Out of grief, a new appreciation

Just over a year ago, I remembering clearly trying to restrain my tears as I drove through Calcasieu Parish on I-10 toward Baton Rouge. I was the next caller in the que for the radio show by Greg and Lisa Popcak, both counselors who open their phone lines daily to callers willing to share their struggles and/or ask for help. I did not want to be a balling mess on air.

My earphones in place, I struggled to get my question out as cerebrally as possible, lest my feelings take over and I revert back to weeping.

My brother, to whose funeral I was driving, had just been unexpectedly killed at the age of 27. How, I pled, could a seemingly good God allow for such a tragedy?

The counselors listened patiently, letting a few seconds pass after my question before responding. They then offered their sincerest condolences before telling me that they couldn’t answer my question. Keep asking God, they said. Argue if you need to, but don’t stop asking.

File_000 (6)In the weeks following my brother’s death, I continued to ask the question. At the strangest times — walking down Highland at LSU, running the Louisiana Marathon or sipping coffee at Highland Coffees — I would find myself either leveled to tears or in a state of total disbelief over what had happened.

Though an “answer” to why my brother died seemed elusive, I held confidence in Dr. Greg’s advice.

As weeks turned to months and I failed to have a Mufasa-style appearance of my brother from the clouds, I realized day by day that the answer to my question would not come with a bang but in bits and pieces.

On visits to Highland Coffees, I began to write my and my brother’s story, which was Screen Shot 2016-01-14 at 4.43.44 AMmarked by more than 10 years of estrangement due to his drug abuse, addiction and imprisonment. Though at times an exercise of tear-wiping more than writing, the more I persisted in reliving our past, the more I was filled with gratitude for the time we had together, even if only a short 27 years.

For just over a year before he died, we had experienced an opportunity to walk a pilgrimage together in Spain to Santiago de Compostela, a journey that provided us with much-needed reconciliation after enduring such distance and hurt.

As well, his death encouraged me to pick up the pen again, having always wanted to write but letting the habit slide amidst duties of fatherhood and being a doctor.

The more I wrote, the more I realized that our story could only be done justice through a book.


Last month, just over a year after his death, I published our story, “On the Primitive Way: Two Texan Brothers’ Journey to Santiago de Compostela.” Reading the comments of readers and reviewers who were touched by the work fills me with gratitude as a writer for having had the chance to play a role, however miniscule in a reader’s search for meaning.

It also fills me with gratitude for the “miracle” of our journey.

While I may always question “why” I lost my brother, I have him to thank for encouraging me to write, reminding me that Job, in his persistent seeking, was rewarded with 10 times more than what he had before.

This article was originally published in the Baton Rouge Advocate here:


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Choosing the right way: on making time for creativity and self-expression even when in a technical career

When I was a student at Rice, I used to walk the outer loop when I needed to ponder an important decision. One of those was what I was going to major in, which I remember mulling over for some hours while (seemingly) endlessly circling the hedges on a Sunday morning my sophomore year. I had already decided that I was going to become a doctor but was not satisfied with going the traditional route of majoring in biochemistry. What drew me to medicine was the closeness to the human experience that doctors witness every day. In fact, it was the funeral of my grandfather, himself a writer, that led me to the choice to become a doctor, as I saw through his memorial my own artistic yearning. Yet as I walked around the outer loop, I pondered the task that lay at hand should I choose to major in humanities. I had already completed nearly all of the requirements for biochemistry. Did I really want to take on another major?

As I walked down Main Street toward University, noting the Medical Center on my left File_000 (3)and the campus on my right, I realized that I would have my whole life ahead of me to develop my left–brained technical skills. The next two years offered me the chance to refine my creative abilities to express myself, giving my right brain much–needed exercise. Returning from my walk, I made the decision: I was going to major in Spanish, the language of my mother and the culture from which she came. Back in my dorm, I logged onto the course catalog and enrolled in Spanish Culture and Civilization (SPAN 340), taught by Professor Castaneda.

The following fall, Professor Castaneda would take us from the Paleolithic history of the File_000 (4)Iberian Peninsula all the way through modern post-Franco Spain. He also encouraged us to refine our Spanish language skills, which motivated me to consistently attend the Spanish tables every week at Jones. Professor Castaneda was also in the habit of giving out to students promotional material from the Spanish tourism office, and mid-way through the course, he gifted me with a poster from the office. It bore some thirty sketchings of Medieval churches with the inscription below: “Camino de Santiago.” Not knowing what the Camino de Santiago was, I asked a fellow Spanish enthusiast and recent friend I had met at the Spanish table, Amanda. She informed me that the Camino de Santiago, or the Way of St. James, is an ancient pilgrimage across the Iberian Peninsula to the Cathedral of Santiago, the rumored burial site of St. James the Apostle. The pilgrimage, she said, still continues to this day.

As Amanda and I continued to see each other at Spanish table, it became clear that we were more than just friends, and by spring we were seen as inseparable: “Landie,” they would call us. Having never been to Spain, we both promised each other during this early time in our relationship that should we ever get married, we would walk the Camino de Santiago for our honeymoon.

Two years later, in June of 2009, we got married in the Co-Cathedral in downtown Houston, and the next day we departed for Europe to walk the Camino. Within a week weCIMG4216 found ourselves wandering on off–beaten paths in the Pyrenees hundreds of miles away from any city with only our backpacks on our backs. Six weeks later, after many blisters, backaches, swollen ankles and knee pains, we found ourselves in Santiago. In the process, we not only cemented our life-long friendship with a bang, we grew close to friends we made along the Way (some of whom we are still in touch with), to nature as we traversed the mountains of Basque country, plains of La Meseta and hills of Galicia and to ourselves, both of us having journaled more than we ever had in the preceding year. We also experienced much- needed recovery after an extremely stressful academic year.

Back in the U.S., we moved to New York, where I returned to med school and the stresses continued to mount. Realizing the healing power of the Camino, we vowed to walk the Way again. In 2011, while on academic leave from med school, we did, this time walking the coastal route, again finding much needed respite and growing even closer together.

A few months before this walk, I found out that my younger brother had been arrested. He had battled on and off with drug addiction since our teen years, and in a desperate place, he made a foolish choice that landed him in federal prison. Devastated by his arrest, I found comfort in the correspondence that we would send each other. Through hand-written correspondence we were able to begin to reconcile after over 10 years of estrangement. Still, we were not able to see each other in person, as I was living in New York and he was in prison in San Diego. Two years after his arrest, when I found out that his release from prison would correspond with my last vacation with med school prior to beginning residency, I proposed that we walk the Camino together.

In spring of 2013, just two months after he served his prison sentence, he and I departed for Oviedo, Spain. Following the less-traveled Primitive Way (“El Camino Primitivo”), we trekked through the mountains of Asturias to Santiago. On the Way, we found much needed time to spend together, not having spent more than a day together in years. Returning home, we realized that our relationship had changed, having grown closer together than we were even as children.

Just over a year later, my brother was killed in downtown Houston.

CIMG4215Though grief–stricken by the news of his death, I found comfort in remembering our time on the Camino. As I sat on the plane to Houston from Boston, where I was doing residency, I recalled seeing the sun shine on the hills of Virginia, just as it had on the hills of Galicia when we were in Spain. The reminder filled me with gratitude for having the opportunity to make this journey with him just before his life was cut short so unexpectedly.

A couple of weeks after my brother’s funeral, I found myself circling the Rice hedges again, just like I used to do in college. Recalling that memory from the plane, I realized that the miracle of us being able to partake of this much–needed healing experience was too deep, too rich to truly recount on a several–page eulogy that I delivered at his funeral. The only way to recount our history was through a book. But did I really want to write a book? I was a medical resident and had a two-year-old at home. Walking down Main Street toward University, I noticed again the Medical Center on my left, the hedges on my right, reminding me of the decision that once lie before my while taking that same walk 10 years prior. By seizing the chance to explore deeper meanings of my existence through self expression, I followed where the opportunity led and never looked back. This was my chance to do so again, and I haven’t regretted it since.

This article was originally printed in the Rice University Thresher on January 20, 2016.



If you’re thinking of walking El Camino, don’t let fear hold you back

This past fall, some chilling news came out of Spain. While walking ElScreen Shot 2015-12-31 at 5.13.52 AM Camino de Santiago, an American citizen, 41 year-old Denise Pikka Thiem from Arizona, was murdered. As Spanish authorities unraveled the circumstances of her death, the story got scarier. We learned that she had been led off path by falsely placed arrows to the house of a thief, who then attempted to rob her and when she resisted, he fatally struck her. I can’t hardly think of the words to describe the gravity of this tragedy.


Yet as fear-inciting as this event is, Spain, and more properly the Way of St James, is still a very safe place. The criminal was caught two month Screen Shot 2015-12-31 at 5.21.03 AMlater and he is now in the hands of the Spanish justice system, no longer able to inflict harm on unsuspecting pilgrims. Yes, like any other travels there are dangers of robbery or (God forbid) physical violence, but an American (or even a Briton) in Spain is still less likely to get murdered than in his or her own country. (The murder rate in continental Europe is about one sixth of that of the US and about one fourth that of the UK.) And to put things into perspective, the risk of death on a morning motor vehicle commute is far higher than any risk of death while hiking in Spain. From personal experience after having walked the Way of St James three times, I can recount having walked the pilgrimage at night at times with my wife and never feeling in danger. We never heard moreover of any of our pilgrim companions getting robbed.


Aside from the safety factor, when thinking about walking El Camino, one has to consider what there is to be gained. If one’s decision to walk holds the potential to offer a much needed personal change, build a new long-lasting friendship or deepen one’s connection to a loved one, then letting fear stop the trip would be akin to following the tracks of the proverbial scare-mongerer, who refused to go out of his house and work because of fear that a lion may one day come and attack.


Over breakfast
Hotel of the Catholic Kings. Me and Cory

As I learned from my last pilgrimage, fear shouldn’t get in the way of reaping the treasures of the Camino. For were it not for the Camino, my brother and I might not have been able to reconcile after over ten years of estrangement. Who knew he would be killed so soon afterwards?


Yes, there will be dangers for any pilgrims on the Camino, as there always have been. Pilgrims have gotten injured or killed along the Way ever since the path existed some 1200 years ago. But still, hundreds of thousands of pilgrims have arrived each year to Santiago, most of them never regretting the risk for even a moment. For anyone considering the Camino but afraid of its dangers, the Camino is a treasure whose fruits will yield harvest on the walk–and for a lifetime thereafter. Is it worth letting the treasure go?

For more information on the treasures of the Camino, visit my website ‘On the Primitive Way.’

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The Green Pilgrimage Network: Carrying the Mission Forward

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“It has to be the individual conscience of everyone of us, supported by faith, that will enable us to go back to living in harmony with creation and in solidarity with the Earth.”
Fulco Pratesi, Honorary President of WWF
These words were uttered on the sunny day of October 31, 2011 in Assisi, Italy.[1] The topic that united representatives of fifteen faith traditions on this day was an unpleasant trend—religious  
pilgrimages have become a potential source of environmental pollution. As the number of people who embark on religious pilgrimages has grown to over 100 million people per year, so too has the environmental footprint of these temporary travelers. These representatives, united to form a coalition to stem the tide of this unfortunate trend.
Organized by the Alliance of Religions and Conservation (ARC) in association with the World Wildlife Federation (WWF), the Green Pilgrimage Network (GPN) formed on this day, developed a series of initiatives: ban on cars on pilgrimage routes; provision of fresh, clean water for pilgrims; and the planting of thousands of trees around sacred sites. Representatives from different pilgrim destinations (Nigeria, UK, India, Armenia, Japan, Israel, Assisi, China and others) vowed to do their part. The event opened with a procession led by Her Royal Highness Princess Michael of Kent, representative of the ARC’s founder the Duke of Edinburgh. This was followed by speeches by the WWF Italy’s Conservation Director, Isabella Pratesi, during which she quoted the words above first said by her father some 25 years prior. At then end of the three-day event, members returned to their homes to implement changes.
MLXLSNow, several years later, the GPN is growing. It now includes some 20 major pilgrim destinations  around the world and has a vibrant website documenting the progress of pilgrimages.[2] It also contains resources on how pilgrim destinations can become more eco-friendly, how pilgrims can lessen their environmental footprint, and even theological statements by different faiths on green pilgrimages.
Having walked the pilgrimage to Santiago de Compostela three times now, I find the message of the GPN incredibly timely. Many times en route to Santiago did I find trash litered along the trail, and it pained me to see—especially along the last 100km from Sarria—vending machines, packed with food from far away places surely made with more fossil fuel than local food. Sadly, as pilgrim traffic has picked up on El Camino de Santiago, especially El Camino Francés, so too has the environmental waste created by pilgrims. Perhaps this is why I have come to prefer the (relatively) unspoiled Camino Primitivo (Primitive Way of St James) as my favorite route to Santiago.
One of the most enduring lessons I’ve come to appreciate from walking El Camino is the responsibility we all have to create a more sustainable community. As a pilgrim, one learns to travelLXLMS only with what one can carry in his or her mochila (backpack), consume only what one needs for the walk, and avoid leaving a mess at the albergue or nearby town. Yet remembering this lesson is all too easily forgotten when I return to the fast-paced, less-personal more-removed-from-nature “civilized” world. I am thankful for t he GPN’s work to help keep sustainability an enduring part of the pilgrimage. For even when back home, we are still pilgrims on this earth for only a short time.
I hope and pray for all pilgrims to take to heart Pratesi’s words.
[1] “PRESS RELEASE: Green Pilgrimage Network launches.” ARC –News and Features – PRESS: RELEASE: Green Pilgrimage  Network launches. Posted November 1, 2011. Accessed December 15, 2015. http://www.arcworld.org/news.asp?pageID=493
[2] Green Pilgrimage Network | Helping pilgrim places and routes become cleaner and greener.  Updated: 2014. Accessed December 15, 2015. http://greenpilgrimage.net

Healing on the Way

At the age of eleven, my younger brother began abusing drugs. First it was the occasional joint at a friends house. Then he began spiraling deeper into more serious substance abuse more frequently. By the time he was sixteen, he was getting high almost every day. As a consequence, he began to isolate himself from our family, spending most of his day in his room. He even slept through the family Christmas celebration. As his older brother, I never wanted to rat him out. Although, we were twenty-one months apart in age but worlds apart in personality, I deeply loved him and accepted him.  I never wanted for him to see my disapproval of his poor choices as disapproval of him as a person.

Nevertheless, when my brother got stoned daily, I couldn’t just sit by and watch. So one day I told our parents. They confronted him. He confessed but refused to quit. Over the next six months, our family endured a collective hell as he insisted on his prerogative to do drugs. Knowing that I didn’t support his substance abuse, he unleashed a special fury on me. Once when I dropped him off for work–with strict instructions from our parents to pick him up at the end of his shift–he told me that he would “fucking kill” me if I ever told our parents that he wasn’t coming home that night. Another time I tipped my parents off about where he had squirreled drugs away in our shared bathroom, and the next morning, he found me in class, pushed me and threatening that he would “fuck you up” if he found out that I was the one that told mom and dad about the drugs. I was so afraid of him that I moved out of home to stay with a friend, feeling unsafe in my very own home. After several months of his destructive behavior, he got arrested for truancy, and my parents, with the help of the judge, were able to get him remanded to an in-patient drug rehab in a rural ranch several hours from our house.

Right after my brother completed long-term rehab, I left for college. Given the scars he left me with, I distanced myself from him. We would see each other once or twice a year for Christmas or summer vacation, but our exchanges were minimal. I would never call him, and even when my mom  would tell me about his struggles with addiction, I would listen silently and not ask any questions. I had forgiven him, but the wounds of his addiction were too fresh. Hearing about his seemingly losing battle with drugs and alcohol was handling bleach with an open wound.

Eventually, his addiction drove him to homelessness in San Diego, where–in hopes of lifting himself out of abject poverty–he succumbed to the temptation to drive an illegal alien across the US-Mexico border. He was caught, charged with human trafficking, to which he pled guilty. Once in prison, he and I began to connect through hand-written letters. Through our correspondence, I learned that he had experienced a genuine change while incarcerated. In the holding cell of a federal courthouse, he recounted, had a heart-changing experience where he let go of anger, hate and spite had fueled his addiction.

As we continued to correspond, our connection deepened. On one of these letters, I expressed to him the hurt he left me with. He asked for pardon for having hurt me and for help to get back on his feet again. While writing one of these letters, it occurred to me that we needed to a concrete plan to truly reconnect after he was released. It had been over ten years since he started using drugs, and he and I had scarcely communicated until he was in prison. So, I proposed that we walk the Way of Saint James, also know as El Camino de Santiago, a pilgrimage in Northern Spain across the Iberian Peninsula to the Cathedral of Santiago de Compostela, where the tomb of St James the Elder, an apostle is thought to be buried. Having walked the Way with my wife several years prior, I believed that it would offer just what we needed–nature, simplicity, and silence to focus just on each other.

Two months after my brother was released, we walked the Primitive Way of St James. Commencing in Oviedo, we began our trek walking through the Asturian Mountains. Spending time together in the wild, I found much-needed healing of wounds from our past. When on a rainy afternoon we lost track of each other in a little mountain town, I was forced to grapple with the reality that my avoidance of communicating with my brother stemmed from a fear of losing him. It was then that I realized the importance of simply living with him in the moment, for I never knew when I would have such time with him again. And when we both had different opinions about where to walk, we were forced to work out our differences in a civil, reasoned manner, which we had not been able to do before then, as I was simply too afraid to engage him at all. At the end, when we arrived at Santiago de Compostela, I remember sitting with him in a small breakfast room in the Hotel of the Catholic Kings, talking to each other as if we had never been estranged. As one pilgrim later told me, “if I hadn’t learned your history together [of you and your brother], I wouldn’t have known…you looked really happy together.”

Not long after we walked the Way, my brother was unexpectedly killed. He was found beaten to death in a parking garage. Devastated, I felt at first like Job, struggling to make sense of such evil in the face of a seemingly good God. Yet thinking of his death always led me to reminisce about his life, the best memory of which I have of him which was from the Way of St James. I would never have imagined that he would die so soon after our pilgrimage, but I am grateful for our reconciliation. For without our reconnection on the Way of St James, we never would have found much-needed healing after enduring such hurt.

A special thanks to Alison Buehler for posting this piece on her blog, “The Healing Wall.”

If you’re interested in reading more about our story, consider getting our book on Amazon here, or visit the book’s website, OnthePrimitiveWay.com 

Tragedy and the beauty of now


I remember when I used to visit my wife in Alcalá de Henares when she lived in Spain, I used to take the Cercanías train to and from the airport. As I would ride the train, I could not wrap my head around the fact that a bomb was placed on this very train on March 11, 2004, killing 191 people and injuring more than 1800. In such a peaceful and relaxed city such as Madrid, I thought, who would have such sinister motives as to inflict terror?


Yet—as I was reminded this past week when my wife informed me of the fatal shootings in Paris—terror can strike even in our a seemingly tranquil, civilized place. Tragedy can occur when it is least expected.


Then, we are left in shock, wondering, like Job, how a good God can let such evil happen to good, upstanding people? This is a completely human question which many family members of those killed by the attacks in Paris are no doubt asking right now.


Yet after experiencing the sudden and unexpected tragedy of losing my brother, one of the best consolations I found was to reminisce not about the tragedy of his loss but of the beauty of our time together. Recalling the beautiful memories we had traversing the mountains of Asturias on the Primitive Way or Saint James, or the heartfelt conversations we shared over coffee we shared in Santiago de Compostela just after our pilgrimage, reminded me of the beautiful opportunities we had to reconcile and grow closer just before he died. Remembering these experiences has often been a cause for me to find joy in his life rather than sadness over his death. Certainly there are times that I cannot but question the seeming existential cruelty of his loss, but in remembering our good times together, I am reminded of how fleeting the blessing of loved ones can be.


Though the possibility of losing them always lingers, the beauty of being able to share time with those we hold dearest to us in life has always been for me the best consolation in times of tragedy.

Left is my brother (left) and me (right). Right is graph of % of US that lives in cities (above) and intersection of East 69th and York (below)

What if Great Minds Fled the City?

Left is my brother (left) and me (right). Right is graph of % of US that lives in cities (above) and intersection of East 69th and York (below)

Just over six years ago, my younger brother Cory wrote me a touching email. After hardly having seen nor heard from him for several years, I was surprised to find in my inbox a lengthy, thoughtful update on his life. (We had not been on the most cordial of speaking terms prior to that due to conflicts related to his drug addiction.) In his message, he spoke about his recent move from the mountains of rural Appalachia to Austin, Texas. In Austin he had finally found a community that was instrumental in his addiction recovery. By volunteering at local public charities, faithfully attending a dance community and altering his work ethic to be less hurried and more deliberate, he was able to see the importance of “the greater good” over the importance of the “temporal indulgence” of his addiction.

In spite of his general contentment, however, he expressed to me some regret over finding his niche in such a large city.

As he wrote:

The only down side to [Austin] whatsoever is that its population is largely made up of young intelligent individuals that all came from somewhere that likely needs them.  The “brain drain” effect to the max.  There are so many amazing people here reciprocating energy off each other, I can’t help but think about all the small towns that are missing that source of personality and income…

I read these words from the computer lab at my medical school in the largest city in the US, New York City. I was taking a study break from neuropathology. As a second-year medical student, I was spending twelve to fourteen hours at the medical school building on East 69th street. What little remained of my waking hours was spent walking to and from my apartment on East 77th street. Looking out the window at the busy intersection of East 69th street and York—one filled with fast-walking pedestrians to and from the buildings in the New York Presbyterian and Memorial Sloan Kettering medical centers—I wondered how our society would look if all the well-paying jobs in the economy were in rural areas.

Imagining this hypothetical scenario, I began a thought experiment that I still repeat from time to time to this day.

What if the economic growth over the past 200 years went in the direction not of urbanization but of ruralization?

In the 1800’s, well over 90% of the US population lived in rural areas. In 1900, that number had dropped to 70%. Today, a paltry 19% of the US lives in a rural area. What if the statistics were reversed? What if 20% of the US lived in cities while 80% lived in the country?

Now, before I advance to far into this status-quo questioning line of thought, I want to declare first and foremost that I don’t hate, or even lament, the existence of cities. I’ve lived in New York City, Boston, London, Madrid, and Houston, and I’ve found a special fondness for every one of them. I loved being able to get up and walk down the street to national conferences while living in New York City and in Boston. In Madrid, I adored the Cercanías train that could get me from Madrid’s Barajas airport to my wife’s apartment near ‘Nuevos Minesterios’ metro stop within half an hour, allowing me to commute every week from my doorstep near Brussels to her doorstep in Madrid within a few hours. I love the cultural, social and economic riches that cities have to offer.

Back to the thought experiment.

If we imagine the rural/urban ratio of present day urban society being not 20% rural: 80% urban but rather 80% rural: 20% urban, the current-day countries that would fit the bill would be ones like Swaziland, Malawi, or South Sudan—countries which have not enjoyed even close to the amount of economic growth as Western countries have over the past two centuries. The accompanying growth of economic standards of living alongside urbanization could imply on the one hand that urbanization leads to economic growth. So has been the argument—urbanization leads to efficiency, economies of scale, economic growth, etc. This trend could also imply that the urbanization and economic growth are simply correlative trends and that one does not necessarily lead to the other.

If we could put historical blinders on—which I know is not entirely possible—would it be possible just for a moment to envision a society with the economic standard of, say, Switzerland (GDP per capita $84,000/year) while still maintaining a rural: urban ratio of 80% rural to 20% urban?

Many would say ‘absolutely not,’ but if we think for a second about essential economic services that are associated with urbanization could just as well be supplied in a rural-based economy.

Take food production to start. The vast majority of Americans’ food supply could theoretically be supplied by home gardening. Many homesteads have been able to supply their entire year’s supply of food with just a half-acre lot on which to grow vegetables and raise livestock. When specialized foods are needed, many can be acquired locally or even bartered for. And when families suffer from poor harvest, famine or pests, those with abundance could support those with less harvest through community pantries—on a local level—or inter-region food-sharing agreements on a larger scale.

Electricity, as well, could theoretically be supplied to a large population in a rural-based economy. Solar panels (especially with advances in production), hydroelectric energy, wind energy and simple conservation—from not keeping large urban office buildings running—could supply much of people’s needed electricity. And when fossil fuels are needed, there is nothing preventing power plants from supplying people’s power in rural areas.

As well, transportation can be made nearly as accessible in urban areas as it can be in rural settings. Cars of course have been the ‘staple’ of rural families in this country, but that doesn’t have to be so. If more people paid for trains to go to rural areas (as in France and much of the rest of Western Europe), a flourishing, extensive train network could transport people between rural cities for much less energy than cars could. As well, even air travel could be made extremely accessible to rural areas by either self-piloting or cooperative ownership of planes, where groups of families share ownership of planes. Many Alaskans manage to live hundreds of miles from the nearest city by flying their own planes.

Finally, quality healthcare could, I would argue, be delivered in a rural-based economy. Country doctors (general practitioners) could supply the lion’s share of medical care, and when more specialized care is necessary, much of it could be handled through e-consults online (as is increasingly the case in rural settings). Many lab tests can be performed on a patient thousands of miles away, and imaging could be read by read by a radiologist from virtually anywhere. Though as much as 80% of people’s medical needs could be met in a primary care setting, certainly there are cases where a person needs a surgery from a far-off surgeon or a drug infusion from a special cancer center. But—with a robust train system, flying cooperative or personal aircraft—a patient could just as well travel a thousand miles in a day. And for the emergent procedures, there are ways to adapt to rural settings (e.g. ambulances with CT scanners and clot-busting agents for strokes).

I will stop my thought experiment here. I have said nothing of entertainment, sports, or education in a rural-based economy, though I think that they can all be made accessible to most people in the scenario I’ve just described. That will be for another post.

My point is not to make a Luddite case against modern technology—which I very much appreciate—but to raise the question of whether the state of urbanization that we’ve reached in the West needs to be the status quo.


After reading my brother’s message, I took an extended break from my studies to compose a reply. I thanked him for writing and encouraged him to continue in his community service endeavors that helped him “climb one rock higher” over his addiction. I also proposed that he and I take a trip together, to reconnect after years of disconnect wrought by addiction. He replied quickly, saying that “he wouldn’t miss” the opportunity to spend much-needed time together. He unfortunately suffered a bike accident after that, after which he relapsed and ended up in prison. Several years later, though, we were finally able to make that trip together. After over a decade of estrangement, we walked the Primitive Way of Saint James, reconnecting in the mountains of Asturias—hours away form any city.

(If interested in reading more about our pilgrimage, see my book website OnthePrimitiveWay.com)

From the Way of Saint James to Saint James Parish: How walking ‘El Camino de Santiago’ led me back to Southern Louisiana

Blog post_9_Nov_2015

Almost 15 years ago, my grandmother, Carolyn Goodfellow Roussel, passed away. Departed at the age of 73 from a relatively sudden illness, her death was a shock to me. Ever since I could remember, Maw-Maw was always there when I wanted to call someone. I could always count on coming to see her and my grandfather, Paw-Paw, at their home in Gramercy on North Millet street. As a child, my immediate family—my parents, my brother, my sister and I—moved around the country. Nevertheless, I looked forward every Christmas Eve to coming back home to Maw-maw and Paw-paw’s, where all of our extended family would be united for the Bonfire Festival. After Maw-Maw died, my grandfather moved out of the “old homestead”. I too, for the first time, was uprooted. Even though our family kept going to Christmas Eve bonfires every year, not coming  back to the family home to Maw-maw and Paw-paw’s left me feeling like I could no longer call Saint James Parish home.

A couple of years after Maw-maw died, I graduated high school and left home for college at Rice University in Houston. With my parents in Victoria, Texas, I didn’t live at home then, and returned to see them only sparingly—perhaps a few times per year. More often than not they came to see me. By then, I no longer had a concrete place that I could call home. I had grown up in four different cities, never staying long enough in any one of them to be able to have “deep roots” laid. With Maw-maw and Paw-paw no longer in Saint James Parish, the concept of home to me simply became synonymous with I was living at the time.

When I graduated from college and was accepted to Cornell Medical School, moving to New York City seemed only fitting. It was the school I wanted to attend, and as an Ivy League medical school, it would offer boundless career opportunities once I graduated.

In New York, however, I found that while career opportunities abounded, I was not at home there. Living in one of the world’s most populous areas, I didn’t even get to know my neighbors. And yet I can still remember to this day that Tom Sylvest was Maw-maw and Paw-paw’s neighbor. Even as I could go to Broadway plays, world-class art museums, and national conferences, it was a struggle to become part of any community. Much of the time, I felt as if I were walking by hundreds if not thousands of people with whom I was living a parallel life—interacting with each them transactionally but never actually taking the chance to get to know one another.

During the summer between my first and second years of medical school, I got married. Escaping the crowded confines of New York City, my new bride and I went to Spain for our honeymoon. Inspired by a poster of “El Camino de Santiago” given to me from a college professor, we began hiking through the Pyrenees in southern France from a small town called Lourdes—with just our backpacks on our backs—towards Santiago de Compostela in Northwestern Spain. We were embarking on the Way of Saint James, a pilgrimage traveled by millions of people dating back to the eighth century to the Cathedral of Santiago where the body of the apostle St. James the Elder is thought to be found. Forty days and 800 miles later, we made it to Santiago. In the process, we had not only bonded with each other but had made close friendships with other pilgrims—closer than with any other friends from New  York—as we weathered the elements of the Iberian peninsula together in our efforts to make it to Santiago.

When my wife and I returned to the New York City from Spain, I felt let down. Now the honey-moon was over and it was back to the grind in the Big Apple. The experience of a young marriage on an emotional and physical roller coaster of hiking days on end to arrive at the Cathedral of Santiago could not be surpassed. The sense of interior fulfillment with completing such an all-encompassing spiritual journey seemed to be the sine qua non of to-do life experiences.

Yet, one of the lessons I came to appreciate afterwards was the importance of the interior pilgrimage. As one of the priests who spoke in the Cathedral of Logroño reminded me, ‘The true Way continues at home.’ There is even a Spanish saying that goes back centuries: “The Way starts at everyone’s front doorstep.” The Way of Saint James is simply a re-enactment of one’s life—the constant journey, the never quite reaching the end (until we die) and the constant hope of making it to the ‘Celestial City’ (the nickname for Santiago de Compostela).

Still, there is something irreplaceable about participating in this over one thousand year-old tradition, which is why many pilgrims return to Spain to walk the Camino repeatedly. This was the case with me. After returning to the harried hectic life of NYC, my wife and I decided to walk the Camino again two years later—this time taking a different route, the Northern route route along the Cantabric sea. Again, our lives were changed as we were joined to a community of pilgrims—one more tightly knit than any group we had been a part of in New York.

Two years after that, my brother and I had a chance to spend time together. In Spring of 2013, he and I walked the Camino—this time starting in the Cathedral of Oviedo and taking a route called the “Primitive Way” to Santiago de Compostela. Walking the Camino with my brother, we reconnected together after a decade of estrangement wrought by drugs, alcohol and imprisonment. When we finished, I remember eating breakfast with him at a hotel in Santiago—just outside of the Cathedral—and him telling me how much he had missed seeing me while I was in medical school. He knew that going to New York for medical school was the right decision for me, he said, but he stilled missed being able to see me nonetheless. Hearing how much he missed me, even as he struggled to keep his life together, I realized that I, too, was missing not being close to family. It was then that I decided that after finishing medical training, I would return back South. Where in the South, I didn’t know, but it would be within driving distance from my brother and the rest of my family.

It was not until a rainy day in December when my wife and I decided that place would be Saint James Parish. We had recently moved Cambridge (Massachusetts) where I was an internal medicine residency, but we were down to visit for New Year’s. After a morning to visit Jackson Square, we headed back to my parents’ house in Baton Rouge. On the way, we decided to stop at Maw-maw’s grave in Saint Joseph Cemetery in Paulina. After we had paid our respects, we continued to drive down River Road towards Baton Rouge. As we were driving through Convent, we came across an empty lot with a ‘For Sale’ sign on it.

“Stop!,” my wife yelled.

Taken aback by her abrupt command, I stopped. Thankfully  nobody was driving behind us.

“This is it!,” she exclaimed, peering out into the empty lot.

“What?” I said.

“This is where we’re going to live,” she affirmed.

“Why here?” I said.

She then reminded me of the Bonfire festivals nearby—that  going to Saint James Parish every year always felt like coming home, even if I grew up elsewhere. More than that, this was where my family was. Even my great-great ancestors are buried in Saint Michael’s Cemetery down the street. We could not miss the opportunity to raise our kids in a place they could lay down deep roots. If we were going to come back South, it would have to be here.

She convinced me.

Eighteen months later we signed a purchase on a plot of land in Convent—the center of Saint James Parish—and two years later I signed a five year agreement on an office in Lutcher—another town in Saint James Parish—where I will start a medical practice.

Were it not for the Way of Saint James, I might not have realized how important it was to go back home. Even if I only went there once or twice a year as a child, I had been part of a community in Saint James Parish, and I did not realize until years later—while walking to Santiago de Compostela—how much that meant to me. Though thousands of miles away, the Way of St James in Spain led me back to St. James Parish.

Also posted on my book website at: http://www.ontheprimitiveway.com/#!From-the-Way-of-Saint-James-to-Saint-James-Parish-How-walking-‘El-Camino-de-Santiago’-led-me-back-to-Southern-Louisiana/colb/564074b00cf2f51f3231ee2a

Direct Primary Care (DPC) is not just for the ‘haves’

Last week I went to a conference: Primary Care in Internal Medicine (PCIM), a week-long educational bonanza at the Kendall Square Marriott (Cambridge MA) run by Harvard teaching hospitals. For five straight days, specialists from Mass General Hospital (MGH), Brigham and Women’s Hospital (BWH), Beth-Israel Deconess Medical Center (BIDMC) and Mount Auburn Hospital (MAH) circled in and out of the conference auditorium to lecture about a wide range of primary care topics, ranging from the foot to the brain and everywhere in between.

While most of the lectures were on the technical aspects of primary care, one
particular one was unique. In his talk ‘The future of primary care,’ John Goodson, course director, Harvard Medical School primary care doctor and founder of Harvard’s Primary Care CrisisCenter for Primary Care Innovation, described with razor-sharp insight how primary care has become the un-favored, underpaid and overworked specialty that it now is. In brief, he pointed to the corruption of thereal-value unit (RVU) –a unit created by economists to ascribe a monetary value to cognitive work—as the basis for the demise of our primary care system. When in the 1980’s the federal govern
ment commissioned a team led by MIT healthcare economist William Hsiao to come up with a new reimbursement strategy for Medicare to contain rising costs, the political mechanics of ascribing a dollar value to a doctor’s time gave preferential authority to quick, procedural specialist-oriented billing codes over the more time-consuming, cognitive primary care codes. This RVU imbalance created in the 1980’s is the reason why the average specialist makes two or three times the amount that a primary care doctor makes, and—I might add—why, among other things, the number of graduating doctor’s entering primary care is declining.

What will the future of primary care be—Dr Goodson asked—when the aging population explodes over the next decade while the country’s supply of primary care doctors implodes? Things will have to change.

Among the new models he brought up as potential gap-fillers in the primary care shortage is direct primary care (DPC)—a low-cost, monthly direct pay set-up between the patient and the doctor. In exchange for flat, up-front fee (usually $50-100 a month), patients have more time with and access to their doctor. This provides the doctor with the opportunity to better focus on the individual patient’s needs without the headache of the 25 patient per day rat-race of traditional insurance-based primary care. It also offers more income flexibility to the doctor (who sees as many patients as needed to make his or her desired income). While this type of arrangement has the potential to attract more graduates into the field, he said, it also can lead to greater healthcare disparity. If providers cherry pick patient’s who might be healthier, sick patients might be left to find care only from doctor’s accepting traditional insurance, or worse, to public care.


This has been a common argument that I’ve come across when explaining the model of my practice to people. As my lawyer warned, DPC could lead to catering to the ‘haves’ and leaving behind the ‘have-nots.’

Having worked with several successful DPC practices all across the country—Qliance (Seattle), AtlasMD (Wichita), Gold DirectCare (MA)—I can say with confidence now that DPC is not just for the wealthy. For $50 (or even $30) to $100 per month for all-access primary care, patients often times are faced with a monthly medical bill cheaper than their cable bill. True, they must pay for insurance as well or—if uninsured—for additional labs or medications, but when all of the cost savings from DPC are added up, the money saved (either on co-pays, cheaper insurance or deductible payments) usually comes out to 30 or 40% less than traditional insurance-based medical care. While paying the fee at present does require out-of-pocket funds, I’ve seen impoverished patients say the fee to have ready access to a doctor is worth it. In fact, Dr Ryan Neuhofel (http://neucare.net/) opened his practice serving a less-advantaged population and has now a thriving medical practice. I would go so far as to say that net income is not the major factor for a patient deciding on joining a DPC practice. So much more is involved in choosing a doctor than income level, and if a patient is so destitute that he or she can’t pay the monthly fee, there is nothing stopping a DPC doctor from offering charity care—care which, unlike most Medicaid-accepting MD’s—many DPC’s offer.

DPC is not a model set up for the wealthy. That is concierge medicine. It is a model set up for those who want more time with their doctor, more accessibility via phone or email and less hassle with insurance companies.

Will DPC surpass traditional insurance as a means of payment for primary care? Who knows. Insurance companies are still very wealthy and have much more money to lobby Congress than DPC doctors do.

One thing is for sure: I’m not letting income alone stand in the way of a patient joining my practice. Catering to the wealthy is not why I became a doctor.

Also on my blogger site: http://communitasblogsite.blogspot.com/2015/11/direct-primary-care-dpc-is-not-just-for.html

My practice location

Happy occupant of office location, owner of LLC and licensed physician. Looking for a shingle…

It’s official: my medical practice, “Communitas Primary Care,” will be located at 10900 Highway 3125, Suite F. Lutcher, LA. Opening date will be sometime around summer or fall of next year. In the meantime I have to find a shingle.