Rough Week

crispydoc Uncategorized 23 Comments

The past week has been brutal:

  • A loved one was diagnosed with metastatic cancer.
  • A loved one was diagnosed with a new cancerous tumor, staging still being conducted.
  • A loved one was diagnosed with a rapidly progressive neurodegenerative disorder, scuttling plans to retire abroad.

All this is in addition to watching a close friend struggle with disabling mystery symptoms for several months that have precluded his being able to work.

This prompted my wife and I to spend yesterday asking what we would change about our lives today in light of the possibility that our future plans could be so easily derailed.

Would we travel like maniacs?

I recently had a conversation with a younger relative who is mother to two kids in diapers. If given the opportunity, she claimed she would pick up a backpack and take to the road in a heartbeat.

I once felt similarly, but something has changed. Perhaps the desperate desire to escape small children has lessened? I can't tell if it's age or maturity (I can safely lay claim to the former, but only tenuously profess the latter), but I have started to appreciate certain routines:

  • The early morning bike ride around the neighborhood has become something I look forward to.
  • Nerds-of-the-world-unite board game night with the fellas is my stolen opportunity to preserve close friendships despite all odds to the contrary as a middle-aged dad.
  • Dressing up in matching costumes with my family for a local carnival won't be something I get many more chances to enjoy with budding teens on my hands.
  • Ditto for school volunteering - a highlight was recently chaperoning a couple dozen third graders on a field trip to learn the physics underlying our local amusement park.

Many of those opportunities require long-term presence on the ground to be considered (the physician author Rachel Naomi Remen has made the point that, like bingo, you must be present to win).

We like our community and feel connected to the people here. We have developed sufficient meaningful relationships over the years that we've opted for a schedule of international slow travel with kids in the summers instead of a year abroad in order to preserve and build on those relationships.

Would we opt out of medicine entirely?

This was my original fantasy in pursuing Financial Independence (FI), but unexpectedly, I fell back in love with medicine by doing less of it. At present, the challenges of emergency medicine and the decreased frequency with which we face them are sustainable.

Working a lighter clinical load has enabled me to pursue tangential medical interests that make me feel more purpose-driven and multi-dimensional, and less like a cog in dysfunctional Big Medicine's wheel.

These factors contribute to a general sense that medicine in its current form has come to replenish me more than it depletes me, although I realize this is a delicate balance.

Perhaps we'd transition out of clinical work sooner if we faced an acute stressor like a health crisis or something that gave our limited time on the planet a sudden hard deadline.

Would we spend more time with the kids?

Parenting inspires a great deal of guilt about what might have been done differently. The problem is that guilt, like most vestigial human properties, has low utility but great potential to cause harm (appendix anyone?).

I am the tougher parent - I say no more often. (I try to do so with love.)

We don't watch TV, although in the past year we've taken to an every-other-week family movie or family karaoke courtesy of youtube.

We have a display case suspended from one wall containing small bits of colored polymer clay figurines. For a couple of years, while her younger brother took his afternoon nap, my preschool-aged daughter and I sculpted. I pass the case daily, and it brings back those moments together.

My kids know me well enough to be acquainted with my faults and shortcomings - what I'd consider to be the definitive measure of knowing a parent well.

When we spend too much time together, we can drive each other crazy, and my shortcomings emerge more often, to my great embarrassment.

I'm grateful for the time we have with the kids, and we realize in the next decade that time will be diminished tremendously based on their needs and preferences. But if I'm honest, my best days are spent half with the kids and half pursuing my own interests.

I don't think I'd change that, and my wife feels similarly.

Where does this leave us?

Seeing awful things befall good people you love is a reality check, and can motivate you to get your priorities in order.

So can milestones like marriage, divorce, career highs and lows, and the birth of a child.

Burnout led me to have this conversation with my wife several years back, leading to the current trajectory we comfortable with.

Our day-to-day is far from perfect, but we ask the big questions often and adjust continually.

Life eventually becomes the sum of these frequent small course-corrections.

Comments 23

  1. Really sorry about the week you have gone through with the devastating health news on several loved ones.

    Health is the great unknown for all of us. We all think we are immune from medical scares but it really can be a game of Russian roulette. Sure we can take precautions to help tilt the table in our favor but even then I have seen incredibly healthy people die young or get major diseases despite making every right choice (conversely I have seen people who against all odds live incredibly long lives despite subjecting their body to every vice imaginable (Keith Richards comes to mind).

    Time is not guaranteed. The FIRE movement helps get you on a path to make the most of it if you do it in moderation so you enjoy the process along the way (does no one good to kill yourself trying to FIRE and then actually dying before you reap the rewards of your sacrifice)

    1. Post

      Amen, Xrayvsn.

      In the ED, we know that if the patient is incredibly nice, the diagnosis will be devastating. The sweet church lady with new painless jaundice is bound to have a pancreatic mass. The speeding drunk driver who crossed the median and killed the pedestrian will walk away with scarce an abrasion. It’s just the way things go.

      So as not to end on a downer, now that you mention Keith Richards, you remind me of an urban legend I heard in high school AP chemistry. Our professor told us how another chemistry teacher reportedly a nailed a twinkie to the wall of the classroom, and it remained unaltered on that wall for a decade thanks to the preservatives.

      Always a pleasure to hear from you, my friend.


  2. I’ll always remember a since deceased partner who had 3 recurrences of cancer and always spent and enjoyed more than others.

    He said to me: you have to enjoy it along the way. He knew what he was talking about.
    At his 3rd recurrence he was gone in 3 months.

    Fire is good but many treat it as religion, as a future life to be enjoyed when the mark is reached.
    But life is now, to be enjoyed in the present , until it is no more.

    1. Post

      Couldn’t agree more, sil, you need to make the journey into part of your destination. Sounds like your colleague knew how to enjoy the life he was granted.

      There is certainly a risk in pursuing FIRE to treat it as dogma let it overpower you – the Mad Fientist in particular has spoken candidly about how saving became such a dominant objective on his path that he forgot to enjoy the way there.

      Despite this risk, the core of FIRE as I understand it is intentional living – we drive beaters but spend on childcare because it fits our priorities. Others may choose the nice car but mow their own lawn. It’s about finding how to use money as a tool to give you the option to live the life you want, and in the case of medicine, to reduce or eliminate the aggravations so that it more closely resembles the job you thought you were entering.

      In the latest issue of Emergency Medicine News (April 2019), Edwin Leap writes, “We said once a new doctor purchased his lake house, he was yours for life.”

      FIRE is about not letting poor financial choices own you or limit your ability to thrive.

      Appreciate your stopping by,


  3. So sorry to hear that you have all this bad news to deal with at once. Just one of those illnesses would be more than enough to deal with.

    However, in reading on, it sounds like you have “won the game,” if you are pretty happy with this life you have now. I always thought it was a little sad to hear people who were ready to leave their home of 20 to 30 years as soon as they could retire. It seemed that if they weren’t happy, they should move sooner, instead of waiting years. I am still working on making my life one I wouldn’t want to change at all.

    1. Post

      Dear IM-PCP,

      First and foremost thanks for the kind words and for stopping by.

      As for winning the game, I’m a little uncomfortable with that terminology, as it implies an arbitrary endpoint for evaluation instead of a continual re-calibration in an ongoing journey.

      If you’ll forgive my parsing of words, I’d prefer to say the life I lead more closely resembles the life I want (with credit to Dike Drummond for the Venn diagram idea). Meaning if I get hit by a bus tomorrow while on that morning bike ride I’ve come to love, it would be less sad than if I’d waiting to start cycling until I’d reached retirement.

      Life is the sum of the small tweaks you make, so (except for my meth patients) the earlier you start tweaking, the better.



  4. Life and luck can be so arbitrarily mean, whether it is from cancer or from an auto accident.

    Thank you for reminding me to take stock and see what is worth sacrificing versus what is not worth the delay of enjoyment or experience. Perhaps next winter my family will finally take that ski trip we’ve been delaying?

    The pursuit of FIRE, like all things, is a delicate balance.

    In reading your blog, I am heartened that you’ve found a nice balance between medicine and other pursuits. It seems that it’s a mutually beneficial situation for you and the patients you help.

    — TDD

    1. Post

      Hey TDD,

      Thanks so much for stopping by and for the words of support. The Hobbes quote that life can be “nasty, brutish and short” comes humming back when arbitrary ill-fortune drops into your life.

      By all means, take the ski trip (although between us a staycation at your beach club sounds more my style!).

      Happy you are sharing your journey to finding the right balance for you and your family – I’ve added you to the Physician Finance Blogger list in hopes of helping you find more of your tribe.



  5. You might recall -dG = dH – TdS, the Gibbs free energy state equation. Why did the twinkie not change? Entropy (dS) is the release of a system’s otherwise unavailable thermal energy and the thing that allows Gibbs free energy to turn negative. As the system heats up the unavailable energy becomes available. The twinkie didn’t change because because it had nothing unavailable left to give. Life is like that as well.

    Today I spent an hour with a 85 yo Army vet. He is dying of prostate cancer. He is slowly selling off his ham radio station as his time approaches and I bought a piece. He told me about his life, he is still quite active. He still has unavailable thermal energy to emit, calories and calories of energy yet to expend into the atmosphere. Today, I dug his company and making his acquaintance. Tomorrow isn’t here yet.

    Your story points out what is ignored by FIRE types with all their “plans” to travel the world. If you’re married your going to die and your spouse is going to die. 1/3 gets CA in their lifetime. Of the 1, 20% die. That means 80% survive. Of the 80% who survive 40% go completely broke in as little as 4 years post diagnosis. At 65, 1/10 are Alzin. By 85 it’s 1/3. 33% of women who live to 65 will live to 90 and 1.5% to 100. If you’re a woman and you pull the brass ring at 85 you have a pretty good chance of needing a decade of memory care maybe including 24/7 care. If the old man used up all the dough fighting his cancer for it only to show up a decade later like my friend, what’s left for mama to spend when she pulls the brass ring? Stick that in your Seychelles FAT FIRE travel pipe and smoke it. This can all be planned for but you have to think about it and move on it decades in advance. Money buys you one thing, peace of mind.

    1. Post

      You find the poetry in math and physics as few others can, Gasem.

      Your point is well taken that money buys peace of mind, and that peace of mind is primarily in planning for the needs of your surviving spouse – a gift way more impactful than any other.

  6. Sorry to hear about the rough week.

    There are times when I feel like your younger relative. I have impulsive urges to want to pack up and explore. But then I am also grateful for the place I live in and the wonderful people I have in my life.

    It’s interesting how life is made up of so many decisions and choices that seem so mundane but can ultimately have a big impact. And of course a lot of decisions are not mundane and quite tough. Life can be hard, even when you deliberately live an intentional life.

    1. Post
  7. What makes us human above all else is the ability to imagine alternate futures. Sometimes these futures are traumatic and sad, other times blissfully optimistic. But the real value of this superpower is using it to inform our decisions NOW.

    As someone who did choose to opt out, travel like a maniac and spend more time with the kids (three for three, baby!) I can tell you that the journey is just as much internal as external. After almost nine months of full time travel I think I’ve come to the conclusion that travel is a tool to open our minds and reflect on our path.

    Not everyone wants or needs to travel to trigger that reflection. In a very practical way, the point is to take a few hours (with your significant other) to pause and think about these things. Then find the gumption to make a change if it’s needed.

    Great post, CD.

    1. Post

      Three for three, baby! That says it all, BFSW.

      The solitude of travel can be as cathartic and transformative as the camaraderie – your internal journey is on the mark.

      I’m glad I’m not the only one who spends time continually fantasizing about where different paths might lead at any given moments. I don’t think it’s quite the Stoic practice of imagining loss to steel yourself against possession, but more a Walter Mitty-ish imagination run amuck exploring alternate endings and plot twists. In the end, fanciful or not, it does help guide decisions about living today.

  8. When it rains, it pours. CD, so sorry to hear about your terrible news. Thinking of you and your loved ones.

    When I hear news like this, I am torn- is it a sign that it was the right decision to cut back to part time and spend more time with loved ones? (carpe diem) Or is it a reason to feel guilty that I’m not spending more time being the doctor that sick patients like these need? Right now, I still think it’s the former, and not the latter. I was that doctor for almost 20 years, and risked being a lesser-than doctor (and person/wife/family member) if I had continued at my previous pace.

    I faced this same question this week when I read “When Breath Becomes Air” by Paul Kalanithi- a devestating autobiography written by a brilliant Neurosurgeon/Philosopher/English Literature scholar who died of cancer just as he was finishing residency. Please PLEASE read it and tell all of your blog readers about it- it is heart wrenching, thought provoking, inspiring, and astounding. Carpe diem indeed.
    Take care,
    “Dr. K” (Kristina)

    1. Post


      Appreciate the kind words. I suspect there’s a balance with a different set point for each of us between being the human being you enjoy and the physician best able to care for your patients – some of us are more Loonie Doc or Dr. McFrugal workaholics where just cutting back to full-time gets them to the sweet spot. I’ve stopped feeling guilt about my set point, and am more filled with gratitude that reaching that new set point is allowing me to enjoy home and work. I’d never call you a “lesser-than” doctor, and I suspect when patients note your glow of happiness they are more drawn to being cared for by you than in previous darker times.

      As for Paul Kalanithi, my wife and I both read his book when it first came out, and it embodies precisely the need to live the moment – I could not be more supportive of your review and impression. Small world moment, he and my sister were on a panel for their ten year college reunion shortly after his diagnosis (it was entitled something like, “Not where I expected to be”). She said he was an incredibly eloquent speaker, something that comes through in his writing. I’ve read interviews with his wife, also a physician, and she’s an equally tough and tender person in her take on Paul’s legacy.

      Thanks for the reminder, and yes – if anyone is looking for inspiration to make those changes now – When Breath Becomes Air is a wonderful, heartbreaking book.



  9. Sorry to hear about all of this sad news, but it does sharpen one’s perspective.

    It reminds me of a thought experiment:
    1. How would you plan your time if you knew you had one year to live?
    2. One month?
    3. One day?

    It focuses you on what is important to you and what is a time killer. In scenario #1, you might still spend some time working (I have witnessed this in other people). In #3, there’s a pretty good chance you won’t be twittering or watching the latest creation on Netflix.

    1. Post

      Thanks, Vagabond. Your thought experiment and comment on scenario #3 makes me feel perhaps my ignorance of current TV is more justifiable than I’d thought.

  10. First, “Pole Sana” as they say in Swahili. It’s a mixture of “Sorry and strength” all summed up in one. Good thoughts, good post. I am sitting in London shedding a tear or two as I see on the news that the Notre Dame is burning. My 8-year-old son didn’t understand why his mom was getting all teary eyed until he recalled I had dragged our family into a room with a display of Notre Dame stuff at Epcot a few months ago and that I had planned some year for us all to go to Paris to see it in person.
    Some things we can’t claim back as the time has gone by (like an intact Notre Dame and sculptures), but others we can still hold on to by staying put and being present-Like physics and third grade field trips.
    Write on my invisible friend 😉

    1. Post


      Thanks for sharing the meaning-rich Swahili phrase. Seeing iconic centuries-old beauty destroyed seems to make the passage of time more apparent and highlights our own short individual tenure (and what if we only ever make junior faculty?!).

      Spoke to the post-op melanoma relative yesterday, and she sounded back to herself after major head and neck surgery, which made me happy. She told me she did not fear death, she just had many more things she wanted to do with life. She also confessed to fearing that others would pity her and treat her differently.


  11. Sorry to hear about your loved ones. I diagnosed my dad’s cancer. He went to see his GP every 2 weeks. Did she ever miss it.

    I have learned to be vigilant for family members.

    Like Vagaabond, I have seen colleagues continue to work even after being diagnosed with metastatic lung cancer. Humans are complicated…

    The older I get, many things I used to see as black and white have devolved into shades I can not even recognize.

    Keep on keeping on CD. It’s the best we can do.

    1. Post

      I can’t imagine the burden of making that diagnosis on your own father, Dr. MB.

      I am more convinced than ever that without an advocate in even the better medical systems and centers, you are hosed. Your vigilance is warranted.

      A few years back I noticed that a favorite radiologist, a sweet fellow with whom I carried on a little witty repartee on occasions I had to discuss ED cases by phone, seemed to be off the schedule for a month. When I inquired about this with a colleague, I was informed he’d passed away of leukemia. He’d worked almost up until the end. I guess if you love the job, it anchors you when you need it to do so.

      Complicated indeed. Thanks for the kindness, Dr. MB

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