Baby Burrito MD

10/27/2024

Last week, I had the chance to have a really transparent conversation with someone at the very beginning of their medical career. These are chances to say to someone else what you wish someone had said to you.

Acknowledging they are just as likely to listen to you as you were to listen to some other old adult about life. 🤪

One of the things that this person wants to do is mission work, moving off to a distant country to work with kids. A very noble desire, very sacrificial, very mindful, very demure.

I know a lot of lovely people who sacrifice every day. So many are burnt out. A stubborn few keep going.

One thing we talked about was something I still discuss in therapy: that idea of nobility. It’s a deep magic, probably steeped in me by the baptismal waters of the church. An idea that the best of us give ourselves away to those less fortunate.

What I’m beginning to understand is that idea of nobility propped up my self esteem for a long time, when I had very little. I may not have been much, but I gave to others.

That sort of noble self esteem seems to me now a “near enemy” of healthy self love. A near enemy means something that we have been taught as ideal, but misses the true mark.

We talked about how sacrificing ourselves can be beautiful and even necessary in the short-term. But if we’re talking about a career that should last decades... in order to sustain that sort of effort over that sort of time, then we have to make choices that feed us rather than starve us.

To the idealistic, that seems selfish. But. If we can find a job that we are truly passionate about—or if we leave enough time and resources for some life-giving relationships and activity for ourselves along the way—then we can gain the sort of skills that can be used to help others while also retaining our own humanity.

It’s when we are filled up with dignity and love that we can provide compassion.

When we are starving for such things ourselves, then even when we give compassion, it often builds up a residue of moral resentment. So often, that will lead to burnout and a lack of self esteem, even when our intentions are so good.

07/11/2024

Despite our reputation, many surgeons are “nice” people, particularly when we started training.

And then we learned to be “mean” the same way a monkey is taught to dance, through a lot of pain.

Considering people still label me as “nice” (me: sorry I was mad earlier. Them: you were mad?), I’ve had time to consider this spectrum. And I reject it.

It’s just that “nice” and “mean” are trash-can terms that encompass too many things to be specific. Society can label someone nice in the same way a cat calls a mouse nice. And people are so quick to call someone mean when they finally start standing up for themselves.

Too many “nice” people are caught between (1) a lack of awareness or suppression of their needs and (2) an inability to ask for what they want. Usually there is societal and family pressures producing and enforcing both of those. The mismatch between those barometers over time can build up into a whole thunderstorm of rage and discontent.

That rage does not simply dissipate, not in my experience. It either explodes outward or it turns inward. Outward toward innocent bystanders or behind the backs of people/systems we should be facing. Inward toward depression and paralysis.

We have all sorts of voices telling us ways to change these barometers and why, and it’s maddening. Like many, I’ve been reading some stoic philosophy (tldr: you don’t need all the things people say you need) lately, which would adjust #1. While I feel it’s helpful, I can imagine the anger I would feel if a hospital administrator prescribed it for me. Meanwhile there are all sorts of campaigns telling us we should ask for what we want or grab it for ourselves—this is consumerist America, after all.

In the end, we have to work out a balance of these two. We have to identify our needs, find ways to believe in their validity, and we have to develop ways of comfortably and consistently articulating what we need in time for it to matter. Otherwise we subjugate ourselves below the powers of others.

We don’t want niceness. We want peace of mind, and that’s the way we find it.

07/09/2024

Speaking as someone who has and will blame himself for every bad thing to happen to anyone ever (only slightly exaggerating), complications in surgery have been difficult to navigate.

Over time, I have identified at least 4 kinds of things I labeled as complications, and identifying them has helped me deal with them.

1) unwanted things that happen because of disease: even now, I almost said “unexpected,” but with experience, I’ve found out that some disease is just hard to treat and it’s even likely that some bad stuff will happen in the postoperative course, ie an infection persisting in an operated sinus
2) unwanted things that happen because of the patient: sure, “don’t blame the patient,” but if he smokes like a chimney, then that skin flap isn’t going to survive. Or non-compliance. Or things that a patient can’t control, like their diabetes.
3) mistakes that happen because of inexperience: you do the best you can, but you learn later on that you could have done it better with this technique or medication or repitition
4) mistakes that happen because of real incompetence or neglect

And realistically, you are going to see all 4 at various stages of your career, and it sucks. And look, you’re going to try to keep all of them down to a minimum, prioritizing #4, but they’re still going to happen because you’re a doctor, trying to treat a whole lot of people through a long career.

What I think helps is that when a patient complains, you can ask yourself, “did I do the best I could to not hurt them?” And if the answer is yes, then largely, you did your job. A negative review can suck a bag of mucus.

You learn from 1-3, and you remedy #4 by keeping your motivations and time and sleep in check. And most of all, the best thing you can do is talk to your community and feel the solidarity of a bunch of people struggling to take care of their groups of humans.

So much of the time, this is an emotional issue, not necessarily an intellectual one. It’s important to process, ideally not in complete solitude.

06/23/2024

Life Lessons from the Eustachian Tube:

So many people come to an ENT practice for ear fullness or pressure. We do an audiogram and an exam. I explain that there is a ventilating tube in the back of the nose on each side that opens and closes when we yawn or swallow, but theirs is not working as it should.

“So do I have Eustachian tube dysfunction?” they ask (ETD). And I say sure, but really it’s not the right way to think about it, yes or no. You have to think of these symptoms on a spectrum, much of which is outside of our own experience. There is mild—maybe with some clicking—and there is severe—with infections or an erosive process called cholesteatoma. Yes, here you are on that spectrum.

“What do I do about it?” And we go through all the different options, like allergy treatment or an ear tube or a Eustachian tube balloon dilation. And I have to say that with mild ETD, I’ve placed ear tubes and then the patient comes back saying they hate it. And then the balloon dilation only has a success rate of around 60%. No perfect way forward.

And so what we do depends on what they want to do, with where they are on the spectrum. It involves their attitude toward risk, their discomfort, their insurance, their ability to pay, their trust in what I’m saying. The decision about what to do depends on their individual relationship to the spectrum of disease.

As I observe the world, I start applying this idea to things other than ETD or medicine.

On broader terms and using even broader generalities, what I’ve noticed is that many conservatives have to learn to acknowledge that nearly everything in life is on a spectrum—not yes or no, not absolute. For me, this was a departure from the evangelicalism I learned as a child, a welcome one.

And many liberals have to learn that nearly every intervention needs to be relational, not dictated or simply expected. It has to meet the needs and desires of people, where they are. At their best, Liberals can be good at acknowledging the spectrum of existence and identity, but—at their worst—can miss the human behind the identity, if that makes sense.

I’ve had to learn both. And I’m still learning both.

06/13/2024

“I believe you,” is one of the most powerful statements there is.

In the past couple weeks, I have cared for patients on the hunt for a diagnosis, patients with chronic pain, a patient with suicidal ideation, many with poor access to care and little formal education, immigrants, and the elderly.

There are some that come in with wary hope on their faces, many more with resigned cynicism. They have seen a doctor that looks like me before.

And just in case you think I’m about to say “they came to the right place” like I’m Dr. House or whatever, I’ll just say that often I have no clue what the diagnosis is. Sorry. I’m just not that great.

But what I can do is listen, and for at least 10 minutes or so, I can suspend my judgement or my disbelief, and I can believe them. I can believe that it hurts, that they’re scared, frustrated, sad. That what happened before was racist or misogynistic. That they really should have used an interpreter.

I am not saying that we should suspend all judgement forever. That’s not our job. We must then act skillfully on what we find or we are just selling snake oil.

But to believe the patient for just a little while opens up not just a lot of possible avenues for diagnosis but also trust and compliance and peace of mind and—rarest of all—connection. It’s not easy, particularly if they are talking about a complication of one of my surgeries. It’s not cost effective or efficient, but it is so very human.

Spiritually, I find hope in this tedious practice of compassionate listening. I do not know where it will take me, if I will someday be able to listen to people with whom I strongly disagree with the same open heart. I hope it will inform my marriage and my parenting.

Maybe, just maybe, I will even be able to believe myself when I say I need a rest.

05/30/2024

I am learning to let myself feel.

I can remember being about my son’s age, about 10, when I started saying that I felt “overwhelmed.” My parents tried to help me through it, though with 4 kids at home I imagine they were feeling something similar. At school and at church I was told to pray through it, to address my worries to God, to “take every thought captive.”

Looking back on it now, I took that to mean that there were some feelings that must be contained or deflected. I was embarrassed by my anxiety, even shamed by my bouts of melancholy and the low energy that came with it.

I hid them, best I could. I believed that I could or should think my way out of these emotions, or that if I prayed correctly, God would rescue me from them. And I wouldn’t have to feel them anymore.

For the better, I’m learning different practices now. Really, I feel like I’m scrabbling them together into something that works for me. On days like today, when I am taken by this wave of terrible anxiousness—about my career and where it’s going—I am learning:

• Get to a quiet place with no one around
• Breathe or meditate until calmer
• Slowly let the worried thoughts surface and then emotions with them
• Allow myself to acknowledge these thoughts and worries without dismissal (“but you don’t have to worry about...”) or defense (“you have to fix this”)
• Tell myself that it’s normal to feel these worries and that probably a lot of people feel this way
• Once I’m done acknowledging and validating and I breathe some more, then sometimes some problem solving will surface too
• Talk to somebody about the worries that remain, when able

I don’t think I’ll ever get it right. But it helped today.

And so why wouldn’t it help tomorrow?

05/23/2024

When I was 26 and a 4th year med student, I made a commitment that I am still living out to this day.

At that point, I (partially) knew two things about myself: (1) I am not solitary, but I am someone who is comfortable with solitude. (2) it was my general philosophy and work ethic that I would work my hardest to keep my options open, to keep any path available, to keep my liberty.

When I committed to pursue surgery, I knew I was giving up both—rather, I was evolving out of both. And I knew it was going to be hard for me.

There were options that would allow me more solitude, but I knew that I needed people around me, that isolation was not going to be healthy for me. I thought that the relationships with patients would be fulfilling to me (mostly true). By taking this opportunity to say yes, I would necessarily have to say no to many other things. But it seemed to me that this chance was as good as I could do.

And so I committed. To being surrounded by teams of residents and colleagues and patients and staff all the time, past exhaustion. To the monotony and the charting. To the glory and gore of a knife in my hand.

I suppose I remember this to try and remember that if I am capable of such a resolved commitment to work, then I am capable of such a commitment to life. I am capable of evolution, even now.

What once seemed necessary was overcome and passed away. The way was not clear but had to be lived out.

My age is on my mind. Like my almost 40-yo stem cells, my choices have differentiated, mostly.

Choice is still there, smaller but momentous. I can commit to each day, commit to love more, to notice and name more things, to be silly more, to enjoy things as they come and as they go.

With age you learn: a goodbye can be just as sweet as a hello.

05/14/2024

Tinnitus, or ear ringing, is a very annoying and common problem. There are probably 30 different things that cause it, and we don’t have the technology to tell the difference between them. Partly because of that, we keep trying different meds and supplements for it, and sometimes they work and sometimes they don’t. But we don’t have anything that works for everybody.

And so patients come in, asking if they can try this or that. Sometimes it makes sense, sometimes I have no idea if it will work, and sometimes I have to say no.

I took care of one patient who went all the way to Mexico to have stem cells injected in their spinal column for this symptom. I met them in the NICU, sedated and critical from complications a couple weeks later. That’s how distressing it can be to people.

My rules for people wanting to try something are three-fold:
1) It can’t be expensive.
2) It can’t interact with your other medications.
3) It can’t be harmful to you.

To me, this seems reasonable and preserves the patient’s right to explore options, particularly in an area where medicine doesn’t have a good answer for them.

And as I’ve thought about it over the years, I find these rules have helped me through a few decisions about living with people that think or act differently from me. When do I say something if I don’t agree with what they’re doing? When do I stick my neck out and disrupt harmony?

Sometimes thinking about the disagreement in question in these terms can help me make a decision, possibly switching out #2 for “can’t override other people’s dignity or well-being.”

After going through these, there have been instances where I’ve kept my trap shut.

And there are instances where I decided that something had to be done that disrupted the harmony of others and myself. At least when I considered it through the lens of these criteria, I felt a little more self-assured that I was doing it for good reason.

03/28/2024

“But getting my tonsils out isn’t really going to hurt, right? Just a couple days?”

“No, it’s going to hurt really bad and for almost two weeks.” *patient’s eyes get big* “The pain meds will not take away all of the pain. You are still going to hurt.”

Over time, I’ve learned that telling patients the truth in plain language with no sugar coating is the best thing. It sets expectations. During recovery from tonsillectomy, that preparation almost feels like a supplemental medicine, and more than a few have thanked me for it.

The honesty honors patients with the dignity of choosing their response to this challenge, and dignity goes a long way.

But then there are my chronic pain patients, even end of life patients. And from so many of them, I have heard that they often receive similar advice to what I give my tonsil patients: toughen up. Don’t be so sensitive. You’ll get over it.

To me, this bitter pill of advice is the wrong medicine for these patients. When we say this, we are telling someone to accept their suffering and lot in life in silence without the compassion of their fellow humans, until they die.

When we tell people like this to “toughen up,” people who are going through a completely different experience than our own, sometimes we say that “we’re just being honest” when really we are trying desperately to keep these suffering people at arms’ length.

And that is because, I think, we do not want to be forced to think about what it would be like if we were sick or dying. Or if we were poor and forced to work two jobs we hated with no hope of retirement. Or if we were alone. Or if we were born in some poor corner of the world with no hope of basic safety for our kids.

We do not want to be honest with ourselves. We would have to face the seeming arbitrariness of the universe or God. That can be scary.

So we are “too honest” with other people, forcing them to take our bitter dose for us. We send them away.

Being honest should also respect the other person’s dignity. If we learn to be honest with ourselves first, then we can recognize and truly care for those around us who are suffering.

03/25/2024

03/24/2024

03/21/2024

You might think that being a surgeon and a people pleaser can’t go together, and I’ll tell you, you’re probably right.

I am both, and I have been for a while, and it’s exhausting.

Asking for things that I need—especially things that might inconvenience someone else—is pretty difficult. I have gotten a smidge better at it. I certainly try to put patients and their health above these feelings, and if it’s a true emergency, then stuff needs to get done no matter what.

But in the day to day, it’s hard to feel like you’re pleasing someone if you have to do a disfiguring surgery or put someone in the ICU. I have had a few generous patients that remind me that the “inconvenience” I feel I’m putting them through is nothing compared to leaving them with their disease, but it’s hard to keep that perspective for long.

I’ve realized a bit better that this people pleasing is very much related to my perfectionism. Both traits have led me to my relative success as a surgeon but also to a lot of anxiety and burnout.

Both traits are attempts at gaining control over my surroundings, born out of a need and desire for safety and security. If I can work hard enough at enough details, then I will be in control of my destiny. If I can control people’s perception of who I am and their feelings about me, then I will be secure in my little community.

But this is maladaptive in a lot of ways and misses the mark, mainly because we are all limited. No one can work as hard as it takes to achieve this, and even if they did, they then lose chances to really enjoy life and family and community. And patient care is a constant reminder that we are actually in control of so little.

I am beginning to acknowledge my limits, and I’m even becoming thankful for that process. Maybe I’ll get to the point where I will be my true self, rather than just the mask that pleases the people around me.

03/20/2024

I’m still crawling out from under all the catch-up work from being gone + a big cancer case today. So here are all my best pics from our trip for .

03/16/2024

From “The Ninth Elegy” by Rainer Maria Rilke:

But because *truly* being here is so much; because everything here
apparently needs us, this fleeting world, which in some strange way
keeps calling to us. Us, the most fleeting of all.
*Once* for each thing. Just once; no more. And we too,
just once. And never again. But to have been this once, completely, even if only once:
to have been at one with the earth, seems beyond undoing.

03/13/2024

03/13/2024

The value of life is complicated then, and as our societies and human ecosystems become more entwined, the existential pressure that comes with each public decision becomes harder to bear.

The calculations have to be done, whether we want to or not. That’s why it’s “Black Lives Matter” or “All Lives Matter” or if you have to work to have healthcare or if trans people should have the right to choose.

Or if that could happen in a small town.

It’s hard to agree. So is it any wonder that so many fantasize about a post apocalyptic world where things are miserable but a lot simpler? Hollywood makes tons of money on such stories every year, and people make the trek out to Burning Man to escape into something like it.

I once had a prepper as a patient, and they were fascinating to talk with. At one point, they said, “I’m a Christian, and I think from time to time about whether I would pull the trigger to protect my family and their food.” I asked, “since you brought it up, I would be interested in what you’ve thought about that.” They looked at me with a blank stare for a beat, and then they said, “Anyway let me tell you which gun you should get.”

Watching all of these value systems and pulls on our empathy burn down, I could imagine, would carry a lot relief for people. To be reduced closer to our animal natures where might means right. Where our individual value is more easily defined by our function and our willingness to kill.

Of course, in these dreams, we are usually imagining that we are the powerful ones, that we are the chosen, that we are the ones who choose.

To tell another story—where we are not powerful, where we are the serf and not the lord—would force us back into our present state, where we must negotiate again.

And where is the money in those stories?