The 12th man

I posted this on the Book of Faces today.  I just felt like it bore repeating.


So I'm a football fan. Obvi. And I'm a Richard Sherman fan, particularly of his passion. Also, this should be obvious. I've reviewed a lot of articles and interviews this week, hoping that the guy I've been defending is who I thought he was. He is. And more. he's the guy who tells his teammate, "don't hit me, I'm going to tip it to you" for the interception. I can't wait for the Superbowl, if only to see him be the guy Peyton chooses to avoid. I love and respect Peyton Manning, and were it not for him playing my Seattle Seahawks, I'd root for him. But since I was a kid, choosing Seattle over the standard Minnesota or Denver (as a kid from Montana with no true local team), I cannot help but love Sherman's passion for life and the game. Add to that Russell Wilson and the rest of a scrappy Seahawks team and how can you NOT love them? I have cheered through bad calls, good calls, bad seasons and good seasons. I have identified with this team that fits no mold for so long that this season felt like finally coming home to win. No matter what happens in two weeks, my Seattle Seahawks, thank you. Thanks for giving me a team that is full of passion, pride, joy, leadership and fun all at the same time. Thanks for making my 8 year old girl ask for a cheerleading outfit for a team who lives more than 2000 miles away because of the sheer joy and fun given to her mother. Thank you for never forgetting that your fans are part of what makes you great and thank you for a beautiful, wonderful season of "OH MY GOD, DID YOU SEE THAT!?!?" I am proud to be part of that remote 12th man: those of us who wear the t-shirts, who show up to road games because you're playing near to our chosen home. I am proud to stand in the middle of Carolina Panther country and count myself as a Seahawks 12th man, despite my distance from my chosen team. Thank you for your heart, your grit and your gratitude for our support as fans. I cannot wait for this year's championship game. And no matter the outcome, I stand proudly as one of the many fans who are, forever, your 12th man.

Of course, at the turn of the year, everyone becomes introspective.  I'm no different.  We also become very expansive in our resolutions: I'll lose 10 pounds!  I'll stop eating meat!  I'm going to exercise every day! Blah blah blah.
I had a friend who one year made no resolutions, other than to do the resolutions of other people: she'd find out that someone else decided to recycle that year, so she'd recycle.  Bob is losing weight?  She'd resolve to lose weight, too.  Mary is cutting out caffeine?  Consider it done!  It lasted about a week.
Which I find is about a week more than most of my resolutions.
I decided a long time ago no more resolutions.  Which, I guess, is a bit of a resolution in itself.  Instead I make birthday resolutions.  I mean that's my new year, isn't it?  My shot at another year around the sun.  I mean the January 1 is convenient, and it's handy for remembering for everyone else, but I really like my birthday better.
Unfortunately, I'm as likely to give up on those resolutions as any others.  It's sad, but true.  I have crappy follow through.  Get organized, eat healthy, go for a walk, clean the house more, it doesn't matter, I fail at all of them ultimately.
The one that I'm failing at the most, though is my interaction with my daughter.  I had a moment of truth with her today.  Pardon the language, but today I completely lost my shit.  And I'd like to say it's the first time or a rarity, but it's not.  I'm fairly ashamed to admit that I did that things parents shouldn't do: I got frustrated and took it out on her.    I can describe the situation and talk about how it really was a result of some of her actions and choices, but really the action and choice that mattered this morning were mine.  And I failed.  Again.
It doesn't matter that she doesn't put my things away.  What matters is how I handle it.  I've spent the last couple of months really frustrated at her response to me when I ask her if she's responsible for something (a spilled cup, a lost item, etc).  She responds in that high, defensive kid voice, "I didn't do it!!"  Sometimes her response is before she even knows the whole question.  Sometimes it's the "I didn't do it on purpose!!" when she is responsible, instead of a simple "oh, I'm sorry."
This morning I realized that I can't just tell her I hate that response and send her to bed when she does it (which I've done in the past, with some success).  It's that I have to respond better when I'm angry or frustrated or tired.  Her "I didn't do it!!" combination yell/whine are a direct, child's reflection of my frustrated, shouty morning meltdowns.
And it has to end.  I'm looking in a mirror and seeing my own kid become the things I hate about myself.  And I'm blaming her for it.  And that is downright shitty of me to do.
So I guess that's my resolution:   No more being shitty to my kid.  No more blaming my kid for being shitty to me.
Attitude reflects leadership, Captain.

Really? No, seriously. Really?

So, I have Direct TV.  I generally love it, except on stormy days. I love the NFL Sunday Ticket.  I'm coming around on the Audience channel, since their programming is improving, and has become less live music and more what seem to be appealing shows.
Anyway, the problem with the Audience channel is that one has to put up with the DTV advertising.  And the worst of these ads is the one for the movers program.
Here's the set up: a guy is packing things from his garage into a moving truck.  While he's doing this, his neighbor comes over and starts discussing how he  (the neighbor) owes the guy moving $500.
The moving guy (MG) indicates that the borrowing neighbor (BN) also owes him a lawn mower.
BN then goes on to explain how if MG calls DTV to get the movers deal, MG qualifies for whole home DVR and the set up in the new place is free.  Which ends up being a savings of over $500.
So the BN does a little happy dance, as if he no longer owes the MG either the cash or the lawn mower.

This is a stupid stupid ad.  Most people who have DTV are going to call to let DTV know they are moving, mostly to change their billing address, if nothing else.  And the whole home DVR is one of those fake deals they give EVERYONE with DTV.

If  a dude came to my house and owed me that much money, then told me about a program about which I was already aware in an attempt to get out of that debt, I'd punch him.
Okay, let's be honest, he seems like a guy to whom I wouldn't loan money in the first place.  "Saving" me $500 is not the same as paying me $500.

Okay, this post is useless but I had to say it.

twenty years

Medicine is a funny business.
I did my residency in Tennessee during the time of TennCare, the managed care approach to medicaid that allowed Al Gore to brag that everyone in TN had health insurance.  The problem is that it reimbursed so poorly that while everyone had insurance, not every doctor accepted it.  We often referred patients to Arkansas, or more often Mississippi, to see specialists when there was no one in west Tennessee who would accept medicaid patients.
It meant that we saw a lot of really underserved patients.  Patients who couldn't or wouldn't afford the lifestyle changes we recommended.  Patients who gamed the system.  Even more patients who were abused, forgotten or mistreated by the system.  I think of them as the circumstantially sick patients.  These are people who probably wouldn't be as ill or in as dire straits in regards to their health were it not for our broken health care system.  Were it not for their circumstances, they'd likely be as healthy as you and I are.  Not that we're all terribly healthy, mind you.  But it would be less about money and access and more about lifestyle choices.
Despite all of this, in residency, we laughed.  A lot.  At things that would make you cringe.  In my three years in west Tennessee, I met people who I still believe are some of the funniest I've known.
As first years, otherwise known as interns, we started to build a panel of patients who would remain our patients through our three years.  These were usually patients who were new to the practice or who had been seeing last year's senior residents who were now graduated and gone.  Some of those seniors assigned specific patients to interns, hoping that there would be a good rapport and personality match, and some patients were just left to be assigned to whoever happened to be on call when those patients came to the clinic or were admitted to the hospital.  Because we cared for so many circumstantially ill people, the chances were great that they would be admitted to the hospital.  Every day an intern is on his inpatient hospital rotation or every night she is on call, she has a chance to become the primary provider for these difficult patients for the next 3 years.  We called it the heinous lottery.
You have to understand that we were young and shiny.  We wanted to save the world.  We had our crisp white coats, pressed green scrubs and our free stethoscopes and we were going to do it.  We were going to teach people about their health and they were going to take medications as we had instructed them without skipping doses, they would eat well, exercise, stop smoking and take baths.  By the end of the first year, our goals were less lofty: patients would take at least a few of the medications we gave them and they'd take a bath from time to time.
The perfect illustration of the difficult patient (and her family) was B.  She was a heavy woman with a history of heart disease.  She had heart failure (a condition where the heart cannot keep up with the metabolic needs of the body, often  marked by retention of fluid--swelling in the legs, fluid in the lungs causing shortness of breath and cough).  Her heart failure would normally be well controlled with the medications we gave her to improve her heart function.  She lived with her son, who did not work, and they survived financially on disability and social security checks.
At fairly regular intervals, B would find herself in the ER.  She would be short of breath, her legs would be swollen and she would be in florid heart failure.  Her son would bring her to the ER and sit with her in the room and order her a meal and then proceed to ask if they could bring him a plate.  And he'd be searching for the remote for the TV.  This was the way that it worked: they ran out of money toward the end of the month:  he'd stop her medication, she'd get admitted, they'd eat and watch cable (albeit the crappy hospital cable), she'd improve, and they'd head home.  We'd see them again in another month or two.  Lather, rinse, repeat.  Maybe that's not the best metaphor.
In one of her rare appearances at the clinic for her hospital follow up (an appointment they usually missed), the resident who had inherited her via the heinous lottery had noticed a strange rash on the back of her neck. Given that we were in a teaching situation, the resident saw a chance to teach. He grabbed a medical student and said, "want to learn how to biopsy a strange looking rash?"
After getting her permission to biopsy the unusual rash, the resident proceeded to choose his biopsy site and clean it with an alcohol wipe to prepare it.  One swipe with the alcohol wipe turned the wipe a very dark brown.   The next wipe came back just as dirty.  The rash suddenly started to look less and less pronounced.
At this point, the resident said, "I believe that this is dirt."  But by hat time, he had committed to the process:  he had students to teach, after all,  and he just plowed on with the biopsy of the now just red skin.  A week later, the biopsy results returned: "reactive dermatitis" (which basically just means inflammation) and "dirt." That's right, our resident had done a biopsy of dirt.
I still laugh at that entire situation.  Not at B's poverty of care or hygiene, not at her heartbreaking situation (literally), and not at the dysfunction of her son.  I don't laugh at the way the system has created her and her son to be a slave of "free" hospital meals and cable paid for by Medicaid.  I laugh at the mere joy we all shared at reading that biopsy results that simply read "Dirt."
B. was such a perfect example of all the things that are right and wrong with medicine: we were able to resolve her heart failure and she would have been fairly well controlled, should she only have taken her medication consistently.  When she was in trouble, she was able to come to the ER and get care and couldn't be turned away.  But she was also able to go home and live in such squalor and poor self care that she became dirtier than any of us could recognize.  She and her son were generally appreciative of their care, but incredibly difficult to convince that ultimately, her care was their responsibility, not ours.
Medicine is a demanding lover.  It changes, it demands excellence, it demands growth.  It rewards lavishly and punishes harshly.  It builds up and breaks down, it can press you to incredible joy and near insanity.  It can show you such cruelty and sadness, followed by such tenderness and love.  It is the most fearful, wonderful, terrible, brilliant and awesome mountain I have ever chosen to try and climb.
For every demanding and entitled patient yelling at the operator because the pharmacy made a mistake on a prescription, there is a grateful one thanking that same operator for taking his call and making his appointment.  One grateful patient makes 10 angry and entitled ones tolerable.  One healthy pregnancy resulting in one healthy baby delivered makes so many frustrating patients seem less important.  One day of laughter over a dirt biopsy makes another night of listening to B's son ask for a dinner plate and the TV remote while in the ER less frustrating.

Is an A for Effort enough?

So, I've been a doctor now for 16 years.  I've been out of residency for 13 of those.  I have had a variable and amazing career and I'm still on the early end of it.  What a great life.

However, I'm still human and still make mistakes.  I'm not talking about dosing mistakes or medical decision making mistakes.  I'm sure I have made my share of those, just as any other physician.  I take great pride in my job and the education it requires.  I try to read and stay current.  I work hard to maintain my certification and take the best care of my patients that I can.

The mistakes I seem to make have to do with my own life.  I have twice taken a job primarily for the money.  I know no one likes to admit such things, but it's true.  Granted, they were jobs in my field, doing what I have spent the better part of my life trying to learn to do.  It isn't as if I took a job selling pharmaceuticals when I really wanted to be a clinician.  But they turned out to be jobs I should not have taken.  My first job was about trying to make a square peg fit in a round hole.  I was the square peg, and Alabama was the hole.  I didn't fit in with the community, I didn't fit in at my clinic, I didn't fit.  And it cost me.  It cost me emotionally, it cost me financially and it cost me in terms of my own self confidence.  I lost a lot in that job.  You would think I would have learned.

But no, then I took the job I was in prior to this latest one, both because they were doing something I believed in and the money was great.  It was actually almost exactly what I was making in Alabama.  This time, however, I did NOT go out and buy a big house and spend myself in to a position where I couldn't afford to leave.  Thank heaven.  


I have taken jobs, rather than starting my own practice, mostly because I know that I am not really cut out to run a business.  I know this about myself the same way I know that Cadbury's mini-eggs just don't have a chance to last more than a week or so at my house.  I get petulant sometimes, I am terrible with money and I just trust people who want to sell things to me too much.  Unless I had limitless investment capital, I just would run out of resources to run an office well.  I am okay with knowing that about myself.  

I am okay with being an employee.  I am a pretty good employee, too.  I work hard, I pitch in, I have finally grown out of that "do just enough to not get noticed" phase of my life.  I will admit I was an 85% kind of girl.  After realizing that no one cares if you get straight As after you get admitted to medical school.  In med school, you are just required to pass.  As we used to say after reviewing our test scores, "P = MD" where P means "pass."    So that meant that getting 85% of the way there was usually enough.  And so that's all I did.  I am not saying this because I am proud of that.  I'm saying it because it is true.  Well it was true.  Now I want to be the kind of person who does what she says she will do and does it 100%.  It's a challenge for me, as a former "do just enough" kind of girl.  I am encouraged and motivated to do it, though, when I consider what I would want from my doctor.  Or my daughter's.  Or my father's.  If I expect it from them, I should be delivering it myself.  

Anyway, that isn't what this is supposed to be about.  But I guess it should be as much as any thing.  The original post I had in mind was all about learning to live on less money because now I'm taking a job for love and respect rather than for money, and it has really pinched my wallet.  But that can wait for another day.  Fantastically, taking the job I am in now seems to have been a real exercise in going all in 100%.  Today can just be about reminding myself that 85%, while it's a solid B effort, just is not enough.  Doing good sake for the sake of doing good work has to be enough. I cannot be about getting an A or being valedictorian or having an award. It has to be about reaching out to patients and doing my best for them.  It has to be about going to bed at night knowing that I did the best that I could for my patients every day.  

That extends to my family, to my home, to my other areas of life.  I admit that it doesn't seem to extend to my household chores.  I guess I should put "needs improvement" on the report card of my life in that particular area.  But at least I'm getting a solid B.  

Breaking up with the political party of my youth

I grew up in a fairly conservative home.  I learned to love God, I learned to pray.  I ate my vegetables and did my chores.  Well, most of the time.  I definitely got in trouble for shirking when I did, for keeping a messy room, for being rude or insolent to my parents.
I worked hard, I studied hard, I wanted nothing more than to impress my parents with good grades, graduating with honors, getting into medical school, and moving into an 'impressive' life.
I was a conservative.  I believed that life had value, that work had value, that people are responsible for their lot in life.  I believed that people could really affect change in their worlds, but that it often was a difficult road.  I believed that giving money to charity was my responsibility as a human being and a Christian, not because I was a citizen.  I believed that my tax dollars should be spent frugally and wisely, and that people who didn't work were probably just lazy.
And then I grew up.  I grew up practicing medicine, watching my friends, living my own struggle.  And things shifted.  Not only did I stop believing that all poor people were lazy bums and that all people who used food stamps were just saving their cash to buy cigarettes, drugs and dog food, but I also stopped believing that needing assistance was a personality or character flaw.  I used to cry, too, for drug testing of welfare recipients, cutting back on medicaid and medicare programs, getting those lazy bastards off the dole and back to work.  I used to rail against 'those Mexicans' taking our jobs and having babies so they could stay here and get on the government hand out train.
I started seeing patients, many of whom were working full time or 2 jobs to equal full time, still being denied health care benefits and the ability to save for their future.  I watched patients who worked as many hours if not more than I did still fail to find an employer who gave them any sense of security in either their work or their reimbursement.
Certainly I saw people squander their resources, spending foolishly and failing to plan.  But more often than not, I saw people who worked as hard as they could to barely get by on what they were making.
More than that, though, I felt something slipping out from under me: the political party I had always grown up believing in.  I had been a republican for as long as I was capable of making the decision.  I was in high school during the Reagan years.  I supported Bush (both of them).
When I grew up in the republican party, I believed that individuals were more important than populations.  I believed in a party that believed in not only liberty and freedom but responsibility.  I grew up with a party that respected life, but also encouraged people to break out of their molds to be part of the American dream.  If you worked hard enough, pushed hard enough, studied hard enough, you could make it.  I believed it.
And in the past 20 years, the party of encouragement, of hard work, of plain old gumption has become one of "you can't do that" and "we won't let you."
The republican party has moved ever more to a socially conservative hard line: you have to look, dress, work, pray like we do.  You can't be any different, you can't worship a different god (or  >GASP< no god), are not welcome to be yourself any longer.  You are only welcome to get into line.  We'll tap your phones if we think you have friends of whom we don't approve.  We'll legislate away your right to vote if you might belong to a group that doesn't traditionally vote for republicans.  We'll beat you into the ground with rule changes and legislation until you just fall into line.
Thank God that not everyone is just falling into line.  I spent the last 5 years that I was still a republican being more and more embarrassed for having identified with that party.  From the homophobic slurs to the racist commentary, from the sexist comments to the anti-science foolishness, I was constantly defending the party in the name of fiscal responsibility.
But finally the past couple of years led me to a tipping point.  No longer could I be a woman who supported liberty but affiliated with a party that said that marriage was only for one group of people.  No longer could I be part of a party that did not withdraw support from candidates who said things like "legitimate rape."  No longer could I be part of a party that actually legislated that a biblical creation story be taught in science classes.  As a physician, a Christian, a scientist, a human being, I just can't stand any more to be affiliated with people who reject science simply because it gives them answers they don't want to hear.  More importantly, though I can't be part of a group that has decided to take huge portions of our population and decide that they are not worthy of the liberty promised them by the Constitution.  
And now, the republicans wonder why they suffered such a loss in the last election.  Here in NC, the state legislature (controlled by the Republicans) is going to see come before it 2 pieces of legislation: one would establish a state religion.  I'm not kidding.  We would be the Christian state of North Carolina.  The bill itself actually rejects that the constitution and that the federal courts have any jurisdiction or say in the state.
While I was still reeling from reading that story, another came to light.  A local state senator has decided to take away the dependent tax credit from parents of legal voting age young people who decide to register to vote at an address other than their parents.  Understand what that implies: college age kids don't vote for us, so we'll make it so they don't register to vote in their college town; they'll have to vote at their parents' addresses.  So students who leave the state to attend college and choose to vote in that state will cause their parents tax hardships.  Students from Lillington who move to Chapel Hill to attend college will be required to register at the addresses of their parents in order to vote, or risk the parents losing a tax credit for declaring the student a dependent.  What?!
I am heartbroken to watch the party of my youth move further and further from reality.  In Oklahoma, a law was passed banning Sharia law (which was later struck down by the federal court system as a violation of the establishment clause of the Constitution).  Racism, fear and insecurity have led to more and more legislation of "conservative values" over time.
My question for the conservative Christians has become this one: is your faith so small and weak that it must be legislated?  Is your commitment so wishy washy that if other people decide to live differently, you can't continue to be faithful?  Is allowing other people freedom that has nothing to do with you so awful that it must be stopped?  How do other people fulfilling their own destinies damage your own?  I sincerely don't understand, please explain how if we allow all people to be free it takes freedom from you.  Please explain how respecting people as individuals with freedom of choice makes your choices less valid.
I've been married 4 years now.  My relationship is not strained by the fulfillment of anyone else's relationship.  My relationship is neither stronger nor weaker if my friends are married or cohabitating, be they straight or gay.
My faith and love for God is not lessened if there is no state sanctioned prayer at the beginning of my day.  It is not up to the government to provide me with my prayers, it is my responsibility, my act, my joy.  My prayers are just that: mine.  They are between me and God.  My marriage is just that: mine.  It is between me and my husband.
I just can't understand the need to legislate someone into submission.  This is not something ever mandated or even requested by Christ.  He just asked us to love.  To love God, to love our neighbors.  Not to legislate or limit them.  When did the republicans wander off of that message so badly and how do we get our party of personal liberty coupled with responsibility back?  I want a party that does not resent the rich for being successful nor does it resent the poor for not doing so.  Is that so hard?  It must be, as neither party truly speaks for me.

Realm Status

For anyone who knows me, they know I am a gamer nerd.  I'm new to this gamer nerd thing, though.

My husband is an old school nerd: he played role playing games as a kid like Dungeons and Dragons.  He played the card games.  He used to telnet into bulletin boards and played text based games.  He loves Tekken and first person shooters (FPS) and massive multiplayer online games (MMO).

I, on the other hand, was a book nerd.  I spent my formative years reading and watching TV.  We didn't have internet or telnet until I got to college and beyond.  I did play around in the MUSH a little, but that was for social interaction, not because I was gaming.

But, for the past 5 and a half years now, I've been sucked into the World of Warcraft.  Sure, it's a nice diversion.  And it's as social or anti-social as one might want it to be.  However, in this time since leaving my last job, I've been playing more.  I know, with time off I should have reorganized my closets, tackled my household budget or even gotten a good running start at the laundry.  Instead, I've leveled up more characters, learned new in-game professions and gotten fat loot, as the nerds might say.  

Every day, I've logged in, tweaked characters, fought monsters, cast spells.  You know, the usual.  However, not on Tuesday mornings.  Tuesdays are the reset week in Azeroth.  Tuesday mornings are the scheduled mornings when Blizzard Entertainment takes down the game servers, called realms, and does repairs, patches, hotfixes, bug fixes and generally makes the morning and daytime crowd who get online at that time go crazy waiting to see their realm status come back up.  There's even a website where you can track the status of your realm while you wait: 

don't worry, I only really play on Eredar

I use the time to catch up on knitting projects, the week's bad television, read.  I spend the time waiting for the realms to come up.  

I started working in my teens as a babysitter, had the odd jobs most kids have: delivery person, ice cream scooper, fast food server, nurse's aid, housekeeper.  They were all teaching experiences and grew me in my desire to be something else.  Then I got my degree and my free stethoscope and I was ready to save the world.  Since my teens, however, I've more or less always worked for someone else.  

I seemed to make bad choices.  I took my first job post-residency for the money.  It cost me financially and emotionally for years.  I took other jobs for the location, for the benefits.  The longest job I had was one that I took as much for location as anything and it was exceptionally rewarding.  I was still out to save the world, one patient at a time.  I believed that you didn't have to force people to come back over and over to get paid.  I balked at the "make them come back in 2 weeks to be rechecked" after every sick visit policy I was asked to institute, when a phone call was more than adequate.  I believed that you could be efficient and ethical and still be reimbursed.  I was working for a guy who didn't share my beliefs.  He sold the clinic I worked at with about 10 minutes notice for me.  The new management was money driven and not care or benchmark driven.  In short, they were jerks.  

I happened to have an out when that happened and I took it.  Again, I was focused on being ethical, being efficient, doing the right thing, taking good care, doing no harm.  Again, I was working for someone for whom the business of medicine began taking a toll on the practice of medicine.  Or at least that's how I felt.  

When I made it clear that I felt that way, and was shown the door.  

Since that time I've been in a bit of a tailspin.  Am I really that ridiculous?  Am I so naive to believe that doing the right thing, being honest, giving good care and worrying about the patients first and money last are just wrong?  

It's easy to paint myself as some crusader, striving for all that is good and right in the world.  I am not.  I am not perfect, and I am pretty sure I can be really difficult to work with.  I'm bossy.  I'm demanding.  I want things the way I want them.  Sometimes I'm too tired to be as good at my job as I want to be.  Sometimes I do just enough to get by.  I'm human.  

That being said, I have dreams for what an ideal practice looks like.  I have dreams that patient care and ethics are still important. I have a vision that we can still give good, personalized care to people, and they can afford that care and it will benefit us all.  I was definitely starting to doubt.  There's nothing that grows your doubts like being a 41 year old highly trained professional and feeling like you can't find work.  My work with pain patients made primary care offices "choose someone more experienced" for their open positions. More experienced?   I've been doing primary care for 12 years, with the last 3 being focused on chronic pain patients (who still have primary care needs).  Who are you going to hire with more experience?

I was starting to feel that my bad choices were that: bad choices because they were wrong.  

I spent the last 2 months waiting for my realm to come back up. 

I'm starting to see a glimmer of hope, though.  I have an opportunity to be affiliated with a practice where patient outcomes are important.  They're the most important.  The business side, but everything is fairly transparent and straightforward, not based on gaming a broken insurance reimbursement system and bleeding patients and payors dry every chance we get.  It's about offering healthcare as a quality service which has value and being reimbursed for that value.  

So, while I was debating my options for the future, including starting from scratch at great financial and emotional risk to me and my family, I now have a new chance.  I'm starting with a clinic at least part time, with the goal of moving into a new location near where I live that would ultimately be mine full time. 

I'm starting to get the  vision here.  My realm is up.  It's a realm where I can play my game, tweak my skills, and yes, even garner myself some loot.