Note to Self

This week we officially finished paying off my student loans, 8 years and 7 months after graduating medical school. We didn’t always make the right decisions (e.g. forbearance for the first few years which racked up interest), but the Lord showed mercy on us and allowed us to get rid of the debt burden. All in all, we ended up paying back $423,700 (on a loan with an original balance of $276, 108) of my loan debt, which was mostly from medical school and a little from undergrad. Before that we also paid off approximately $100,000 of Katy’s loans from Wash U. 34.8% of what we paid on mine was interest. That’s the real “crime” in all of this…the whole racking up of interest on a federal loan. If they were to just lower interest rates to a more manageable level…like 1-2%…it would take some of the burden off people. But that is another issue for other people to discuss.

I like to think that God allowed us to get out of such a ridiculous amount of debt because we were still consistent in tithing and trying to be generous in giving even when it was not easy. We also tried to live frugally and not buy luxuriously or things we wanted but didn’t need. This allowed us to make large monthly payments to get the principle down. In doing this, though, we were not able to save hardly anything (apart from the standard employer retirement accounts), but I think that’s overemphasized anyway.

While it feels good to be out of debt, I know that this is when the real challenge actually begins. You see, when I was in debt, I would often give myself an “out” of being overly generous by saying something like “We don’t actually have X amount of money…we’re actually in the negative.” But now, I have no excuse.

Even more importantly, now is when the challenge really begins to avoid the trappings of wealth. The Bible is full of warnings for people to love money and are wealthy. I am thinking of one example in Luke 12 when Jesus rebukes someone in the crowd for asking him to tell the man’s older brother to divide the inheritance with him. Jesus said “Watch out! Be on your guard against all kinds of greed; life does not consist of an abundance of possessions.” He then proceeds to give a parable about a farmer who had such an abundant crop of grain that he built many new and huge barns to store it in, not knowing that afterward God will demand his very life from him. The conclusion of the parable was “This is how it will be with whoever stores up things for themselves but is not rich toward God.”

So that is the challenge, to give abundantly so as to not excessively store up treasure for yourself for retirement, assuming that you will have that time or that you have to have a certain quality of life in retirement.

There’s also the questions of how to give “responsibly”, as people often mention the book When Helping Hurts by Steve Corbett and Brian Fikkert. While I don’t disagree with the idea that continuously giving a person a lot of charity can have the effect of keeping them in poverty, I feel that perspective is a little too black and white, politically-driven, and not led by the Spirit. Furthermore, blaming poverty on charity when the real causes are extremely complex (e.g. historical, geographical, racial, etc.) is an oversimplification, in my opinion. Furthermore even still, I think we often have the mindset of wanting to lift people out of poverty and then all will be right. They will have good schools to go to, good healthcare, personal security, jobs, etc. Ministry would be a lot easier. In other words, they will be more like the West, and isn’t everything just great spiritually in the West? But, obviously God loves the poor because they aren’t able to put their security in material wealth and are therefore more easily able to put their trust in Him.

So the real problem is not the poverty, and therefore focusing on “poverty alleviation” is not correct (“You will always have the poor among you”). The problem is spiritual…it is the absence of true love, of the Gospel. So I think the call of every Christian is to respond to every situation in front of us. If we see a need that we can meet, then it is our responsibility to meet it, otherwise it is greed and sin.

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COVID-19 Increase and Lockdown

For the first 6 weeks or so of my being in clinic, I didn’t see any COVID-19 patients. It just didn’t seem to be a major presence here, even though it was around. However, the surge is here now. We just don’t know how high or severe it will be. The clinic probably tests at least 10 patients a day and the percent positivity rate higher than 60% for those who are symptomatic. So we are diagnosing at least 6 people daily. If I work in the “sick clinic” I will see some of these patients to assess them, particularly if they are older and/or with comorbid conditions, but unfortunately the clinic is so pressed for rooms that many are just tested in their car, assessed for severe symptoms like shortness of breath, etc. and sent home if their symptoms are mild.

The clinic was told to switch all “non-urgent” appointment to telephone calls. This is a little hard to do when managing chronic conditions like diabetes and hypertension, especially when I know there are patients who would be coming in for their “check-ups” with a blood sugars in the 400 or 500s, or, like the other day, 705. I am somewhat expecting those in charge to call me to work at the main hospital in Pine Ridge to treat COVID-19 patients there, though I hope that does not happen.

In addition, the tribe initiated a reservation-wide lockdown for at least 7 days starting on 10/23. This is in addition to the already present checkpoints which blocks anyone from out-of-state which means that neither side of our family can visit us, which they had both planned to do this month.

We found a very small local non-denominational church here in Kyle few weeks ago that is now shut-down because of the surge. We are praying that it can open up soon as major revival is needed here.

Badlands
Bighorn sheep
Mule deer
Badlands

First Impressions of a New Home

Sheep Mountain Overlook

For our struggle is not against flesh and blood, but against the rulers, against the authorities, against the powers of this dark world and against the spiritual forces of evil in the heavenly realms.

Ephesians 6:12

Dry, arid, windy. But beautiful.

Thus far we have enjoyed our time here on the Pine Ridge Reservation, although it has not been without a few minor difficulties. The people have been pleasant (the few that we’ve been able to meet given the ongoing restrictions on any public meetings due to COVID-19). We are slowing growing accustomed to the different social nuances and living 1.5 hours from any major shopping.

I am somewhat in a constant state of shock over how dry the land is. The grass has long turned brown and yellow. It has basically rained a significant amount only once since we’ve been here. There’s a lot of dirt and dust blowing around.

Work in the clinic is good, although difficult. Unfortunately the clinic is fraught with inefficiency, a terrible EHR, and is woefully understaffed so the days are sometimes long and frustrating, especially when combined with patients that are very complicated. Another big impression is that patients don’t seem to mess around when it comes to their various disease states: they suffer major complications, have major drug side effects, etc. There’s a bizarre phenomenon of early onset diabetes in patients in their 20s and 30s, many of whom are not markedly overweight. I surmise that there is a genetic predisposition to it, possibly relating to omental adipose deposition combined with extreme deviation from their traditional diet within a relatively short time period. The modern western diet hit the Native population hard.

I sometimes get a feeling of a subtle and hard-to-explain urgency toward the providers, like me, to fix the patient’s serious medical issues, but at the same time notice a complacency on the part of the patient to take basic lifestyle measures that would be the first step in correcting the serious medical issues.

There seems to be a subtle haze of despondency or hopelessness over the reservation which I may be imagining or may be not. A generality or not, I definitely see it in the clinic. There’s so much alcohol abuse and drug use. I sometimes get the feeling that I’m really only seeing the “tip of the iceberg” of this world of substance abuse and darkness, as the majority of people involved in the drug world probably try to avoid the clinic.

I have also noticed the high rates of depression and anxiety. Most people immediately attribute this to a phenomenon called “historical trauma,” which is defined as “multigenerational trauma experienced by a specific cultural, racial, or ethnic group.” While that idea generally makes sense to me, I am a little curious about exactly how traumatic events that occurred in the 1860s-1890s reverberated through multiple subsequent generations to cause mental health disorders now. I do not discount the idea entirely, but I feel that blaming current problems entirely on the past seems somewhat incomplete, that there are likely other factors at play leading to such high levels of anxiety and hopelessness and turning toward mild-altering substances to distract from the realities of life. Even though I’ve only been here a very short time, I think one must consider economic factors (poverty, lack of jobs, marked lack of housing), physical factors (extreme weather, physical remoteness), and (most importantly in my opinion) spiritual factors as well.

What is clear is that this is a not a spiritually neutral or ambiguous place. There does seem to be a purposeful engagement of the spiritual realm done for what seems to be both in the name of maintaining cultural tradition and petitioning spirits for blessings, asking them to help the spirits of loved ones pass on into the afterlife, etc. In talking to just a few people, we are slowly coming to understand some of the native spiritual beliefs that seem to culminate annually in the Sun Dance ritual. And the more we learn about it , the more we are realizing that it is an engagement with demonic forces.

On the day we first drove in to the reservation we were briefly behind a large caravan of vehicles, the first of which was a truck with a large trailer hauling a very large tree. The vehicles all turned down a long road following the tree, and I wondered what this was, but didn’t think much of it.

The other day in clinic a patient showed me one of her arms which was completely covered in scars from near the shoulder down to near the elbow. She told me this was for flesh offerings. Since meeting her, I have seen several other people in the clinic and community with scars on their arms. I asked her to tell me more about it and she said it was from the Sun Dance. She said there were almost 100 Sun Dances on the reservation this year, which occurred in August as opposed to June due to Covid-19. She said the dancers dance in the sun for four days while also praying to a tree and giving flesh offerings from their bodies. The ritual starts by cutting down a large tree, moving it to the Sun Dance sight, then erecting it in a hole in the ground.

Another person we met said that each Sun Dance utilizes “heyokas”, which are a kinds of sacred clowns or spiritual men of sorts. The heyokas go into a “sweat” and ask the spirits to come upon them. The heyokas then act and “do everything backwards” for the remainder of the Sun Dance. Everyone prays to the tree and to the spirits for their various requests and blessings, culminating in a sacrifice of a puppy by a heyoka. The animal is prepared in a soup and consumed.

I don’t know a lot of detail regarding the Sun Dance. I know that it is usually closed to outsiders (non-natives) and a lot of people don’t openly talk about it. But from the little I’ve heard, there seems to be a willingness to open oneself to the spiritual realm which can obviously lead someone and possibly a whole community open and vulnerable to forces of darkness. I have to think that this may be part of the reason why there seems to be a cloud of anxiety, despondence, etc. here. I felt something very similar on mission trips to the mountains of Oaxaca where idol worship was extremely prevalent. The areas were extremely spiritual, yet extremely dark and filled with substance abuse, domestic abuse, etc.

I wanted to share with that patient about Jesus who was God incarnate and who was the ultimate and final flesh offering who gave himself for all sins of the world. But I wasn’t brave enough and I haven’t figured out how to broach the subject yet with people steeped in the tribal religion. But I will keep trying to figure out how to do that in a way that won’t get me fired. In the meantime, I take hope knowing that people from “every nation and all tribes and peoples and tongues” will be standing before the throne worshiping in heaven, as noted in Revelation 7.

Arrival to Pine Ridge Reservation

Badlands

We departed Missouri on Friday July 31 and stayed overnight at my Grandpa Hadsall’s house on the Osage River near Taberville, MO.  It was a great family reunion of sorts.  He surprised us with the mounted deer antlers from the buck I shot last fall.  He and I fried catfish from one of his trotlines.  Our family slept in their large camper which the kids were excited about.  Overall it was a grand time.

We arrived in Kyle, SD on Sunday August 2.  My parents drove with us to help with the kids, etc.  The landscapes are gorgeous as you enter the southern part of the reservation because of a preponderance of large, rugged hills topped with Ponderosa Pines.  As you drive north into the open plains the vistas are largely bereft of trees but still strikingly beautiful in their own way as one can see for miles and miles as you look upon the gentle rolling yellow hills.

Our house is standard government employee housing of 1300 square feet with an unfinished basement. They had done some major remodeling to the kitchen and bathrooms which we really appreciated. We were very pleased with the house despite some needs for quick repairs such as a leaking toilet, bathtub faucet that leaked into the basement, a water heater that periodically shut off, and other more minor things. Our belongings arrived Sunday August 9.

I started work yesterday. So far it is mostly endless online computer modules for all employees which seems to be the government’s way of trying to kill your joy from the very “get-go,” but I won’t let it get to me. The people in the clinic have been very kind. I look forward to starting to see patients but feel I still have so much to review. The clinic seems slightly more higher acuity than the typical primary care clinic, which I believe is due to its physical isolation.

In general, we are happy with the isolation, forced focus on intentional living, being the minority, and other major changes, although difficult. One of the biggest difficulties is that people seem somewhat socially distant which I assume is because we are different in so many ways. We have been praying for opportunities to meet people and to develop good, solid relationships.

Before we moved, our son Jesse cried one night that he was scared because all the kids in his new school would be “speaking Spanish.” We thought this was cute and funny and reassured him that Native Americans speak English now. But we just found out that his online-only “preschool” will be some sort of immersion preschool which is taught entirely in Lakota, so his fear is coming true. We are trying to navigate the wisest way through that one. Fortunately, just tonight our kids met 3 kids who sometimes stay with their grandmother a few houses down and they had some fun riding bikes together. At one point Jesse told Katy as he rode his bike “Mom, they don’t speak Spanish!”

The bike riding ended as a storm rolled through and afterward an amazing rainbow appeared over the town of Kyle. We thank God for these blessings.

Rainbow over Kyle, SD, 8/11/2020

Kyle Grocery
Thornless honeylocust tree

Departure

Wommack Mill, Fair Grove, MO, 1985

We are leaving Missouri in August, headed to a new life in South Dakota. The feeling at the forefront for me is a sense of excitement, as I feel this is something we have been called to do – to live among the people there (in this case the Oglala Lakota), learning from them, showing them love, trying to be light in a place that is at least characterized by things of darkness (e.g. alcoholism, suicide, low life-expectancy). I’m excited about learning about another culture and seeing a new place. I’m nervous of the challenges of the primary care job with patients with advance disease and limited resources. I am glad that our kids will be exposed to hardship and race. This physical departure from the Ozarks also conjures up a feeling of nostalgia in remembering where I grew up. My families on both sides resided here for several generations. My parents moved from Buffalo to Fair Grove in 1985, just before I was born. Growing up there I was ingrained with a deep sense of community and “place” that I feel is increasingly lacking in modern American culture. Do I romanticize the life and time? No doubt. I am aware of many imperfections to my community (which exist in all) such as drug use, racism, “cultural Christianity”, etc. And I see this strange phenomenon that each individual’s experience and view of the same exact place is drastically different based on their upbringing, friends, exposure to adverse childhood events (ACEs), extracurricular activities, etc. With those caveats in place, here are a few sort of symbolic experiences for me that stand out in my mind and their associated lessons I feel I learned from them.

Spending all evening driving all over the countryside to go Christmas caroling to older church members such as Raymond (1913-2010) and Zetta Ricketts (1916-2000), Eileen Farmer (1919-2009), Hubert and Joann Harral, and many others. Lesson for me: By showing love through upholding traditions of music to the aging people in the church, great memories can be formed.

Visiting Eileen Farmer at her home and seeing her husband’s very extensive arrowhead collection tediously mounted in wall displays throughout the house. Lesson for me: Value the history of the land and those who came before us.

Playing in and around the restored Wommack Mill. It always struck me as impressive that people would be so daring to undertake such a large project like restoring a dilapidated gristmill built in 1883 despite all the naysayers. One time I got several of my fingers stuck in an old apple cider press on the front porch of the mill while my mom was attending a meeting there. Members of the Historical Society used butter to get my fingers out. Lesson for me: In this flash of life we’re given on earth, we have the freedom to pursue hobbies such as restoration of very old structures from the pioneer days.

Kayaking the flood-stage Pomme de Terre River with friends, usually from just east of Fair Grove downstream to Pleasant Hope. Lesson for me: Nature can be beautiful, powerful, and exciting. And fellowship with fellow Christians need not be boring.

Going with Darrel Crawford up to re-roof a small country church near Stoutland, MO with some of his friends from Campers on Mission. We spent two days taking off 100+ years of old shingles and put on a metal roof which was badly needed. We spent the night at the Laclede Baptist Camp and had a very peaceful time around a campfire with the others. Darrel and I walked down to the nearby Gasconade River and admired that for a while. Lesson for me: Christians use their gifts/skill set to meet the needs of others.

Margaret Hotelling (1929-2018), with whom I went to church, would write me notes and letters while I attended medical school in Saint Louis. These were like a glimmers of light and hope during difficult days. Lesson for me: we are made to be in community; when one is absent, reaching out can be of tremendous encouragement to them.

I will miss the landscape of hills, bluffs, dense forest, and creeks. Last year Katy, the kids, and I spent a few days in Shannon County, MO in the eastern Ozarks. We hiked down to Greer Spring (with an 8 month-old baby, a 4-year-old, and a 5-year-old) just before sunset, visited Blue Spring, Round Spring, Alley Spring, Rocky Falls, and Klepzig Mill. It was a delightful and slightly treacherous time with little kids, but the simple natural wonders are great to behold. Lesson for me: Fun vacations need not be expensive and one does not need to travel across the country to enjoy one.

Growing up appreciating nature and community I have often longed to settle down on a hilly piece of land with a spring or creek and build a home and have a simple, somewhat agrarian life. We would be comfortable, have the freedom to garden and have animals if we wanted to, go to church, and try our best to be in community. I could even fulfill my dream of building a hand-hewn log cabin with concrete daubing, making it look like one of those old restored pioneer cabins (no pre-fab red brown logs for me). But as time went on, I realized that I clung to this picture of an idyllic life such that it had become somewhat of an idol. It was not only idyllic but probably idealized, for such a life may bring some joy and peace but it would not ultimately satisfy. Jesus told us that “if anyone would come after me, let him deny himself and take up his cross daily and follow me” (Matthew 16:24). Next he said “Whoever wishes to save his life will lose it, but whoever wishes to lose his life for my sake will find it” (Matthew 16:25). There seems to be a paradox that those who live seeking their personal satisfaction actually end up bringing themselves more dissatisfaction. I see it in doctors who buy very large houses and nice cars and keep their kids busy in many extracurricular activities. They keep working more and more to support their expensive lifestyle but no deep or underlying peace seems to be found, just more work on the treadmill of life and moving along with the cultural undertow. I don’t fault them for this because it is a logical thought process to seek after the things one assumes will bring contentment, and probably no one has told them clearly that they are pursuing a mirage in a desert. No, I think the only way to find actual peace and contentment is to not seek it, but rather to love God with all your heart, soul, mind, and strength; and to love your neighbor as yourself. That is the paradox. Seeking pleasure or peace or contentment in anything else is self-deceiving. The more I think about this idea, the more ground-breaking and life-changing it is and can only come from an omniscient God who is all-loving.

For a couple years or I’ve had sort of an internal conflict of whether we should stay and work locally or go as missionaries, sort of a pulling in two directions. I have been greatly impacted by people who have “stayed” and lived amazing Christian lives in primarily one place. I’ve also been greatly impacted by missionaries who gave up so much to go to where there was great spiritual and physical need. Obviously, a Christian can love God will all his heart/soul/mind and love his neighbor anywhere whether he goes or stays. But at the same time I believe God controls all details of every believer’s life if He so chooses, and He can specifically call a Christian to a specific town in Ethiopia or Mississippi or China, just as He answers specific prayers. I was never tempted to join a country club or own a mansion or drive a Porsche to work or achieve high societal rank. But I am drawn to other worldly pleasures. As time has gone on, Katy and I have learned through God’s word and the Holy Spirit that (for us) we do not feel called to stay, even though it may be more comfortable.

So, we are responding to what we feel God is calling us to do for now. I don’t know what our lives will look like in the next 2 months, 2 years, or 20 years. We will continue to listen to the Lord, whether it be in obvious signs or a “sound of a low whisper.”

Rocky Falls “Shut-Ins,” 2019
Blue Spring
Eileen Farmer, August 2004
Fair Grove Square

Things I didn’t learn

I value my K-12 education, for in general it was decent in setting me up for future “success.” But why didn’t I learn about the French Revolution, the Wounded Knee Massacre and other atrocities against Native Americans, the Holodomor, or how Stalin destroyed the Cathedral of Christ the Saviour to build his planned Palace of the Soviets, just to name very few examples? I don’t know how or why school curriculum is set up the way it is, but surely it would be feasible to cover major topics and pivotal events of domestic and world history throughout one’s middle school and high school years.

Some Unconscious Ills of Social Media

Within the last year I have tried to simplify my life in part by relinquishing some of the modern social norms such as Netflix, Twitter, and Facebook. I never had an Instagram account but I grew somewhat dependent on the constant scrolling feeds (all this new information!) as well as silently peering into the lives of others. It never quite felt normal, but I accepted it as normal. It became normal to spend 5 or 10 minutes or longer several times a day checking on these feeds while at work or at home with my family, as I halfway paid attention to them. After already making many important and healthy changes in my life, my wife confronted me with the idea that maybe I should do away with social media because they seemed to be functioning as a great distraction and because they were acting as hindrances to my walk with God. At first I was somewhat angry and resentful that she would suggest this, as all addicts react when you confront them; then, gradually, as I came to terms with more of my own weaknesses and insecurities, I realized she was right and I somewhat reluctantly gave them up. Since then I have had time to process the above in more detail. I wanted to write out my thoughts on the issue because I feel it is such a major one in society and for Christians. Also, I believe it can be dangerous to just passively accept things culture throws at us without questioning what effects it is having on us.

I do not believe that all social media use is bad. It can be used for good…espousing good ideas, good causes, promoting things of beauty, keeping people connected. Many things are probably just neutral. But I am saying that one must weigh the costs and benefits. For me personally, after weighing everything I feel the costs are too high and the resultant benefits of being off social media are worth more than the benefits social media provide. Since quitting these things I have been more efficient with my time at work and at home, have read more books, caught up on old journal articles, started painting, have found a deeper joy in reading the Bible, and have generally felt happier.

1 Corinthians 10:23: “All things are lawful, but not all things are profitable. All things are lawful, but not all things edify.  Let no one seek his own good, but that of his neighbor.”

Here are some of the inadvertent “harms” that may passively affect someone:

1. Relaxation of behavioral norms (i.e. less likely to be polite). Most importantly, social media in almost any form brings out the worst in people, as rules of social behavior are often relaxed or ignored. This is easily identifiable when reading comments on YouTube and Twitter. Apart from simply being rude, extreme viewpoints are espoused and promoted as though they were the norm, and those who are weaker and of like-mind latch on and adopt these views as their own. This leads to a mob-mentality that further perpetuates the underlying “culture wars” that have existed in society for centuries. False dichotomies arise. “Is it the carbs or the fat??!” It easily amplifies one’s preconceived notions regarding any topic by allowing one to “follow” those with whom they tend to agree. They therefore only see data that will support their beliefs and their ideas, right or wrong, become more entrenched. People are established in their various “camps” as though they were preparing for a Civil War battle. It goes without saying that social media is a breeding ground for misinformation, which I will not belabor as it is discussed in great detail elsewhere. This is all a distraction.

2. Distraction. Carving out time for something digital that takes us away from more important things like family, neighbors, nature, books, other hobbies, etc. Most seriously it gives us less time for meditating on God’s word, serving our neighbor, pursing humility, becoming more like Christ.

3. Self-focused. I am presenting myself in a digital form to the world. It is my life, how I want it to be seen, with my opinions, my outrage, my children, my whatever. I can promote any thought that comes to mind, no matter how well informed or uninformed, no matter how judgmental or alienating, no matter how wonderful. There will be some actual great things said. Is what is portrayed on social media real? One could easily argue that is it merely a virtual reality. You never really know someone until you are face to face, spending time in actual deep conversation, learning their hopes, dreams, fears, insecurities. This seems to be getting rarer and rarer in society nowadays.

4. Hysteria. Easily promotes hysteria or mass-outrage at whatever big story is going on or whatever crazy thing someone said. People see others get worked up about an issue and think “Maybe I need to be outraged about this as well” and find themselves caring about something a lot more than they would if they were not on social media. This heightens controversies. This “mass hysteria” can exacerbate underlying anxiety in prone individuals.

5. Targeting easy targets. Related to the point above, high profile individuals on social media are good at identifying easy targets (i.e. the low-hanging fruit) of whoever or whatever is thought to be outlandish, all paired with its associated scathing comment/critique. This is posted and then commonly spreads through the “viral” sharing by others on the platform, leading to more mass outrage among those who are like-minded. This specific anger burns for the day, until the next day brings forth the next outrageous thing. An example would be the sharing a clip of an outspoken “evangelical” leader who says the 2019 novel coronavirus is God’s punishment on sinners, then espousing this as clear proof that Christianity is nothing but hateful bigotry. This is low-hanging fruit. It is lazy. It is divisive and further broadens the bitter culture wars in America. It is clear that social media thrives on heightening tensions and divisions. In our sinful nature, we are drawn toward drama (like gossip and controversy), if for no other reason it is cheap excitement under the guise of “something important” like politics, religion, sexuality and other social beliefs, human rights, diet-wars, music, and everything else they are up-in-arms about.

6. Dependency. Easy to get pulled in and feel dependent on it. Once one is signed in to the digital world of (literal) endless scrolling, flowing pictures, “viral” videos, and words, it gradually becomes something you feel you need. That endless dopamine release when scrolling and seeing new pictures and videos pop up literally changes pathways in the brain causing it to feels like something you need. If you don’t get it you feel like you’re missing out on a whole world of people and knowledge and information. Spend much time away from and you’ll start feeling a pull to check it again to see what you’ve missed, like those who are thirsty unconsciously start desiring a drink of water. Breaking away can be hard. For me, I had to do away with it completely, because, like a box of doughnuts sitting in the kitchen, if I know it’s there, I am 95% more likely to eat it than if I hadn’t bought them at all. But why do we feel we have to have the information immediately? Why is just getting the news once a day any less ideal? I believe it is simply because our brains have grown used to it.

My biggest personal dilemma in abandoning Facebook is the feeling of not being as connected with people I once was. But as I reflected on this, I realized that when I was on Facebook I actually very rarely interacted with people in a personal way (and vice versa). Usually it was time spent at seeing photos and videos others had posted. I suppose the level of actual human interaction is dependent on what you make of the social media platform, but it never quite seemed conducive to conversation. I believe humans are meant to be in an actual community, face-to-face, where they can’t easily ignore you or unfollow you.

One might rebut by asking “what if I use social media to advance the gospel by spreading uplifting messages, standing up for the truth against those denying Christ, etc.?” But isn’t it common knowledge that no one ever changes sides after a social media debate. Something about it inherently causes dissension and discord in ways that face-to-face interaction do not.

One may see and grasp these ills and retreat from technology as a whole and instead turn to a more isolated existence. They see the ultimate ideal as being a secluded cabin and a more agrarian livelihood, free from all the problems of modern life. But while there may be beneficial psychiatric effects with this approach, I’d say it’s the wrong avenue to take as we were still made to be in community. Self-isolating in order to flee from modern ills is still ultimately a selfish act and is therefore less focused on how to serve others. Like the monks of Mount Athos, the risk is to be so isolated as to produce little spiritual fruit on earth. So what does being “in the world but not of the world” really mean? Where does one draw the line of “too worldly”?

The ultimate answer is a radical pursuit of holiness and being pleasing to God, yet still being involved in the community in which one lives. The question of “how far can I go” is immediately wrong, as the ultimate aim is pleasing the Lord. Instead of asking “can I watch this R-rated movie,” one should ask the harder question of “is this going to be beneficial in making me holier and closer to God.” Civil service, work, community involvement, helping the poor, etc. can all be directly supported by and motivated by the God’s word without being watered down by the world. You don’t have to be a socially awkward recluse trying to avoid human interaction for fear of being “tainted.” In fact, to do so would be antithetical to the spread of the Gospel.

At the core of the matter is faith– faith that our brief life here on earth matters and that God desires our full obedience not only to bring honor and glory to Him, but also for our own betterment and thriving while we’re here. For we must believe that the pursuit of holiness is actually worth it, that in the end it will pay off for us, that this physical world is not all that there is. So, if social media is an encumbrance to pursing God to your absolute maximum, “let us throw off everything that hinders us, and run with perseverance the race marked out for us.”

Sense of Place and Home

All of this is theoretical conjectural pondering.

I’ve been watching a Chinese-produced documentary about culinary traditions of China called “Bite of China.” It’s great and right up my alley. It has got me thinking about a lot of things. It got me thinking about traditions…techniques and values passed down. It also got me thinking about people living in the community in which they grew up versus moving away to the city.

On one hand, it seems that the choice whether to stay or move has pretty much been available to all mankind since the beginning of time. However, thinking more of recent times, as the United States has moved away from an agrarian society in the 2nd half the 20th century it seems that we have become a more mobile culture than we were prior to that. I’m not just talking about people leaving their ancestral lands of their forefathers (rarely a thing nowadays anyway). I’m talking about people who grew up mobile, or in the suburbs far from where their parents grew up, who then move far away one or multiple times. There’s no sense of taking root. I am myself guilty of this, of course. Of course there are certain occupations that do tend to require one to be more mobile such as those in the military or ministry jobs, etc. Obviously when there is such transiency, there develops a lack of a sense of place, or a feeling of a true home.  Development of local culture is hindered like growth in a Petri dish would be if you don’t leave it alone.  Grown children would not have that sentimental nostalgia when looking back at their childhood home.

Now, as we are here in 2019, it seems that the continued advancement further into the digital age and the “social media age” has accelerated changes in American culture such that people are even more socially disconnected than ever before. That seems like an incorrect statement, but I believe it’s the truth. I believe the psychology behind it is this: When you have the ability to communicate via a cellular app or computer it normalizes communication that is not face-to-face and makes it possible to spend the majority of one’s social interaction remotely. This obviates the need for “getting out” and exploring places with friends, knocking on an old friend’s door, calling up people unawares, venturing into a new joint hobby, and other social activities. This also affects the nuances of face-to-face social interaction. My guess is that the youngest of Gen Z will be more socially inept than generations before them because of the predominance that remote social interaction has in their lives. My overall gist is this: people just seem to be more confined to their homes. The garage door goes up, in the car goes, and the human is generally not seen. And they seem less socially connected not only in spite of social media but perhaps in part because of it. And this seems to be true of all generations nowadays, not just the youngest. I am definitely guilty of all of this myself.

On a side note, the polarization of the political climate just makes this worse. There seems to be a distrust of others that is heightened by cable news and social media.

After thinking about the above, I feel there are two sacrificial remedies that would help counteract these social trends. 1) The first would be settling down somewhere and really digging in and taking root. What I mean by this is investing in a place whether this be rural, urban, or suburban and trying to make it better. Make it morally better. Or make it asthetically better. Or make it a better place to live by preserving something of its history or increasing recreational activities, etc. Or show love to those in need. Or just be a good citizen by being nice to people and taking good care of your shit. Notice I just said somewhere. Not necessarily the place you grew up. I really think it only takes maybe 5-10 years for roots to get established somewhere. Obviously, the longer the better. 2) The second would be overall less communication via instant messenger apps on phones and less social media use in general. I have no idea how to achieve this on a societal level and it basically seems hopeless to me. But oh well.

One (I) may ask, “does any of this really matter?” After all, we do live a “post-truth” society (sarcasm) and we are all just cosmic stardust with no absolute moral reference with which to govern our lives (more sarcasm). Well, for Christians, I would argue that it does matter in the sense that the more (truly) socially connected we are the more opportunities we will have to make the Gospel part of the every day public square interactions of life. In other words, there would be more missionary opportunity, especially as secular culture drifts further away from “cultural christianity.” This makes me want to go on another tangent but instead I’ll just link to an article on the topic of Christians living in secular societies.

And the irony of posting this on social media does not escape me.

Wendell Berry Quote

“Several years ago I argued with a friend of mine that we might make money by going ahead and marketing some inferior lamb.  My friend thought about this for a minute and then he said “I’m in the business of producing good lambs, and I’ll not go selling the other kind. He also said he kept the weeds out of his crops for the same reason that we washed his face.  Surely no one would question that the human race has survived by that attitude.  It still survives by that attitude, though now it can hardly be said to know it, much less acknowledge it.  But this attitude does not come from technique or technology.  It does not come from education.  In more than two decades in universities I’ve rarely seen it. It does not come even from principle. It comes from a passion that is culturally prepared.  A passion for excellence and order that is characteristically and maybe exclusively handed down to young people by older people whom they respect and love.  When we destroy the possibility of that succession, we will have gone far for destroying ourselves.”

Analysis of my difficulty with primary care (please rebut)

I feel the need to examine my 2-year foray back into primary care.  I failed miserably at it.  I did not necessarily fail in my medical decision-making (though looking back I can think of several individual major short-comings that I wish I had managed differently).  I did get great compliments from patients and there are several patients I will miss.  But I did fail in that I was not able to sustain my job and my satisfaction therein.  Even though I literally only worked in clinic 4 days per month on my off-weeks from my full-time hospitalist role, I could no longer bear the thought of continuing.  Why?  The answer, it seems, is complicated.  But I feel the need to examine some of the reasons.  I’m not going to go into my little “pet peeves” I dealt with such as always having to fill out paperwork, insurance denying first-line medications, patients showing up late, and so on.  Others have dealt with why they think physicians are getting burned out (EMRs are often cited as a large part of the problem).  My thoughts deal with more deep-rooted problems with health in America and how this affects primary care.

I will start by saying that I think it takes a very, very special type of person to be a good or great primary care provider.  Not only is there the obvious need for good social skills (e.g. making a good interpersonal connection, knowing how to stop a tangential patient, etc.), but they have to be good at time management and familiar with diagnosis and management of hundreds of problems that range from orthopedic to cardiac to psychiatric and so on.  They also, ideally, need to have genuine sympathy in dealing with the kind of patients I am going to describe.  That some people do this kind of work 4 or 5 days a week every week is extremely impressive to me.  I do not have the fortitude or skills to do that.

I feel my biggest personal problem in primary care is the dilemma of the doctor caring more about the health of the patient than the patient himself. It is encountered all the time.  I’m thinking of the COPDer on 3L of oxygen who still smokes.  I’m thinking of the 45 year old with three coronary artery stents who eats bacon and sausage nearly every day who has no interest in a heart healthy diet and does not think (or perhaps care) that many of his problems can literally be reversed by strict lifestyle changes.  It’s clear to the physician that the patient is a ticking time bomb.  It’s like you see someone on a raft heading toward a waterfall, but when you tell them what to do, they really don’t seem to care.  Motivational interviewing can only do so much.  Attempts at education can only go so far.  Usually they know that what they’re doing is unhealthy.  The problem is that they do not care.  They have decided that the costs outweigh the benefits.  What is life if they cannot enjoy their meat-based American diet?  For me this is a hopeless feeling that I personally struggle with.  How am I supposed to help someone when I care more about the situation than they do?  We like to think of sick patients as those who yearn for a cure, such as a patient with a heart defect or infectious disease in a 3rd world country.  But in rural America chronic diseases are often tied to lifestyle and social ills, and countering such diseases is often not only takes a lot of work and sacrifice on the part of the patient but also requires changes that are countercultural…too much of a leap.  Diet and lifestyle in the U.S. is such that it is actually countercultural to live healthily.  An individual’s level of care about his or her own health is a spectrum – from suicidal on one end to “health-obsessed”/health-anxiety on the other.  When a patient is more toward the former, trying to education them is often futile.  Since I am by nature closer to to the latter, it is hard for me to empathize with those on the other end.

Another qualm with primary care was the sheer burden of deep rooted psychological turmoil of high complexity.  In rural areas this is exacerbated by very limited availability of psychiatric or psychological services.   There is something about poverty which has a strong association with high levels of abuse, trauma, cycles of violence, etc. that really mess people up.  I think it’s more than just a “normalization” of bad behavior or “growing numb” to dysfunction.  This early exposure to evil (direct and indirect) literally changes one’s neuronal circuitry leading to more socially-deviant behavior, self-destructive practices, severe mental health issues, and (VERY fascinatingly to me) somatic dysfunction like problems with chronic back pain, dysmenorrhea, etc.  They often end up on multiple psych meds and many times end up on chronic narcotics.  In a lot of cases they get back surgery.  They almost universally smoke.  Marijuana, alcohol, and other forms of mental “escape” are common coping mechanisms.  For me, these are difficult patients to take care of for many reasons.  1) Their problems are in part due to and interwoven with their entire background which cannot be changed.  2) They engage in very unhealthy behavior, making it seem as though they are apathetic about their own health.   3) They never really “get better” but go through various cycles of ups and downs.  You invariably go through various SSRIs, SNRIs, atypical antidepressants, and antipsychotics all in various iterations trying to find something that will make the patient less depressed and/or less anxious and/or in less pain and/or more able to sleep.  You may or may not find something that works.  A lot of times you don’t.  Or they really need psychotherapy but this is not available to them or they are not willing to go.  This is a “normal” patient in primary care, especially in rural America.  Yet it’s clear that nothing here is normal (as it should be).  Nothing here is physiologic.  Nothing is working properly at it was designed to do.  What’s going on here?  They were born into excessively high levels of sin and dysfunction.  Maybe they were abused, leading to severe permanent neuronal damage.  Maybe they inherited some genetic predisposition toward alcohol abuse.  They have disordered and unhealthy family relationships.  They try to cope with the drama and turmoil as best they can, but have practically none of the biopsychosocial tools to do so.  They are not only victims of their own immediate surroundings, but they are also victims of the food system, corporate advertising, and the general consumer culture in which things are made obsolete within a few years.  They are victims and victimizers at the same time.  I want to help them, but I feel helpless because the only solution is a world without sin and suffering.  So I try to pray with them or share the Gospel, but this is hard in the office setting.

Another, although less frequent, issue to be dealt with is the patient with complex psychosomatic symptom(s) who frequently request expensive and unnecessary diagnostic testing and referrals to specialists.  Examples of this would be a patient with fatigue who is convinced she has chronic Lyme disease or hypothyroidism (and does not think a normal TSH rules it out).  They are usually swayed by what they read on the internet and heavily by pseudoscience and/or personal experiences of family or friends (N of 1 anecdotal evidence).  On many occasions I would come across patients so deeply steeped in pseudoscience that getting them to understand something of their own health would actually require them to erase everything they know about the issue and actually go back to high school biology and physiology class.  Examples of such insanity include systemic “yeast overgrowth”, benefits alkaline water, vaccinations causing diseases, high levels of heavy metals in the body (with no objective signs), and so on.  Internet communities and online articles are making all of these absurd notions much more common than they otherwise would be.  They erode confidence in doctors, medicine, science.

I know this comes off very cynical.  It is.  That is why I’m taking a break from primary care.  I wish I could offer solutions to these problems, such as coming up with ways to educate people such that making healthy decisions weren’t so bizarre.  I would guess that the answer most would give me is that physicians are by nature reactive (treating whatever disease that presents itself regardless of why it occurred).   I think of people like Dr. Tom Catena who alone treats patients (surgical and non-surgical) in the Nuba Mountains of South Sudan.  I’m sure if I were to glimpse into his practice a lot of my qualms with clinic would seem pretty trivial.