how i came to be a family doctor. again.

Title: How I came to be a Family Doctor, Again.

Part 1: The Indecision

"Miss, you have such a beautiful smile."

'Aw, thanks sir.'

It was then I realized I was smiling like a fool and didn't even notice..

"You from here, dahlin?"

'Yeah, just south. But I lived here for years, it's home.'

"You sure don't sound like you from here!"

I give my standard answer to this comment... 'True, not much of an accent, but don't worry I eat and drink like I'm from here.'

He responds with a hearty laugh.

Thirty lazy minutes, eight dollars, and six-hundred calories later I leave entertained, stuffed, a little drunk, and completely satisfied to continue my stroll down Chartres street. I sneak out the secret back alley from the bathroom in the courtyard.

"Bye, Miss Emily. You have a great day. Come see me again soon, hear."

And with that, I turn around and wave bye to my flirtatious waiter at the Napolean House with an even bigger smile than I came in with, whistling the tunes that I danced to the night before on Frenchman Street at Spotted Cat.

The Spotted Cat is a bar in a part of town called the Marigny. It's an old and run-down historic bar, and my connection to it's history goes something like this: I have brought in every New Year from 2000 until I moved to Utah at that Bar. It is the essence of Joie de Vie. It's timeless. There are no days of the week or times of the year, those detail are meaningless. Every night someone is playing jazz, and every night someone is in there to listen to it. I have listened to and danced to some of the best jazz of my life in that place. I know some of the musicians personally from a clinic I worked at during medical school. They never have a cover, and the bar only takes cash. I also happened to meet the love of my life in that bar, a chef originally from the midwest who accidentally found himself in New Orleans via his job in Portland, and subsequently embodied the essence of the city by somehow being both stubbornly carefree yet fiercely passionate. It's an interesting dichotomy about this place, those two conflicting but genuine characteristics. Shortly after I moved to Utah and finally left the memory of that boy behind, my house burned down. Shortly after that, Spotted Cat closed.

It was the end of my world. And the beginning of my anger toward myself for leaving my Home.

New Orleans has this tradition called a Jazz Funeral, and the loyal patrons of that bar had a jazz funeral for the Spotted Cat. I read about it and cried. So you can imagine my surprise and elation at seeing that familiar sign when I walked down that street the first night I was home. Spotted Cat was resurrected! Someone responded to a passionate cry to keep our beloved place of rest intact.

"The Spotted Cat was a cornerstone of the entire street," Byka said. "It will again be a home to unamplified, traditional jazz that is lacking in this city, but people crave and demand it. People are very happy that it's going to be open."

I have a lot to think about these days. I have to decide what the hell I am going to do with my life on a deadline. It's all about the deadlines. And this one expires in about 4 weeks, which I find has been the normal duration of the cycles of deadlines in my life for about the past 20 years.

I came home to become an anesthesiologist. I'm a resident in Family Medicine, a career I chose back when I was an idealist, and ultimately decided I couldn't take it anymore. I've become a Skeptical Realist. And I'm selling out. That's the term I use, and I mean it when I say it. I'm gonna do something reasonable...

Primary care is the sort of beast I've never had to fight in my life before.

I chose to be a family doctor for many reasons, but largely to be of service and because I have always loved stories. All stories, any stories. I like to hear them, to make them up, to wonder about them. Family Medicine is a perfect outlet for that love.

Unfortunately, I charged into medicine and primary care with a shocking naivity. When I think back about what I used to think this job would entail, I feel a mixed sense of sadness and amusement. I knew Family Medicine would be a challenging and sometimes frustrating career, but I enjoyed it and felt it was needed. And so, with that attitude, I charged into Family Medicine. Then, Primary Care and Residency took a giant chunk out of my will to do anything except to save myself.

Here is an excerpt from my journal around the time I made my decision:

I feel like I should care as a family doc, but truthfully, ultimately I'm just sort of bitter that I'm spending my time on such hopelessness all the time. That patient is morbidly obese, disabled, alone, with cardiac disease and fibromyalgia. I can save her from a UTI, but what about everything else? I have to wonder, why is this worth hours of my time? I will never forget this smell off of this 450lb mentally retarded guy in his 40s that 4 nurses and I were heaving over to clean the diarrhea off his back this week and dress his pressure sores. Or the drunk jerk who spit directly into my mouth in the ER at 4am, slurring and bucking his restraints wondering how he could have gotten pneumonia in the summer time. "Because it's aspiration pneumonia, you jackass. You puked, then you inhaled it. That's how you get pneumonia in the summer."

It is these sorts of things that have made me stop caring about people so much.

So this was my general attitude when I decided to become an anesthesiologist.

Part 2: The OR.

I strolled in on day one wearing my green scrubs and blue paper hat. Stood in front of The Board. Scoped out what there was to do and see. I introduced myself to a few friendly looking folks wearing custom-made Saints surgical hair covers, and explained my goals. "I want to be an anesthesiologist. Teach me."

I did a couple of intubations, a few LMAs. I learned about the MACs of various inhaled anesthetics. I learned about how to titrate morphine to a patient's pain level based on their blood pressure and heart rate. I learned what to do when you overcalled that and the patient stopped breathing. I helped recover patients, consistently amazed when they woke up that it was all over.

Afterwords, I learned how to do regional nerve blocks for various surgeries. The shoulder, the ankle. First, you "make a patient comfortable" with some Versed, then when they are sufficiently high, you find the nerves on the ultrasound and stimulate so that you know you're in the right place. All of the muscles in the arm start twitching. Perfect! Then you inject local anesthetic. Bam, numbness. I can't feel ANYthing, the patient slurs, then falls back into a peaceful, benzodiazepine-induced sleep.

After that, I found out that I couldn't touch any more patients because I didn't have malpractice insurance.

That is when I started talking to the patients in the holding area.

In many ways, this was much more fun.

The first guy I chatted with was a middle-aged black guy. He was getting ready to have his left knee meniscus laparoscopically operated on for the third time. It's given him trouble ever since an injury that happened when he was in the military, but they can't really find all that much worth fixing when they go in. Wear and tear, probably should get his knee replaced, he says. But that doesn't stop anybody. Here he is again for round three.

Why do you keep getting it operated on?, I ask.

He says "Well, I'm a mail delivery guy uptown and I have to walk on average about 10-14 hours a day. My knee gets so swolled up and painful by the end of the day I'm thinking about gettin me one of those motorized wheelchairs you see on TV, you know. But I figure, I'm young, got plenty of time for that later on. I got my pride. Plus the battery's gonna wear out if I get it now, he chuckles. Then on the weekends, I work at the superdome for the Saints games, which is one job I can't give up. I get to watch every single home Saints game live! But the tradeoff is that I gotta walk up and down them stairs over and over. Man, it's painful."

Why don't you get your knee replaced?

Well, I don't know that I can take that time off work.

You ever try steroid injections or that artificial knee joint stuff?

Well, no.

Hm. Well, anyway, you have any questions I can help with, sir?

Yeah, when can I get back to work?

Well, sorry I'm not sure. You'll have to ask your surgeon that.

OK, well thanks Emily. You a Family Doctor, huh? Where you work at?

Utah.

Alright, well I guess I'll just have to look ya up when you back down here then, huh? Thanks for listening.

No problem.

Part 3: The Clinic, a.k.a. My Nemesis.

Something has been nagging at me since the beginning of residency.. I hate clinic. This bothers me, because I used to love clinic. And I can't seem to identify a reason for my hatred. It came out of nowhere. Looking over my schedule made me cringe. I avoid it until the last possible second, until the moment I have to know what is the complaint of the first patient that's sitting ready in the exam room. Then I look and cringe harder. Painful. I suffer through every second, scowling. Why? others ask me, and I can't answer. I used to love it and decided to spend my life doing it, now I hate it. What's so different?

My leading theory for this change of heart was the shift in responsibility. Clinic was fun when I was a medical student because I could chat with patients about whatever they wanted, form a list of ideas about what is causing their problems and what we could do to remedy the problem, then talk it over with whatever attending I happened to be with. It was fun, every kind of patient with every kind of problem would present to the clinic. And I could participate, but ultimately had no real responsibility for anything. In my residency clinic, I had to decide things. And take responsibility. Follow-up. Always a folder or an inbox or charting, never ending. Literally the second you finish, another thing pops up. Thankfully, there is an attending available to help, but the shift is perceptible. It made clinic harder, more stressful, and made me feel a lot more pressure about the decisions I was making.

So that was my leading theory.

My secondary theory is the fact that I am working in residency clinics. Everyone tells me this is my problem. But I have trouble with this theory, because then am I just being picky about my patients? Doesn't that sort of defeat the purpose of what I intended to do if I only wanted to be a doctor for the types of patients I choose?

But today, I was walking through WalMart of all places when I discovered the ANSWER! I found it! It is clear. The answer is community. I lost my community.

It sounds so ridiculous, but the real reason I wanted to do family medicine was that I felt a strong connection to the patient population and community that I lived in while I was in medical school. It was the community I grew up in and understood. I enjoyed their stories and personalities, their accents and their phrases. When I moved to Utah for residency, I tore myself away from every form of community that I have ever been a part of. I am thousands of miles away from my family, my friends, my patients, anything edible. I immediately appreciated the culture shock that I had to adjust to personally, but I failed to appreciate the affect that had on my relationships with my patients and my dedication to my job. Because not only was I having trouble adjusting to a new culture, I had also for some reason developed a strong animosity toward the culture in Utah as well. Because I couldn't find a place.

It's not an unwelcoming state overall, but Utah and I have had a mutual misunderstanding of each other from early on in our relationship. I have no sympathy for some things here, and vice versa. We clash. For example, someone genuinely attacked me in the elevator the other day because I was wearing an LSU sweatshirt. It wasn't jokingly or teasingly, either, it was like this raging sentiment he had toward the waste of the country's resources to bring back Southern Louisiana after Katrina.

Katrina, the four-letter word that this asshole will never understand.

Oh, he went on, and you have corrupt politicians, too! He continued by citing some kind of factoids about various corrupt politicians from Louisiana.

I was in shock, standing there trapped in the elevator, still drinking my first coffee of the day, actually feeling kind of upset about the LSU-Florida game the night before... I'm watching the lights. "A....1.....2....." He somehow manages to finish off with a comment about LSU losing the football game. I glare at him.

This is me, living the dream, working 30 hour shifts every 3 nights in Salt Lake City, and some Utah bastard is standing here talking shit about LSU.

This attitude of cultural disrespect fosters some reciprocal animosity. I immediately wanted to say something obnoxious about that fact that I couldn't find a single place to get breakfast on my way to work simply because it's Sunday, and I'm not LDS, but I am hung over and I drink coffee especially on Sunday mornings and I want some bacon and eggs, and LSU would wipe their asses with the Utes, so suck it. But I bit my tongue.

I admit that this isn't a typical scenario, but it happened nevertheless. It wouldn't have happened at home. It wouldn't have happened if I would just leave my LSU sweatshirt in the closet. It happened because of a cultural misunderstanding. He clearly doesn't understand what makes Louisiana great. And I live and breathe it. Here is a clue: it isn't our politics or devastating natural disasters.

It's more like eating crawfish. It's hard to understand crawfish in other places. But eating crawfish is delicious and fun, believe me. Who knows, maybe Utahans feel the same way about mixing mayo and ketchup and calling it Fry Sauce. (Yeah, it's the same stuff we dip our crawfish in.)

Probably, truthfully, someone visiting New Orleans wearing a Utah t-shirt would get similarly chastised about mormonism. These things happen. In fact, our very own Dirty Coast T-shirt company has designed a t-shirt mocking mormons as "Bicycle couriers for god." And I think that's kind of funny, though admittedly culturally insensitive.

I knew Salt Lake wasn't New Orleans when I moved here. But I am on their turf.

The problem with being on their turf is this: Try to be a supportive family doctor in a community you that have absolutely nothing to do with.

It is everything that is missing for me. And it's been bothering me. I have been unable to form a bond or sense of any kind of connection in clinic because I am completely disconnected from this place. And even when I am in clinic more regularly, I have no appreciation for these people's lives, history, problems, or goals. I understood a lot of those things, unspoken, at home simply by which high school they went to or what part of town they lived in, what their family business was. I was able to develop that relationship with patients in Kanab because my experience was initiated with Donkey Basketball and concluded with four-wheeling through the sand dunes. I delivered babies there and saw them in clinic, circ'd them, took pictures with them. A sense of community is essential to my desire to be a Family Doctor. But I didn't want to live in a place like Kanab! To me, this meant that I didn't want to be a family doc in either urban (SLC) or rural (Kanab, Utah) settings. This was the beginning of my crisis.

When I realized the answer, though, walking through WalMart, I wanted to talk to Peter Weir... We had started a conversation a while back that had been bugging me. He asked me what the problem with family medicine was and why I wanted to do anesthesia, but he framed the question in some way that I couldn't manage to formulate an answer. I didn't know the answer. All I knew was that I hated everything I was doing and had to get out. I had to bail to something I couldn't hate so much and that couldn't hurt me so much.

He told me something I've been thinking about. "Be careful of leaping if you don't know what you're aiming for."

Part 4: The Resolution

Standing in the O.R. at Tulane, taking my first steps toward becoming an anesthesiologist, I became very thankful for this step I have taken toward the edge without jumping. Looking over the edge from up close suddenly seemed a lot less appealing when I was staring down the airway of a paralyzed person. Especially because the ironic thing was that this patient was the same guy that's getting his knee operated on so he can keep running peanuts and bud light at the Saints games on Sundays! And I know that's what he cares about, and this operation isn't getting him one inch closer to that goal!

It all made so much sense to me at the time. But there are problems here, problems I can admit when I am away from it all.

1. We still need good primary care doctors. And few people are willing to do it.

2. You can learn how to be a good primary care doctor. You have to listen and become the ultimate utilizer of resources. These are learned skills.

3. Not everyone who does anesthesia is "selling out," but I am. And I refer to it that way because I feel a strong obligation to do family medicine. And I am choosing anesthesia for the wrong reasons. And I can't live with myself if I do that.

4. Everything I have referred to above about Family Medicine is negative, and most of the work is positive.

When I was in Kanab, I rediscovered my desire to be a family doctor, and my secondary realization was that I had no desire to live in rural USA, or more specifically rural Utah.

What I did not appreciate at that time is this: I can always move back home! It's so obvious, but I have been missing it somehow.

I love the people here and I understand them. Clinic here consists of that waiter at Napolean House, the guy getting knee surgery, the musicians at the Spotted Cat. I remember now. I would love to be a primary care doctor for this community. And in the meantime, I can take my experience in Utah for what it is, something different. I think perhaps I was having trouble admitting this because I have always wanted to move out West, and felt like this is where I belonged.

I have been stubborn about certain things during this whole process. I have a long tradition in my life of creating unrealistic expectations. I'm a proud and devoted dreamer and wanderer. My visions of reality are always much better sorted out than actuality. It's like my writing. I love to write. It's a great passion of mine to be able to sit, think, and sketch out a process or a story. Then I can edit and perfect it, play with my words and ideas until they perfectly depict what I intended to convey. I've known this about myself for many years. Unlike my writing, though, my idealistic visions have to face the reality of the situation. They have to meet head-on, glaring at each other, and decide who will win. If reality wins, I have to stay and face it, sacrificing my carefully-designed vision, watching huge pieces of it fall off, horrified by my own reaction to various injustices. If idealism wins, I have to float off to some other place that will surely fulfill everything I ever wanted. Idealism keeps winning in my life, which is why nothing in my life sticks and I am constantly moving forward to focus on something else to idealize.

Hence, here I am, single, alone, lost, don't own a car or house, and won't claim a job title.

I have been unwilling to listen to people I admire and who know me very well. They are warning me now about abandoning Primary Care because I do not like residency. I have been defensive, because in a way, I'm envious of the people who have chosen careers with primarily selfish motives. I honestly haven't done that. I have not chosen this career with a selfish motive. I ended up here because I have been searching for something that has some meaning. But many times over the past year, I have wanted nothing more than to be freed of this burden. Why shouldn't I be able to have a selfish career? Leave me alone! Like some sort of rebelling two-year-old. And everyone answers this whining plea of mine with, "You can. Do whatever you want, Em. But be careful of leaping."

I still have this underlying concern that you are wrestling with some type of crisis of meaning that is larger than this residency, and medicine. If I am right, there is some risk that this feeling of discontent moves on with you. I think that it is really important that you have someplace outside of medicine to work through all of this.

I remember my advisor saying one day how he thought it was so curious in a sad sort of way that a radiologist friend of his felt so apathetic about his job. I remember thinking, I'll take apathy over pain, frustration, difficulty, hopelessness.

But the real question is: will I accept apathy over everything else? Over laughter, hope, relationship, reward? Over self-respect?

“Offer them what they secretly want and they of course immediately become panic-stricken.”

Jack Kerouac quote