Sachin Narayan—From Premed to a Purposeful Medical Career

Sachin Narayan is the founder and former CEO of Cathartic, a nonprofit company that focuses on preventative health of under-resourced populations. He is recent graduate from the University of Southern California and is matriculating as an MS1 this fall at the Stanford School of Medicine.

In this captivating podcast episode, join me as I sit down with this remarkable young man who achieved the extraordinary feat of getting accepted into the nation's top medical schools. Discover the secrets behind his success, delve into his insights on navigating the pre-med journey, and explore the intersection of AI and medicine. Together, we explore the inspiring story of how he started a social impact non-profit, while also discussing the profound question of knowing whether a medical career is truly the right path for you. Prepare to be inspired, informed, and empowered by this enlightening conversation.

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Is Being A Doctor Worth It?

She was a little older than me, had no medical problems, and was in my operating room with no heartbeat. She was found down in a snowstorm and brought in with severe hypothernmia. For the remainder of that freezing night I forgot about the long work hours and the hundreds of thousands of dollars of debt and worked with the other doctors, putting our patient onto cardiopulmonary bypass, warming her up, and getting her heart beating again. She woke up the next day and was totally fine. A few days later she walked out of our hospital. I will never forget how one moment she was dead…and then she was fine.

Practicing medicine is a highly respected and prestigious profession. However, it comes with long hours, stress, and significant financial investments. It’s extremely difficult to get into medical school and a long road to becoming an attending.

It’s no wonder why the #1 question I get from students is: is being a doctor worth it?

If you had asked me that when I was a second year medical student or an intern, you would have gotten a different answer than what I’d say today.

Myself, the 2nd year Medical student: Oh my God, what have I done? All I do is study. I have no social life and it’s only going to get worse. I really don’t know if I did the right thing. I like learning but I’m not really seeing patients. I’m just not sure if it’s worth it.

Look what second year med school did to my hair!

Surgery Intern: I’m ALWAYS at the hospital. I’m not seeing my friends, I’m not exercising, I’m getting yelled at and ridiculed. This isn’t worth it.

It’s not true that I was ALWAYS in the hospital. Look, here’s me in Ecuador—pretty sure I was having fun that day!

Today: It’s absolutely worth it. It’s satisfying to do hard things. I love the non-stop learning and it feels good to be taking care of people. Every year or so, there is something really hard to deal with: a big exam, a patient death, etc. None of those things are enjoyable, but each challenge pushed me to grow. I don’t think I could have grown as much if I had chosen an easier path. Now I’m working part time and have time for my family.

In 2021, I took a radical sabbatical and lived in an RV with my wife and kids. I don’t know if I could have done that if I had not worked so hard. Moab 2021

I want to ackowledge the downsides. Yes, the educational path to becoming a doctor is a long and arduous one, involving many years of study and high levels of competition. Yes, it requires a significant financial investment, with medical school fees alone averaging around $40,000 per year. And yes, the high levels of responsibility and pressure that come with the job can lead to significant levels of stress and burnout. Yes, all that is true but it doesn’t mean it’s not worth it.

Christmas at Yale New Haven Hospital. At least we had each other!

There are many compelling reasons why being a doctor is worth it. The opportunity to help people and make a positive impact on their lives is incredibly rewarding. We doctors save lives, alleviate pain and suffering, and provide hope to patients and their families.

In addition, the medical profession offers a high degree of job security and financial stability. The demand for healthcare services is only increasing, and the average salary for a doctor is around $200,000 per year. While this salary may come with significant student loan debt, it is typically considered a good return on investment, particularly given the ability to make a real difference in people's lives.

A career in medicine is an acquired taste. Estonia 2010

Moreover, being a doctor provides a great deal of flexibility in terms of career paths and opportunities for advancement. Doctors can choose to specialize in a particular area of medicine, such as cardiology or pediatrics, or they can pursue research or administrative positions. This allows doctors to shape their careers in a way that aligns with their interests and goals.

Working as a doctor in New Zealand was a great way to get to know this wonderful country! Milford Sound, NZ 2012

Being a doctor offers a sense of fulfillment and purpose that is difficult to find in many other professions. Doctors are part of a respected and trusted community, and they have the opportunity to work alongside other healthcare professionals to make a real difference in people's lives.

In conclusion, whether it’s worth it depends on who you ask and when you ask them. I don’t think I would have given out good advice as an intern because while there are certainly challenges associated with pursuing a career in medicine, the benefits are significant.

Being a doctor is great! Being a patient is not. South Sudan 2010

We all need to spend our lives doing something. Having the opportunity to make a real difference in people's lives, the financial stability, and the sense of purpose and fulfillment that comes with being a doctor make it a highly worthwhile and rewarding profession.

Ultimately, for those who are passionate about learning, helping others, and willing to make the necessary sacrifices, being a doctor is definitely worth it.

What do you think? Is being a doctor worth it? If you’re a premed or a medical student, let me know what you think?

When Everything Clicks Into Place: How Foreign Travel Can Make You a Better Doctor

This essay can be found on the Whitecoat Investor Blog.

Malaria check negative!

I was always going to travel. I’ve known this since I was in fifth grade, when as an exchange student, my French “mom” shoved a few francs into my hand and dispatched me, a kid from the North side of Chicago, into the streets of Paris for bread. The urge for adventure never left me.

I put on the white t-shirt with MSF in red letters and flew from Paris to Kampala to Juba. I disembarked and the most unusual thing happened: nobody noticed me. There were no touts, nobody selling, and nobody asking for anything.

The next day, I flew to Wau and finally to my village, Aweil, about a hundred clicks south of Darfur. We landed a sketchy twin prop onto a patch of red dirt. The heat was a kick in the groin, like summer in Phoenix, but humid. I sweated buckets and looked around—no airport—just dirt—in every direction. I wanted to ask the pilot to take me home, but six flights in as many days was wretched enough. Besides, I didn’t speak Arabic. 

A land-cruiser with an MSF flag appeared, as if by magic, to fetch me. We drove past fields with straw and mud huts and reached a compound surrounded by stone and barbed wire. I went into a non-ventilated stand up latrine and dry-heaved. Then, before even setting down a bag, Nancy, the medical director, asked me to go straight to the hospital and do cases. 

“Now?”

“Yes, now,” she said.

“I haven’t eaten. I haven’t slept.”

“After lunch, then.”

Read the full essay on the Whitecoat Investor Blog.

An RV Dog's Life

December 17, 2022

This essay originally appeared on The Dog’s Life blog.

By Dr. Michael Mulick

In January 2021, we sold our home and hit the road to live full-time in an RV for nearly a year. We left during the peak of the pandemic, hoping for a better life for us and our two kids. Our dog, Sophie, was forced to come along.

Sophie was a stray, which is unusual as she is a pure-bred Border Collie. We rescued her when she was one-year-old. I named her after a character in my favorite William Styron novel, Sophie’s Choice. Since then she has picked up many other names: Snowfie, Snoopie, Snoop a loop.

She had been traumatized as a pup. She was an angel in the house but we couldn’t take her for walks. If she saw another dog (even a block away), she snarled and barked. She even bit. Snoops (Sophie) did well at dog parks. People commented “I cannot believe how fast she is,” as she morphed into a black and white blur. But we had to stop walking her. She did best roaming the yard and chasing squirrels.

The transition from a 2200 sq. ft. house to a 200 sq. ft. trailer put Sophie perpetually under our feet. There was no yard to which she could escape. We have a big rig but there are not many windows. Sophie had to climb onto the kitchen bench to look outside. And she could not let herself out. There were other constraints, too: Dogs can’t roam free in RV, State, or National parks.

We all adjusted to the small space. The summer heat wave became our biggest problem. We couldn’t take Sophie on excursions .You can’t leave a dog in a parked car, and the air conditioner in our rig only worked at RV parks. We found ourselves considering Sophie’s safety and well-being more often.

Despite many challenges, the trip turned out to be a lot of fun for all of us. I wasn’t working and was “home” a lot. We were always outside, often in wide open spaces. Sophie loved chasing me as I rode my bike. Snowfie (we sometimes call her that) really loved running in the snow. Our little Snowhead chased us sledding when we were in Colorado for the winter. Sophie seemed to tolerate the trip but I’m sure other dogs would have had an easier time. The most surprising thing was how well she did in the truck I drove to pull the RV. She seemed at peace while driving on the highway. Once we hit a consistent speed, she would lie down on the bench between my wife and me and close her eyes. Once, I drove from Idaho to Wisconsin, driving eight hours a day, for three straight days, and she slept most of it with her head on my lap. I think riding up front was a slice of heaven compared to how she used to ride in the back of our old van. She’s a good car dog. She rarely gets antsy and never asks for a stop.

Border Collies are an intelligent breed. They need a job and if you don’t give them one, they’re not happy so they will invent a job. Sophie constantly monitors the location of our family members wherever we are. But long drives were such a restrictive environment and everyone (the family) was accounted for. With nowhere to go and nothing to do, riding in the truck’s cab was one of the few places she could truly relax. Animals get stressed with major changes to their environment. But as long as they get to be with you, they can tolerate a lot. Sophie did okay on the road even though she is much happier in a house with a yard. Most importantly, though, she showed us she just wants to be close to us and to go wherever we go.

We Sold Our House and Hit the Road

Hey everyone! In January of 2021, we sold our house, I stopped working, and we hit the road. My wife, two kids, and I moved into a trailer and started full time traveling. We've had starry skies, national parks, breakdowns, tire blowouts, natural hot pools, and seen a lot of America during a crazy year.

You might be wondering a few things like: did we get into trouble or did we buy a gun. Yes, trouble and no gun, but we did buy some pepper spray. Did we get covid? Of course we did. Weren't we careful and didn't we get vaccinated? Yes and Yes. Did we go to the hospital? No, we didn’t get that sick but I can tell you that you’ll know if you have covid when beer tastes like soda water.

Main Point:

More importantly, why did I do this? Well...I have decided to switch gears this year and I'd like to explain it all...in a book! Yes, I'm trying to write a book and I'm taking a much needed break from medicine (it's called a skillbatical). You're getting this email because at one point you and I have crossed paths and I want to reconnect. I'm so sorry for letting time slip by and not writing or calling....life has been so hectic. So please write me back and tell me what you've been doing.

And if you need another reason to write, well...I need your help. I need some people on my side in order to get a publishing company to take me seriously. So tell me what you think of all this OR if you're perfectly happy just getting a letter from me now and then, please subscribe to my newsletter. Thanks!

Quote I’m pondering — "Everything popular is wrong" Oscar Wilde

Feel free to write me here, twitter, or instagram.

Much love to you and yours, Mike

Relationships and the Road

You can’t have a typical relationship while you travel the world, but that doesn’t mean romance is always out of reach.

Only the Essentials

The last year of travel have been a story of reduction. When we first set out, I was proud of living in a 200 sq ft trailer. Today, I see the world with only five essential items.

Trailer Park Etiquette

Just as sailors abide by the laws of the sea, trailer park inhabitants live by a code that keeps everyone safe and happy.

Taking a Gap Year is Changing My LIfe

It’s pretty common for college students to take a gap year after graduation. What about once we’re forty years old and married with children? The answer is that we need time to recharge and reflect at all points of our lives. Think of it as temporary retirement. What would you do if you took a year off?

How to Run Without Pain: From Couch to Marathon, 5 Tips

By Dr. Michael Mulick, DO

I remember wanting to smash my heart rate monitor into pieces and scream.  Another marathon attempt now over.  It had been over 20 years since I was able to run without knee pain.  I ran cross-country and track in high school and college but ever since that first year after college, I just could not run.  Ever since then my best has been about 20-30 minutes.  I always wanted to run a marathon.  Every few years I would gather some courage and get inspired and set up a training calendar and make sure I had some nice shoes.  Each training attempt would then explode leaving me frustrated.

In December of 2015, I was reduced to running 5 minutes and maybe cycling 20 minutes.  I decided to get serious, hire a coach, do physical therapy, strength exercises, ice frequently--basically I did everything I was supposed do.  And 18 months later I completed an Ironman triathlon which included my first marathon.  I ran the whole thing with no pain.  Here is my list of 5 things to do when you get so frustrated about your running pains.

1. Ask for help

It's not working.  If you have tried the same thing more than once, chances are that it isn't going to work.  It's time to ask for help.  I kept going to doctors.  That should have worked.  I was wrong and so were all those doctors.  I recommend getting physical therapy, hiring a coach, getting some books, listening to podcasts, and getting some ART (active release techniques).

2. Change form and strengthen your body.

I bought a book called The Cool Impossible by Eric Orton.  This book taught me how to change to a healthier form.  I now run with a much faster cadence (around 180 steps per minute) and I land on my mid foot instead of landing on my heels.

3. Hire a coach.  I hired a coach who helped me put all the pieces together.  A coach will help you figure out all the things you are doing wrong if you allow yourself to be coached and keep an open mind.  I found out that I was doing so many things wrong that I was completely embarrassed.

4. Slow down.  Most amateur runners are running too fast on their easy days and too slow on their fast days.  You need a heart rate monitor for this.  They should be spending a lot of time in zone 2.  Zone 2 is that slow pace that you can do all day.  When you train 80% of your time in zone 2 you build up the muscles, capillaries, and mitochondria and the joints and ligaments are able to keep up.  If you go too fast, you trash your body and you get injured.  Most people are surprised how slow they have to go.  Yes, it really is that slow.  You can get a lactate step test for the most accurate method to determine your zone 2.  The formulas are not that accurate.  There is a method in The Cool Impossible book.  My quick method: run breathing through your nose only.

5. Don't run every day.  In fact, don't run as your sole activity.  It is hard on the body but you can build up to doing it right.  A great way for endurance athletes to build up to running a marathon or ultra marathon is to add swimming and cycling to the mix.  As an example, I would do a swim+run workout to get the benefit of a long workout but without running the whole time.  If you swim for an hour and then immediately run for an hour, you get the chance to run on tired legs without having to bash the legs for 2 hours.

What do you think?  Do you have any tips on how to stay healthy while logging a lot of miles?  Or even just a few miles?

St. George 70.3 Race Report

This post originally appeared on my first website, Physician Travels.

By Dr. Michael Mulick

Wow, what a weekend.  It was a beautiful venue with an incredible group of volunteers.

The race was hard, very hard.  Hills, heat, and wind.  I am grateful to my wife and coach for helping me finish this amazing race.

Here’s how it all went down…

Friday: The day before the race.  We started the road trip on Thursday and spent last night in Las Vegas to break up the drive.  We got a relaxed start on Friday and pulled into St. George, Utah around noon.  I definitely was overwhelmed with the whole race check in which included two separate transition areas 20 miles apart.  There was a time limit to get it all done so it probably would have been better to arrive on Thursday instead.  In addition, bringing the family including our child made it it a bit more complicated but that’s the way I wanted it.  I want the family included.  Of course, I can see the advantages of going alone.  If you feel that you really need to focus, then perhaps leave the kids at home.

It was a very hot day on Friday and it would have been best to get it all done early so as not to get drained by the heat.  I was out running around in the hottest part of the day so that wasn’t the best.  I was at least hydrating well.

Dinner was a little tricky.  All the other athletes had the same idea to go to the best Italian restaurant in town: Cappeletti’s.  We did manage to get a table but then had to leave because our child was too fussy to sit through dinner.  So we had to take the food to go.  Then a miscommunication with my wife about where to meet up caused us a little delay in getting back to the hotel so we ended up eating later than I wanted.  After dinner, I felt disorganized and so I spent some time organizing my food and the transition bags plus tinkering with the new food storage box for the bike.  All of this made it a busy evening.  I would rather have just relaxed.  But it’s not really an issue that I see ongoing as I’m such a newbie.  I had to get a few things worked out, i.e. how to store stuff on the bike, where to store my tools, and getting last minute essentials like body glide and a sun visor.  I set all my stuff out on the floor and plugged in my heart rate monitor for a charge and went to bed.

Race day: I didn’t really sleep that great.  Spent a lot of time thinking about all that I needed to do in the morning and it took a while to get to sleep.  Then I was up very early to eat.  There was a one hour time zone change thus making my wakeup very early.  I also didn’t have everything I needed.  We ran out of bananas yesterday.  And I did not have a bowl to cook my oatmeal.  D’oh!  Ok, no problem.  I improvised with a coffee cup.

I grabbed my stuff, caught the hotel shuttle, dropped off my run bag at T2, and then caught the bus.  I sat next to a pro who seemed extremely nervous which made me less nervous.  Good luck my man!  You will do great.

It didn’t take me long to set up the new stuff on the bike but while setting up everything in T1, I noticed I had made a major error.  I put all my gels into the run bag that I had dropped off at the T2 and thus I did not have what I wanted to eat on the bike.  Ok, calm down.  Luckily I planned for this.  I brought some extra things that I will now have to eat.  It was a bit funny because my coach even asked me what my backup plan would be if I lost all my food.  I thought it was a ridiculous question. How could I lose all my food.  Well now I know because it happened.  I was very lucky because I grabbed a bunch of things as I left the hotel: banana, a sandwich I had made with almond butter that I thought I might eat on the bus, and a bagel.

I was a little slow getting to the swim start.  There were very long lines for the bathrooms.  And I had to put my wetsuit on and then drop off my “morning bag” at the drop-off point.  Once I got into my wave group and approached the water, I felt the nervous energy.  We got in the water and I took off.  Whoa, that water was cold!  I did not realize how the start actually worked which I should have figured out ahead of time.  The groups enter the water and swim up to the start 100 yards deep and then wait for the horn.  But it was a little confusing because the horn was going off every minute.  I thought our wave started right at the shore.  So I got a little surprise.  Next time I’ll know to be more attentive.

Swim: As I mentioned, the water was cold: mid 60 degrees and the athletes had the option to wear booties.  I am happy I stayed warm prior to the start because it was quite a shock.  Right from the horn, there were collisions everywhere.  Lots of contact.  The cold water (despite wetsuit) put me in a bit of a crisis mode.  I was not very relaxed.  I was breathing every stroke.  I also got a tiny bit of upset stomach too but nothing major.  It took a few minutes to settle into a rhythm.  There was already a lot of wind which made the water choppy and I got a few unexpected mouthfuls of water but no big deal since I have been swimming a lot.  Once I got into the rhythm things seemed fine but it was hard to know how to pace.  Plus there were people swimming crooked lines and running into me.  I caught a lot of people from previous waves so I was dodging bodies here and there.  I didn’t want to blow a ton of energy so early since I knew it would be a long day.  I should have taken a little time to look at the course the day before so I didn’t really know it well but the course was well marked and I stayed on course fairly well.  It was only right at the end where it was a little disorienting where you couldn’t see the exit easily unless you stop.  The goggles were a little foggy by the end.  37:57.  Not terrible but I think with a bit more open water practice I could really shave off a lot of time.

T1: 5:48  This was the first time I ever had wetsuit strippers help me.  They were fast.  I didn’t really want to run so I half walked/ran and it was a little uncomfortable on my cold feet.  I sat down to put my shoes and socks on.  I took a massive drink of water even though my coach encouraged me to get all the drinking done on the ride.  I really wanted to get my fluids going early.  It only took a few extra seconds.

Bike: 3:36
Average speed 15.4 MPH
Average HR 133, max HR 153

My HR was high right away and it was a bit frustrating when 100’s of people flew by me. Nevertheless I stuck to the plan and was patient and let my HR get under control.  I was a little disappointed that the first hill was so soon and I was already doing a fair bit of work early on.  Plus that first hill got my IT bands fired up way too early and I felt the tension begin.  My HR jumped up to 150 and I really had to go slow to get it down again into my mid Z3.  During hour 1 I ate my entire almond butter sandwich plus the half banana.  And I was drinking constantly.  After 45 minutes I was settling in.  I had to pee a lot which was uncomfortable.  I’m still not sure how the pro’s do it well.

Once settled in it was a nice ride in to town.  We had a bit of a head-wind so I didn’t fight it and stayed in a higher cadence and lower gear.  I did enjoy a few of the rolling hills because I was very fast on the down and if I knew it was a short hill I was able to put in action the method of dialing up the intensity just a bit at the base and up through the hill to keep some momentum.  Unfortunately I am still not that good of a cyclist so most of these hills really crushed me.  I not only didn’t train for hills but I have been avoiding them to prevent provoking my IT bands.

The middle section was reasonable.  Once we made it to town, we headed up to snow canyon and it became difficult.  Snow canyon was very VERY hard.  The hills just kept going.  My thought during the snow canyon section was “I’m not sure what I was thinking when I signed up for this race!”  It was really hard to keep the HR down and I recall the goal of trying to not burn too much of my Z4 time.  I think I was burning more z4 time than I wanted.  I played around a bit with different gearing.  I tried a bigger gear and standing but this immediately jolted my IT bands with pain so I kept it in my lowest ring and sat down.  I think at one point at the steepest section my cadence dropped into the 40’s or 30’s.  But that was brief.  For the most of the hills it was higher but still far from my usual 80’s to 90’s.  Once I got to the top it was a huge relief and there were some spectators that were shouting some words of encouragement.  “You just destroyed Snow Canyon.  I know it feels like it’s the other way around, but you did it!” he said.  There was 10 miles to go and I took off.  Indeed I was smiling as my coach had predicted.  I had conserved my energy and my IT bands survived some nasty hills.  At this point I thought to myself “I can finish this thing.”  On the descent I was feeling good and I kept up my HR in my mid zone 3 while others coasted.  I saw a lot of that: people pushed hard on the hills and backed off on the flats and I was always the opposite.  I hit over 50 mph on the down which was probably not wise with the intense cross wind.  It was pretty scary and a few of the gusts were so strong that they almost blew me over.  I also had a bit of a hard time passing people as they would ride barely faster than the person they were passing and there was very little room.  At 45+ mph with little room it was tricky and I was wishing I could just get away from people.  So my suggestion to others doing this course is to just be cautious here.  I had heard of at least one crash in this section.  It was an abrupt finish after a grueling ride and my left achilles was quite sore as were my IT bands.  Plus my hands were going numb.  And my neck and back a little sore from over-gripping and being super rigid during the wind gusts.

T2: 5:18 I prepared an electrolyte drink for myself to carry on the run but I just chugged it.  I didn’t want to carry anything.  I found all my lost gels and happily put them all in my pocket.  I let the volunteers quickly put sunblock on me (this was my second round, the first being prior to swim) and I was happy I did because I still got sun burned.

Run: 2:21
Average pace 10:42
Average HR 142, max HR 167

It was a very tough start to this run course.  It was 3 miles of uphill to start.  My HR was 130 on the start which was about where I was trying to keep it.  My left achilles was very sore on the start and I was worried this would be the thing that could make me drop out.  The plan was to keep it real easy on the first two miles.  It was all uphill so just a slow easy shuffle as per the plan.  And again I was being passed by a lot of people.  I kept the HR nicely parked in mid zone 3.  There wasn’t really a HR plan for the run so I arbitrarily decide I would stay around 130-135 for the beginning to conserve.  After I got my legs back I let it go up to 142.  My achilles eventually stopped hurting and I was very happy.  I was definitely happy that after all this.  I had no pain nor soreness now so I started picking up the pace.  I stopped at every aid station and drank two little waters, 1-2 little gatorades, and put ice cubes in my suit.  Did I mention it was hot?  It was HOT.  I think it was over 90 degrees by this point.  I think I had 4 gels total on the run.  It was a bit of an experiment still as I have not had to eat while running this hard.  I just went slow and took a little bit of gel at a time.  I was pleased as I was running 98% percent of the time.  I just walked very short periods of time if my HR got out of control or if it was very steep.  Halfway through the run I was passing everybody and I was enjoying it.  My pace dropped down to the 10’s, 9’s, 8’s, and then 7’s.  Wow, 7:40 mile was fun.  I haven’t been able to do that in practice.

On the downhills I would push it as long as I wasn’t pounding too hard.  I let the HR creep up a little and then bring it back to see how I would react and then slowly push again to see what I could tolerate.  Once I got to 4 miles to go I brought my HR up to 150.  I started the run with a 13:44 min mile and by the end I was in the 7’s.  I really enjoyed this fast ending although in hindsight maybe I could have pushed harder all along.  Honestly I don’t know.  I paced it exactly as planned.  The nutrition and hydration is still new for me.  There were times when I was just worried about whether the old painful body parts would flare up so bad that i couldn’t continue.  I definitely did not expect to be able to run a smooth fast finish.
1. 13:44
2. 12:04
3. 14:18
4. 11:33
5. 9:53
6. 10:01
7. 11:46
8. 10:12
9. 11:53
10. 9:31
11. 8:57
12. 7:48
13. 7:44

Total time: 6:46
This was a really fun day.  But it was very long.  I was hoping for a time more closer to 6 hours but given the difficulty of the course and the heat, I am pretty happy to have not only have finished but finished with energy leftover….or at least enough to significantly pick up the pace.  Also I finished without knee or ankle problems.  For sure this was a lot harder than I thought it would be.

Here are some conclusions about my experience at Ironman St. George 70.3

1. It was a fantastic host city and the volunteers were incredible.  The whole town was aware of the race.  Our hotel staff was extremely accommodating and wanted to do whatever they could to help.

2. With regard to my race, I think I enjoyed most having a race plan in place.  At every single point during the race I had something to think about and I continued to execute the plan despite people passing me like crazy.  And then it was fun to pass people later on.  The run was the most fun.  If I did not pace it as I did, I do not think it would have been fun to be walking that run to the finish.

3. I was pretty sore for sure but nothing out of commission.  So I am very happy to have finished with no injury.  No damage.  But for sure I was sore.  And my stomach was a little funny in the evening.  Plus a headache.  Kind of felt like a hangover.

4. I really conserved my energy and did exactly what the plan was.  Easy the first part.  Shuffled up diagonal.  Almost too easy.  Then gradually picked up speed.  I started passing people.  By the time I got to 7 or 8 miles I was picking up speed and felt good.  I kept the heart rate right around 135 in the beginning and the. Up to 142.  And little by little I would increase the intensity and them bring it back down to see how I would respond.  And then I brought it up to the higher 140’s, then 150’s.

Resources that made this race possible:

Books:

Eat and Run by Scott Jurek

Finding Ultra by Rich Roll

The Cool Impossible by Eric Orton

Man vs Wild

I don’t think of myself in competition with nature. Nature recharges us. Wild animals prefer to be left alone. Snakes want nothing to do with humans and. Far more sharks are killed by humans than humans killed by sharks.

Six Things to do Before Quitting Your Job

I’ve had nine different jobs as an attending doctor which qualifies me to talk about quitting.

Everyone loves a good quitting story. But it may not play out like your fantasy.

Living with Hypoxia: Mountain Climbing and Single Ventricles

Last summer I had the privilege of climbing Denali (formerly known as Mt. McKinley), one of the world's seven summits and it was one of the hardest things I have ever done.  20,322'.  My measured oxygen saturation on the summit was in the 80's.  The air temperature was well below zero with wind speeds approaching 30-50 miles per hour.  The only thing I could focus on was eating, drinking, staying warm, and keep on moving.  

As a pediatric cardiac anesthesiologist, I started thinking about my single ventricle patients living with hypoxia every day, often with sats in the 70's and even high 60's on rare occasions.  At high altitude, we are compromised by low barometric pressure rather than a low concentration of oxygen.  Denali is unique in that because of its extremely north latitude (63 deg north) the cold temperature drops the barometric pressure even further.  A mountain of higher altitude closer to the equator could have actually have higher barometric pressures than on Denali.  But it is specifically the low pressure that makes climbers hypoxic and on Denali, it is more than most climbers have ever experienced. I recall many arguments over the years with young college students who would tell me that there is less oxygen on Mount Everest.  Hah!  It's all so beautifully illustrated in this simple yet painful equation:

PA02 = Fi02 * (Pb - PH2O) - (PaCO2/RQ)

On the top of Denali, the barometric pressure is around 360 mm Hg which translates into more than a 50% reduction in the oxygen available to your lungs.  

But what does that feel like?  After I got home and indulged in all the pleasures of modern life, I begin wondering what does it feel like for the single ventricle baby who goes home after their Norwood where their acceptable sats are between 75-85 %?  Well from my experience, lower sats do not feel good, period.  Although you can function, everything is hindered from your appetite to your cognitive skills.  At altitude, everything harder.  Sleeping above 18,000' can be a real nuisance.  Imagine getting winded just rolling over in bed.  And getting up to go to the bathroom outside?  Forget about it!  The energy it takes to get out of your sleeping bag and put on your warm layers followed by mountaineering boots is such a colossal use of your energy that it simply isn't worth it.  That's why high altitude climbers have a bedside bottle.  The gastrointestinal tract is less perfused so that even if you eat well, you may absorb less than half of the nutrients you consume.  We had to hunker down at high camp for a few days waiting for the weather to clear and we just laid in our tents.  Food was not especially great, we did not sleep that well, it was cold, very cold.  And life was hard.  I've always been fascinated by how remarkably well the body will tolerate low sats with good cardiac output and that high sats with poor cardiac output is a deal breaker.  We see evidence of this when our single ventricles go through their glenn and fontan stages.  If the pulmonary pressures are too high, a fontan an be fenestrated to allow a pop-off which lowers the saturation but maintains perfusion.  I see it happen in the mountains all the time.  Climbers function with mild hypoxia but they do not tolerate dehydration.  

Summit day is such an unusual day.  Its beautiful yet dangerous.  It takes a tremendous amount of determination to not only train for a big mountain, but the hard work on the mountain is harder than any training you could simulate.  I made attempts at cold winter camping alone, pulling a sled while wearing a heavy backpack.  But you just cannot replicate these workouts with the same time of cold and altitude.  When we reached the summit, we could only stay for 10 minutes to take some photos, eat and drink.  You can't even take your glove off for 1 second as it was instantly numb.  And you could not miss an opportunity to drink and eat.  Your system had to be perfectly efficient.  It became so abundantly clear to me more so than ever that we were really right on the edge of danger.  This was an extreme environment and the margin of safety was always very slim.  We gave a few celebratory hugs and started back knowing that reaching the summit meant were only halfway home.  The most dangerous part of an expedition was the descent and it was very long.  Every step counted as we were on steep ice.  A total of 13 hours was our round trip summit day.  And every second was crucial for any misstep meant a fall and risk of major injury to ourselves and our entire team.  It's hard to think about being able to concentrate in the operating room for that long and thats under the best of conditions.  I am amazed at how we achieved such a feat of extraordinary concentration under such harsh conditions. 

But one of things I had to remind myself was that single ventricle babies acclimatize starting at birth.  Although they have a chance to get used to their hypoxic state, they have to live with it constantly.  I guess we shouldn't be surprised then that most of our Norwood babies need feeding tubes.  They just don't eat well nor gain weight without some help.  It's the same high up on the mountain.  I knew I had to eat, but my appetite was terrible.  I forced the food down anyway but every day at high altitude, we all lost weight.  

The Variety of Anesthesia Jobs for Doctors

By Dr. Mike

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I needed the flexibility of locum tenens to be able to climb Aconcagua.

A lot of young doctors have been telling me to write about my work experience.  So I finally decided to start a blog.  Here goes nothing!  I finished my anesthesiology residency in 2008 and since then I have done every type of job that can be done after anesthesia residency.  Now obviously there are a lot of folks out there that have done more and let me tell you that I would love to hear from you!  But currently I do not know anyone who has had the same breadth of experience in such a short time.  I completed a pediatric anesthesia fellowship, then did private practice (salaried), Doctors Without Borders (MSF), locum tenens, worked in the Australian/New Zealand system (anesthesia and intensive care), fee for service (eat what you kill) practice, a second fellowship in pediatric cardiac anesthesia, and finally a highly sub-specialized academic practice.  Am I crazy? Maybe just a little.  But many people I speak with tell me that they wish they could have done the same or at least tried a few different types of practice.   I kept changing because I wanted to see it all and do it all and decide for myself what really worked best for me.  And I keep finding better and better jobs.  If I had never left my first job, I would never have known how much better it could get.    

So without further ado, I present my thoughts on 7 different job types available to the attending anesthesiologist.  There are of course more; these are just the ones with which I am familiar. 

People often talk about 4 major things to look for in a job: location, money, the nature of the work, and the people.  I have added safety and flexibility to this list since these are very important to me and hopefully you as well.  I have provided an example of how I would score a potential job in each category from 1 to 5 (1 being the worst and 5 being best).  Try scoring them in your according to what you think would be important to you.

Safety: This is always my number one issue.  Quite simply are your patients safe and are you safe?  There are some jobs out there that are just not as safe as they could be and new grads can get pressured into doing things they were taught not to do.  I won't get into the details; take caution.  Your number one duty is to cause no harm.  The highest chance of having a major error or crisis is during the first five years after graduating residency.  Here is where a fellowship can be useful.  A fellowship gives you a little bit longer in that protected environment where somebody is supposed to watching over your shoulder.  You will also learn new and more specialized skills.  Whether or not you chose a fellowship, learn how to make and keep your practice safe and carefully examine jobs for potential issues with safety, especially when you are fresh out of training.  Once you have at least one or two years of experience, you are less likely to do do unsafe things.

People: It is critical to like the people with whom you work.  After a few months/years when work becomes routine, you will like what you do when you like the people.  Some groups are simply not fair to new doctors although I think that most are extremely fair. This can make or break a job and I usually know which job feels right by a gut feeling and this comes from meeting the people.  Which job had the best people?  I think it depends on your own personal culture.  I think I found that I had some of my best times in Africa and New Zealand because the culture was new and exciting.

Flexibility: I like flexibility more than most people and I think a lack thereof is what forced me to to look around.  By changing jobs every year, I introduced flexibility into the mix.  I like being in charge of my schedule.  I enjoy doing very long medical missions and mountaineering expeditions and although most jobs won't tolerate long absences, there are ways of getting the time that you need.  The winner here is obviously locums although my New Zealand practice was top choice for a permanent job.  

Nature of work: Anesthesia jobs are surprisingly different.  You may end up doing bread and butter with or without peds/OB/cardiac.  Some groups ask you to do pain.  Sometimes you may have to do a lot of regional.  And sometimes you may have to do ICU.  It helps to be doing what you like best and for some people, that means a little bit of everything.

Location: Ideally you need to have your one or two dream cities picked out but you may not always get the job you want or be able to live close to work.  Living close to work is the ultimate goal and there is nothing worse than having a long commute twice a day. Desirable locations may have fewer to no jobs so you might have to wait if you choose a stellar location.  If that is the case, consider a job that may be nearby or could be a good lead into your dream job.  I know many great practices who want a pediatric or a cardiac anesthesiologist and those who have done these fellowships have an advantage.  My favorite location so far was my New Zealand job where I lived on the beach and was able to ride my bike 20 minutes to the hospital.  The job was home-call and I was able to drive there in 10 minutes.  I must say that I really like walking  5 minutes to my current job.  The children's hospital where I currently work happens to be in a wonderful neighborhood so I am taking full advantage.  I often will not even start my car for a week!  Imagine the extra free time you would have.

Salary/Benefits: Last and I think least is the money yet it boggles my mind how often residents will look at this as the main issue.  No!  Don't do it.  All the jobs will have a reasonable salary and you really need to look at all the components of the job.  My private practice job was a higher paying job yet I wasn't so happy to be working late every night while working two weekends a month.  Imagine if you had a complication because you were working such long hours to make more money.  That would not be worth it.  There is hidden value in safe practice.  And if you can get 3 or 4 out of the 5, you probably won't mind making less money.  The top priority (after safety of course) in my humble opinion should always be your happiness.

1) Fellowship (or staying on faculty where you trained)

Wow, who wants to delay gratification yet another year?  Seriously, one more year of being under the thumb of the institution, ongoing debt, long hours, and low wages turns most people off immediately.  But hold on a second.  If you consider that your career should last around 30 years, then 1 more year in the long run is nothing, especially if you carve out a special niche for yourself that you enjoy and can out-compete non-fellowship applicants when the job market is tight.  And when it comes to safety, this choice probably beats every option except maybe just staying on as an attending at your home institution where you can get backed up like a resident and still get paid as an attending.  These are top notch ways to continue to develop your skills in a more protected environment and for the new grad, this should totally outweigh the loss of income compared to going private.  Caution should be exercised for non-acgme fellowships because you might be able to acquire those skills without a fellowship and some fellowships are not required to practice in a certain field.  Peds and Cardiac for example are two areas where you still can work without having done a fellowship but it is becoming less common and in order to get a job doing either of these would require proof of significant experience in these areas.

Here is how choosing to prolong your misery but increasing safety scores:

• Safety: 5

• People: 4

• Flexibility: 4

• Nature of Work: 5

• Location: 3

• Salary/Benefits: 1

Overall: A superb option.  Just don't overdo it like yours truly.  Total score: 22

 2) Private (non-fee for service)

This is a non-academic job where you get paid either a pre-determined salary or your paychecks are determined in some other manner completely different than fee-for-service. Generally these jobs will provide you with benefits and you are paid by W2 as an employee of the group or hospital.  Depending on the group, you might be doing all your own cases, supervising CRNA's, residents or a combination of all of the above.  There may or may not be a partnership track and the group may or may not honor the track.  I have heard a few horror stories of firing a physician just before making partner.  Fortunately this is rare.  The vacation time might be reasonably good (6-8 weeks) although depending on how many are in the group, you could end up working a lot of weekends.  It also depends on whether senior partners are taking call and begs the question of whether you are considering a fair group.  Some groups have a buy in period of 2-3 years where the salary is less and the call and workload is higher.        

• Safety: 3

• People: 4

• Flexibility: 2

• Nature of Work: 2

• Location: 4

• Salary/Benefits: 5

Overall its a good deal if you find the right group and can be rough if you don't.  Score: 20

3) Independent Contractor (fee for service)

This is also private practice but the way you get paid and get benefits is totally different and this changes the feel of the group and also changes the way people practice.  In a strict fee for service job, you get paid what you personally bill for so if you do two long ASA 1 hernia cases you would make much less than if you did 4 rapid ENT cases or cases where you put in an a-line or an epidural.  More complex cases like thoracotomies have more startup units so that all translates to more money.  Needless to say, there are some people out there that try to do the cases that bill more units and also may try and put in more regional blocks or invasive lines than they would otherwise do.  Fortunately that type of abuse is rare.  You get paid as a 1099 which means the money is pre tax and you are responsible for paying estimated taxes each quarter.  This can be beneficial as you can write off business expenses off the top before you even get hit with taxes and this can be advantageous if you have a saavy accountant.  Rich people are profoundly good at paying less taxes and my dad who isn't a physician would always tell me "it's not what you make but what you keep."  Under these circumstances it may make sense to form an S-CORP or an LLC.  You will have to set up your own 401k, health benefits, etc since you are considered an independent contractor.  This type of job is fine if people play fairly.  One concern I have is whether or not there are enough people around on any given day should you need help or a break.  In my experience, this type of practice was absolutely fine as there was a very fair system in place where the assignments varied each day based on who was on 1st, 2nd, 3rd, and 4th call and post call.  And call was random and equitable as well. Vacation is a little strange as its one of the few jobs where people do not seem to care as much about how much vacation you take.  The rational for that is that if you are not working, you are not making money as opposed to the other jobs where people continue to earn the same paycheck even when they are on vacation.  You need to factor this as well as the lack of benefits when comparing salaries to a salaried position.  A consequence of all of this seems to be that the individuals in these groups are a little more hungry for work and turnovers and downtime can be very painful as you do not make money unless you are doing cases.     

• Safety: 2

• People: 3

• Flexibility: 4

• Nature of Work: 3

• Location: 4

• Salary/Benefits: 5

Overall can be good but depends on a fair group.  Score 21

4) MSF Doctors Without Borders

Now we get into the fun stuff!  I loved working for MSF.  I worked in Sudan and Nigeria and spent time in New York, Uganda, and Paris for security meetings.  The missions were truly those of a lifetime.  Everyone on the mission had a general sense of purpose and adventure and the local people were always delightful and very very grateful for what we did.  I saw things that I only read about in textbooks like neonatal tetanus.  I had to do much more intensive care, pain medicine, emergency medicine, and minor surgery than a standard anesthesia job.  The role of the anesthetist is a bit different in the rest of the world and with MSF your responsibilities are more than back in the USA.  Depending on where you go, the missions can range from chill to downright dangerous and very stressful.  MSF sets up a huge number of sites where people have been displaced by armed conflict so be aware that this is not your standard run of the mill vacation mission.  The living conditions are pretty basic.  It was so hot in Sudan that I did not sleep much and I got pretty ill from the food.  But even though I suffered, I loved it and had the best experience of my life.  I came back a different person and felt more alive than ever.  A trip with MSF can take a person jaded by the routines of the american medical system and completely rekindle that passion that drove them towards medicine in the first place.  The trips can be exhausting however and you could be the only anesthetist which means taking call 24/7 for your entire time.  A mission for an anesthetist or surgeon can be anywhere from 1 to 6 months whereas primary care doctors are required to commit to 6 months minimum.  There is very little pay, but it isn't nothing.  There is a small monthly salary paid to your US bank account. All your travel, food, and accommodations are paid for.  MSF provides very very good international health insurance.  Honestly, it was the best I have ever had: cigna international.  I wanted to keep it going after I got back but it was ridiculously expensive and they require you to be traveling.  You also get a small contribution into a 401k of your choice and local spending money.  But the truth is that you only do this for the experience.  This type of work appeals only to the very young and older physicians whose children have grown up.  

• Safety: 1

• People: 5

• Flexibility: 5

• Nature of Work: 5

• Location: 1

• Salary/Benefits: 1

You would have to decide for yourself how you would score the location because it could be either a 5 or a 1.  I gave it a 1 for the risk involved but some might say it was a 5 because they would otherwise never go to such unique places during dangerous times.  Also when I talk about risk, I generally mean the risk of having a complication in your practice.  In this case, there is not much medicolegal risk in some of these impoverished areas.  The patients will be very sick, you will not have other experts around to help, and the equipment and resources are limited which increases the risk of having complications compare to that of your practice in the USA.  It should be understood that practicing anywhere in the world in underserved areas can be like this.  

Score: 18 

5) Locum Tenens

This is a bit of an oddball category.  I was told by one of my program chairs not to do this because you do not get any benefits and you are the perpetual "new guy."  But I have done locums and I see an advantage when the circumstances are right.  Being the new person or the "locums" person can be a negative thing in many places.  You may not be assigned to anything complex as nobody will trust you and you certainly will not know your surgeons or where the heck to find equipment when you need it.  You may be quite facile with all of your home equipment but odds are that something along the way on a locums job will trip you up.  The thing about anesthesia is that we interface with so many different pieces of equipment and technology and there is such a huge variety from one hospital to the next.  You may flail with the wrong intravenous catheter as I once did when I used new catheter in small babies and the catheter was much shorter than the needle compared to others I had used.  There are many different types of anesthesia workstations, IV tubing sets, and drug delivery systems.  Each component by itself is not that complex but when you add it all up and its all new to you it will hit you all at once at the worst time.  For example if you struggle with an airway with nobody to help and all the equipment is just a bit off, let me tell you that it gets stressful in a hurry.  Think about who will back you up if you have a problem or a complication.

So, why bother?  Well, a locums job is not a bad thing either, you just have to understand what you get yourself into.  There is nothing that matches its flexibility.  You decide your own hours. Take caution however as you may not always get hours when you want.  The most common Locums positions available may generally be outside of big cities and may be during holiday seasons.  And you may not get enough work or the job may be very short lived so I tend to look at it as a very temporary thing.  There have been two situations where the group has asked me to stay on as permanent so locums can be a way to try a group out without making a permanent commitment.  

You get paid by 1099 but the payment might be fee for service or could be based on a pre determined hourly wage.  You might be paid by the hospital, the group or a third party.  There are companies that act as intermediaries between you and the hospital.  They pay you and provide your benefits but you don't actually work for them.  The pay can be good to very bad and I have seen a downwad trend in the amount people are willing to pay locum physicians so its good to check out what's out there all over the country and keep your standards high.  

• Safety: 2

• People: 3

• Flexibility: 4

• Nature of Work: 3

• Location: 3

• Salary/Benefits: 2

I don't think flexibility is truly a 5 because its only flexible when work is abundant and you can freely accept and turn down work.  It does not always work this way as mentioned above and you can get stuck with no work in the specific area you want.  There is however always work somewhere in the world which means this is an acceptable back up plan.  

Score: 17 

6) Foreign/Australian/New Zealand

My work in New Zealand was my favorite so this of course will be severely biased.  I loved the medical system for its relative freedom from medicolegal issues and production pressure.  There are malpractice lawsuits but very uncommon.  The ACC (Accidental Compensation Corporation) serves as a taxpayer funded means to pay for injured people.  That covers anybody injured 

7) Academics