broke”. Because, I used to think that rich was how much money you earned, not how much money you had in the bank.

I have over $300 000 in debts; student loan, line of credit, and Bank of Mom debts. This means that I have no money in the bank. I am broke. And every 2 weeks when I get my pay check I continue to be broke.

I was recently told by a financial advisor that I didn’t need to worry so much about my $190 000 line of credit debt because the interest rate was at prime. I told him that I was about to go on this mission to just pay that debt down as fast as my little surgical fingers could spin that money out.

Meh. He said.

That is low interest debt. Put money into savings, buy RRSP’s, save up for your next house downpayment. Pay that debt down at a rate that works for you. (No, he is not given kickbacks by any financial institution that I am affiliated with). And I was lulled into believing this. I can afford the payments therefore I can afford the debt.

Oh FUCK NO.

Ok, let me put this into recent context.

I’ve been doing a lot of reading and thinking and learning about the concept of minimalism, money management, debt repayment, financial freedom, need, greed and when I'll be able to step away from mandatory employment. 

As part of this quest I watched this interesting documentary about minimalism, started listening to their podcast* as well as the Dave Ramsay and Planet Money podcasts. I read "Your Money or Your Life" updated by Vicki Robin, as well as "Total Money Makeover" by Ramsey, and am currently reading "Beyond Wealth: the roadmap to a rich life" by Alexander Green. I listened to a mind-blowing interview** with Mr Money Moustache and have since spent hours and hours reading his blog and putting his advice into action.

I downloaded a free budgeting app called "Everydollar". I also downloaded a frighteningly sobering app called "Debts Break" which shows you how much money you are paying on the principle, how much interest you are paying each month, and how much total interest you'll pay by the time the debt is paid off. 

After this flurry of reading, listening, watching and information absorbing I felt as though I had been awoken from a long, dreamy, line of credit induced financial stupor. It's embarrassing to admit how little I understood about these basic concepts of personal finance and the greater concept of money. There are so many gems I've collected in the resources listed above that I would do no justice to any of it if I tried to summarize or recap. But I will say this, if you are in debt (even a little bit) I urge you to check out some of the links above and start your own journey into mindful spending, debt control, and financial independence. 

AND GET RID OF YOUR DEBT BEFORE YOU DO ANYTHING ELSE. 

I shudder to think of how much money I've already wasted in ridiculous interest payments (not to mention all the brainless cash I've thrown out for acquiring things I didn't need). 

We've gone into basically a spending freeze here in the Blackbear household. My husband even took a job nearly 3 hrs away in order to beef up the "hammer the debt" campaign. We are getting out. It's not going to be easy and it's not going to be quick but man I am so glad that I only wasted 6 months as an attending before I started this new way of thinking. 

The main change to spending has come, not from just stopping the spending of money (which is like just deciding to crash diet - a temporary deprivation which will eventually rebound and probably over correct in a bad way) but of changing the way I look at how I spend my money and my relationship to money. 

I do the Mr. Money Moustache and minimalist approach before I buy anything. 

1) is this purchase adding a positive or taking away a negative in my life?

If it is the former then it is not allowed. It is easy to think that adding a nice sweater will make me happier (for about 30 sec) but it is really the false belief that it is adding a positive. If the purchase is taking away a negative, i.e. I have no winter coat so I will buy a good quality winter coat that I will treat well and cherish and wear for years, then I can buy it. 

2) Is this purchase worth my freedom?

Okay, I know what you are thinking. That is a bit over the top. But it isn't. Currently I am a slave to my debt. I will HAVE to work for years and years just to pay off my debt, not just to live, travel, eat, drive...So every dollar I spend is a dollar I am not paying onto my debt, which means I continue to protract my debt repayment servitude. Prolonging my required employment. 

3) Is there room for this item in my life? 

I hate having stuff I don't need or use in my life. I did a giant Mari Kondo purge last year which was so liberating. Now everything I bring into my life has to have a purpose, a physical space. 

4) Is this worth my life energy?

This sounds really flaky, I know. But, you have to listen to "Your Money or Your Life" to get the full gist of this one. It boils down to this; money is what we are given in exchange for working. Work is the concrete expression of our life energy, which is then converted into money. So, essentially when you spend money, you spend your life energy. It's an interesting way to look at money in a more abstract way and to see that our life energy is finite (like our years of existence on the planet) so how do you want to spend that finite resource. 

I know this is a bit of a long post and I am sure that I have lost many readers at this point for a variety of reasons, which I totally accept. I wouldn't have been ready to hear any of this before I was GOOD AND READY and it was seeing the totals at the bottom of the screen on my debt app which really propelled me into action. I also accept that I am probably the stupidest person on the planet when it comes to finances so I am hesitant to even elucidate how I am dealing with my money situation now, though I think I am on a right-ish track. 

I felt the need to write this post though because we are given so little information about any of this as physicians (and just humans in general) that if some of this sparks and interest (or outrage) in any of the readers of this blog then I am beyond delighted. 

I'll keep you posted on my progress and how the process is going.

The devil is in the details.

* I love these guys and their blog and podcast are very high yield when you are on a crash course to minimalism and mindfulness. Unfortunately, in a recent podcast one of them mentioned their chiropractor and the other mentioned his adrenal fatigue. Thus I called into question every ounce of wisdom I had taken from them. I have since reminded myself about the concept of throwing out the baby with the bathwater and have come back to allowing that though I will never never never agree with their non-evidence based pseudoscience quackery promotion, I can accept that in other areas they have valuable information and ideas that are worth considering. 

**Tim Ferris. What can I say. I have a love hate with this guy and what he puts out there. I love his work because it has introduced me to fascinating people who have done extraordinary things with their lives. I hate him because he is annoying and markets himself an expert on everything from matcha tea to exercise to boxing to studying to saturated fats to writing. I just can't. Yet I do, and I hate myself for it.

 

It's Geting Dark in Here

So for Christmas Duncan bought be some great books. Maybe true love is someone who knows what books to buy you.

I am currently reading The Antidote: Happiness for people who can't stand positive thinking by Oliver Burkeman and Awake at the Bedside by Koshin Paley Ellison. They are both SO intriguing and thought provoking. I am trying to be monogamous, but it's not working. These books have many overlapping themes and central ideas despite being about very different subjects. I love how they randomly came into my life at the same time.

I never really had any proper training in palliative medicine, which I feel was a major gap in my medical education. Yes, I did 18 weeks of general practice, 15 weeks of internal medicine, 15 weeks of surgery, etc etc. but zero weeks in palliative care during medical school and zero weeks in residency. Weird because, uh...we ALL die. We might dodge the nephrotic syndrome, the massive stroke, the carcinoid metastasis, the glioblastoma, the neck fracture, but we all...die. So why is this universal outcome so ignored and unexplored in medical training? It's absurd really.

I'm left trying to sort out how to manage the physical manifestations of this fact while learning how to listen, problem solve, know when it is not time to problem solve but just listen, juggle oncology telehealth appointments with finding out how to get a ramp made so my patient can get into his house with a wheelchair. It's a clash of the ultimate in existentialism, spirituality, and bowel care. The logistics of continence and difficult discussions and denial and heartbreak weave in and out of daily interactions, most of which I feel woefully inept at.

So I make mistakes. Say things I shouldn't. Extend myself in ways I won't again and retreat in times I should have been present. But I am trying to learn, LISTEN, read, think, reflect, improve.

I've learned that the Ellison book is not for bedtime reading. Unless you want to go attempt sleep with questions like "who do you want with you when you die?" or "what are the fundamentals of a good death and how would you like your death to unfold?" rolling around in your head.

I started this post before going on post-Christmas holidays. I brought so many books with me in the hopes of enlightenment and insight. I read about 2 paragraphs over the 2 weeks. So I am still here, at the same place. But now the pressing paperwork, charting, forms, follow-ups, tasks, notes and labs are pouring in and as usual I find myself mostly living in the "urgent unimportant" world.

So I will leave this for now. A poem that hit the nail on the head for me at a time when I needed it.

The Last Time
Marie Howe

The last time we had dinner together in a restaurant
with white tablecloths, he leaned forward

and took my two hands in his hands and said,
I'm going to die soon. I want you to know that.

And I said, I think you do know.
And he said. What surprises me is that you don't.

And I said, I do. And he said, What?
And I said,  Know that you're going to die.

And he said, No, I mean know that you are.