forward with purpose.

I've been listening to NPR on my commute, and they've been talking about the Washington state school system "crisis" regarding their soaring budget needs while admitting poor results... I'm hearing this stuff on the radio at the same time as reading the biography of Steve Jobs by Walter Isaacson…

All of it really makes me wonder. Wonder about a lot of things, but primarily… what is it that makes people great?

First and foremost, it makes me think that nothing ever got better by hucking a bunch of money at it. There has to be a vision. A plan. And maybe even something that could be realized with less or no money if the idea is great enough. Secondly, we have to start taking ownership of our jobs and roles in society again. Great teachers are great teachers because they have decided to become great. Same as most professions. No doubt, money and equipment and a good support system help, but one of my best teachers was paid probably $35,000 a year and worked in the public school system in Cut Off, LA. Because he took ownership of it.

All I am hearing these days from politicians is this sniffling because the money has to come before anyone can come up with a good plan of action. And really, it should be the other way around. How can we make things better with what we have? Ideas really are free.

The fascinating thing - or one of them, because there are endless examples - about this guy Steve Jobs.. is his defiance off the normal track to achieve his greatness. His defiance was to the extent that it makes me ashamed. Defiance of college, of working through ranks, of accepting stability over risk. The frank defiance of all of the things that I have chosen. And I honestly, truly, intensely believe that these strategic choices of defiance are the things that allowed him to maintain a sense of truth and creativity that it is hard for the rest of us to maintain.

I don't mean to "blame" the usual ranks. After all, clearly, it is the road people like me take to survive to a certain extent. How does one transition from being a child to being an adult? We start with the prescription of college and move forward from there until we take a prescription of employment. There are so many things to worry and care about as an adult. For me, the choices I made were certainly along the road that was able to take care of many of those details of "life" away from me and force them to be as external from me as possible. Which is exactly what I wanted. I wanted to externalize these unpleasantries from my life as a separate entity. As an adult, I always want to believe that my anxiety problems are a consequence of an external force. Or my financial situation. Or my relationship problems. Or my career opportunities. I have made choices that have allowed my employers and my teachers to decide what I can and cannot do in this world so that I don't have to deal with deciding that myself. In that way, I can externalize the blame. "I can't do that because I owe too much money from stupid med school." How many times have I said that? Not, "I decided to borrow money to go to medical school to actualize my career dreams." One decision after the other, I made decisions that required the least "introspection." In fact, I would argue that by choosing to take this road I have deferred to think about the things I care about. I have outsourced these decisions so I can externalize the consequences. But perhaps embracing those issues we are externalizing is exactly what we need to do to regain our sense of purpose..

It makes me think about medicine from the top to the bottom. An administrator saying, "Well the doctor ordered it." A doctor saying, "I don't know, it didn't happen on my shift." A medical resident saying, "I can't do that, I'll be over my hour restrictions." A nurse saying, "I don't usually work this cart, I don't know this patient." A patient saying, "I have no idea what medications they have me on now." An aide saying, "I'm on my break, I can't help now." An insurance company saying, "We're not gonna pay for that. Please fill out some more paperwork." A social worker saying, "Sorry, I don't work on the weekends." All of these people are saying the same thing... Not my problem, not my responsibility... instead of taking ownership of their jobs and their roles. And I think that probably takes away from our sense that we are doing something meaningful. I wonder what the shorter shifts and increased hand-offs is going to do to medical residents for that reason...

It's interesting, I have always considered myself to be a fairly introspective person. It's something I've tried to value and harness and embrace…But I took it for granted without feeding it or caring for it, especially in the past 2-3 years. I put my introspection in storage while I pushed through residency and made some decisions about where to go, what to do, and who to do it with. However, I have been realizing in this post-residency phase that it is much harder, and requires much more effort than ever before to embrace what I believe in and care about. Almost like I've lost that ability. It has atrophied from disuse.

It makes me ashamed to read about a person like Steve Jobs who cared so intensely about everything. When I read about how much he cared about what he "decided" to ingest with his dietary choices, how much angst he went through to decide on what kind of sofa to buy… I realize how far I am from reaching his intensity and his embracement of choice and ideas.

On the other hand… I can actually remember being a child and believing things with that kind of intensity. It's just that I've lost that along the way. I actually remember the first time I cheated in a swimming workout as an early teenager. I would never have dreamed about doing that as a child. I believed so strongly in working as hard as possible at all times during swimming. I was never the fastest or coolest or prettiest or most hard core swimmer on the team, but I was "the hardest worker" several times. I intensely believed that pushing myself to my own limits was the key to success and I felt success via that path. After I cheated for the first time, I felt the slip of apathy set in. I started to realize that for a mediocre person such as myself, it didn't make much of a difference to the world if I cheated. It wasn't that bad. It was kind of easy. Nobody was watching. Nobody cared if I swam 2 less laps on warmup. Or started my watch timer a little late. No one knew… It was setting the beginning of the precedence I still feel in my life to a certain extent. I never push too hard, and I know I'll always come out somewhere in the middle and no one will notice much about it. But I never feel great leaving the work. I just feel done.

Maybe not "because" of the path I've chosen, but surely in part because of my departure from my approaches as a child, I've become much more apathetic. As a child, it seemed that things were right or wrong. Things were never OK. I had very strong opinions about politics, the death penalty, abortion, the environment, religion. I used to seek out as many "clean-ups" as I could because I loved the idea of picking up trash. In school, they called us "eco warriors," and I loved that! Now everything is OK and nothing is right or wrong. I don't believe in anything anymore with intensity. Religion, politics, medical decisions, who I should spend my time with. Important stuff. Everything is "eh." I could be persuaded in either direction of almost any argument. I am a modern day politician. Whatever will give me the least resistance in my path and smooth the potholes of day to day life is the road I will choose. The fastest, smoothest route to nowhere.

How to regain that intensity? How to believe that my life and my choices matter in some way? How to care about things again?

It's hard.

It's been a moving experience from me - reading Jobs's biography. While I am, or perhaps was, a dreamer by nature, I would prefer to at the very least remain a dreamer than to go where I am headed…. that is the indecision to stay stagnant and still.

Think about this: I have decided to remain in my current job for 3 years because if I stay longer than 3 years my employers stated in my contract that they would repay my "tail coverage" for malpractice insurance.....

Yes, this is the method of decision making I am embracing in my life at this point!!

Why? Because… I have nowhere to go and nothing to do. So I have to grab at these arbitrary ultimatums as "waypoints" of decision-making in my life. I haven't created any goals of my own. Something so meaningless as whether or not my tail coverage will be paid by my employer or myself is how I am choosing to make the next target decision in life. But, of course, that waypoint is no less meaningless than my last target which was finishing residency…. and the one before that of finishing med school… and the one before that of finishing college… and the one before that of finishing high school. They are all similarly external from myself. The last important decision I've made in my life with purpose is whether or not to go to West Point. Everything since then has been trudging along choosing arbitrary experiences that seem like an OK idea at the time.

Steve jobs said something like.. The difference between those who do things and the dreamers are the willingness to pick up the phone and ask the question.

I realize when I reflect on Jobs's statement is yes, that's true. But there is another category also… I am in the category of people who have lost the ability to even form a question first, much less dream about picking up the phone.

I sometimes wonder about our generation from that point of view. We seem very disconnected from the whole thing. Clock in, clock out, work your shift, pass the buck, not my problem anymore.... Working on a salary, our value is not connected to our quality of work. This is the biggest problem with medicine currently. Our value is connected to things that mean much less, like what type of degree we have... As one of my wise old patients told me the other day when I said all doctors have the same training at some level, he answered, "Yes, but not all of them stayed awake in class. And not all of them care about their work."

Interestingly, lately I have been seeing children as a powerful force amongst my friends and relatives to return some sense of meaning to their lives, which is fascinating to observe...

It seems to me that the difference between dreamers/do-ers and the rest of us is that some people are at least trying to imagine better and bigger whether they succeed or fail and the rest are watching from the sideline. Sitting on the train track of life. Copying. Redistributing. Repeating. Doing what someone told us to do. Staring out the window. Maybe with a soft distraction of a twitching muscle representing that nagging intuition that something very big is missing from our lives. Not all of us can be truly great, but all of us can at least move forward with purpose.

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You can't connect the dots looking forward; you can only connect them looking backwards. So you have to trust that the dots will somehow connect in your future. You have to trust in something -- your gut, destiny, life, karma, whatever. This approach has never let me down, and it has made all the difference in my life.

Steve Jobs

Remembering that I'll be dead soon is the most important tool I've ever encountered to help me make the big choices in life. Because almost everything -- all external expectations, all pride, all fear of embarrassment or failure - these things just fall away in the face of death, leaving only what is truly important. Remembering that you are going to die is the best way I know to avoid the trap of thinking you have something to lose. You are already naked. There is no reason not to follow your heart. ... Stay hungry. Stay foolish.

Steve Jobs

If you haven't found it yet, keep looking. Don't settle. As with all matters of the heart, you'll know when you find it. And, like any great relationship, it just gets better and better as the years roll on.

Steve Jobs

Innovation has nothing to do with how many millions of dollars you have. When Apple came up with the Mac, IBM was spending at least 100 times more on R & D. It's not about money. It's about the people you have, how you're led, and how much you get it.

Steve Jobs

No one wants to die. Even people who want to go to heaven don't want to die to get there. And yet death is the destination we all share. No one has ever escaped it. And that is as it should be, because Death is very likely the single best invention of Life. It is Life's change agent. It clears out the old to make way for the new.

Steve Jobs