Halfway There Is Nowhere

We’ve met here before, you and I. These pages afford opportunity: for me to share and define. For you to reflect and identify. As I describe my current reality, you’re along for the ride for however long you find my words serve. The gnawing discontent I tried to capture in A Question of Soul has aged yet eludes definitive characterization. Unlocking mentally by pushing harder physically (as in Kellermensch) is a band-aid. Next comes the pruning of ideas and habits that no longer serve. I long resisted this for fear of what I might find, but learning was worth the confrontation. Career isn’t the god it’s proclaimed it to be, materialism is a simple hedonic treadmill, anger isn’t the all-purpose emotion. But the greatest realization I had is I started work without understanding who I was.

Each job has been a role to fill, a way to earn a living. Each has been an objective with the express desire of fitting into the system. This desire co-opted understanding myself, for the system does not require us to be happy or content. It just requires us to be useful.

An interlude necessitated by past events:

“For the avoidance of doubt, and by way of clarification arising from prior usage herein, the term ‘system,’ as employed throughout this document, shall be construed to refer collectively to the healthcare system in its entirety and in a general sense, and shall not be interpreted as a reference to, or designation of, any single entity, organization, or institution, whether named or unnamed herein.”

This realization prompted other questions (as in The Courage to Question): is my baseline enthusiasm truly ephemeral?¹ Am I a caricature of what I once was? Does this period of discontent mean I’m having a MIDLIFE CRISIS?? It could, but I think we approach ‘midlife’ all wrong. It’s a socially agreed-upon line where one phase of life ends and another begins. A forced reckoning with the assumptions of youth. It’s a rite of passage, not a crisis. Purpose is what separates a rite of passage from a crisis. And the purpose of midlife is to allow us to see that we’re not living for self any longer. We’re living for others, as David Brooks argues in his book The Second Mountain². Purpose is a choice, an attitude informing how we see a set of circumstances. I’ve uncovered that my purpose is choosing to help others realize their full potential, be it my family at home, patients in clinic, colleagues in the workplace, students in a classroom, or friends in the mountains.

As an individual, I need the “why” that purpose provides. Always start with “why”³. In knowing “why”, we can then begin to work on “how”. If we focus only on moving forwards, we forget to stop and ask if our direction suits us. Or if we even want it at all! To find out my “how” I draw inspiration from the artist Michelangelo creating the masterpiece statue of David: “I saw the angel in the marble and carved until I set him free”. So too I will carve away what doesn’t fit until what’s left is myself and where I’m meant to be. I am the obstacle, so therefore I am also the way. Resolution of my midlife phase requires space and time, but I have the gall to put it all into words, to try and move through it while sharing with you in hopes that it does the same for you. In so doing, the material of self is imbued with purpose via action.

The first action I took was analyzing how our chosen profession has become so….modern. Wherever we look, we see toxic busyness, influencers of varying tropes, use of hacks and fads instead of deep work, pursuit of attention and titles instead of substance. All of this is shallow. We sense it in ourselves and others. In the book Capitalist Realism, Mark Fisher calls this the “slow cancellation of the future”⁴, where we have lost the ability to imagine that things could be fundamentally different than they are. We are profoundly lost in our working lives because we don’t have the machinery (mental or otherwise) to look forward, so our profession can only reference its own past .This manifests as the inability to conceive of working lives that don’t follow the existing template produced by previous generations. So we end up repackaging practice ideas and re-marketing staffing models and wonder why we’re still seeking, still dissatisfied! It’s because we can imagine different roles (inpatient, outpatient, pharma, etc) and salaries, but we struggle to imagine a different relationship to work itself. Is it really the center of our lives? Do we want it to be? We’re living and functioning inside a system that has stopped producing new futures. So we’re left haunted, carrying an imprint of a future life that doesn’t exist. Is it any wonder that following the prescribed path and conventional advice no longer serves us?

Part of this ennui relates to Fisher’s idea of the “privatization of stress”. This idea postulates that systemic problems are reframed as individual failures or personal psychologic issues. In our case of the existing healthcare system (again, see interlude related to ‘system’), this causes burnout, overwork, uncertainty, and mental stress to be treated as private issues instead of the products of structural and political conditions – essentially privatizing what are fundamentally public problems. When systems (see above, you’re getting the idea now) produce widespread unhappiness, the dominant rote response is to locate the cause inside of individuals. Naming the system as the source would require acknowledging that suffering is structural. And wouldn’t you know it, structural problems are uncomfortable to sit with let alone solve. It’s far simpler to shift responsibility to the individual. When therapy, self-help, and medications aren’t helping, it becomes the individual’s fault: a mindset issue, a failure to align or optimize. Now, don’t get me wrong here. There’s no question that we need to work on ourselves. Self-knowledge and understanding are what change our lives. But without this wider context, individual work by itself is a way of letting the system off the hook. Without systemic critique and the ideas and vocabulary to do so, pharmacists can only assume their dissatisfaction is a personal failing. This keeps the structural conditions producing the desolation invisible and thus unchallenged. We need to recognize that the disorientation we feel has a source outside of ourselves. The gap between what was promised by our existing system and what was received is a “feature” of the system. If you feel this way, know that you’re not alone.

Now that we see the walls of the box we’re in, we can ask better questions. Not questions of how to compete within the existing structure, but questions of how to redefine the game, how to win it. Questions like “does the game itself still make sense?”. Rene Giraud’s concept of “mimetic desire” captures this – are we doing things because we want them, or because we think we’re supposed to want them?⁵ Do we desire something because it makes sense for us, or someone else wants it? This idea is unsettling but sheds much light on our predicaments, both personal and systematic. Is the latest “best practice” actually the best way for us to do something? Or are we implementing it simply because some other hospital did and blindly adopting the practice prevents us from needing to think critically? Are we working beyond our means to “get ahead’ because that’s what someone else did, without asking if we actually want to “get ahead”? These are hard questions but illuminating ones. Then again, my style is to create chaos and uncover the hidden harmonies therein (my wife calls it being a s—t disturber). The realization that I can manifest my unique character in my chosen field of work has been incredibly freeing. Previously, I paid the price of conformity in order to escape the student loans that enabled me to get where I am. That resulted in me being out of place, like the swan in Rilke’s poem: when on dry land the swan waddles awkwardly since its true self isn’t revealed until it enters the water.⁶

So how do we emerge on the far side of the midlife journey? What can we each do in the here and now? Mark Fisher’s ideas are a mental model for understanding why so many capable and honorable people feel profoundly lost in their working lives: we’re attempting to navigate using a map in a city that has already been demolished. We’ve been trained to find the right answer, not to ask different questions. The end goal of this model is that one oncology pharmacist can be replaced with another of equivalent certifications and produce the same results, akin to a factory worker on an assembly line.

“There are actually few organizations that can support passionate employees – even if they say they want them. That’s because the original industrial revolution was designed to support productivity. Productivity means you produce. That’s how you’re measured. Passion is difficult to quantify…passionate employees believe in something bigger than themselves. They’re not interested in punching the clock, and sometimes they break the rules”

- David Armano

We’ve emerged from school and residency and work experience extremely well-trained for a working life that is rapidly disappearing, in a system that is rigid and resistant to change. We must now identify what it is we do each day that only we could do. What is unique to our skills and us as individuals? Is it creating genuine human connection where none existed before? Is it explaining something to a patient and enabling understanding where others had tried and failed? Is it a single sentence in an email string summarizing the core issue and facilitating meaningful change? Our goal now is to identify the commonalties between these activities and use it the schwerpunkt, (German, “the focal point”) for what we do next.

My schwerpunkt is questioning. My self-therapy is writing, performing acts of self-rescue in public. Punk rock indeed. I don’t write for attention. Or acclaim. Or money. I write to exorcise these thoughts, words, and themes from my head and codifying what I think. To me, this purging is about learning how to be a better person. If it resonates with even 3% of readers then I’ll have succeeded. My writing (and your reading) is practicing awareness, practicing feeling and thinking and being. It’s about being both uncomfortable and in control. Normalizing being aware of our discomfort, not running from it. For personal growth, but also to avoid Lewis Carroll’s ‘Red Queen’ effect, where staying in the same place is falling behind: we have to co-evolve with the systems in which we interact⁷. The human species must constantly adapt, evolve, and proliferate in order to survive. So too must oncology pharmacy. What, then, can we do?

First, we need to make oncology pharmacy practice more concrete. Our goal as a profession should be transitioning from information storage to information synthesis. This moves us in harmony with the AI age and allows us to engage in higher-order thinking - moving from “what is the data?” to “what does the data mean for this individual patient?”. Shifting our thinking will anchor the electronic health record (EHR) to a real person instead of an abstracted idea. One misgiving I have with AI is that it’s too easy to confuse probability with possibility. Having a plethora of information at our fingertips leads to overthinking, overindexing, and overinforming, creating the proverbial analysis paralysis instead of telling a story. We humans need the power of stories to see possibilities⁸. In fact, stories are how we organize information and what I think makes us truly human. Incorporating the data into each patient’s story brings it to life!

Second, we need to connect the results of our work directly to our effort. Too many times our work is abstract. We verify an order by reviewing photographs of what components were used; we calculate doses from a weight on a screen; we answer questions via instant messages instead of in-person. This all disconnects us from our work. Every day when I walk out of clinic, I know I was busy, but there’s no clear explanation for what I did all day. My answer will take at least a few minutes and depends on the mood of senior leadership, the opinions of patients, the roles of my colleagues, the functioning of the EHR, and a host of other external factors. But ask me if I took care of the patient, and suddenly I have a simple answer. Philosopher Matthew B. Crawford writes that “despite the proliferation of contrived metrics, [many jobs] suffer from a lack of objective standards”⁹ We’re running on treadmills where the pace and incline keep getting faster and steeper. We have to keep up, but we don’t know what the goal of the run is.

We humans crave what psychologists call ‘autotelic experiences’, or ‘fulfillment that arises from doing something well for its own sake, when you can connect the result directly to your effort’¹⁰. Autotelic experiences require a clear standard; one built into the activity itself and not set by managers or algorithms. When we reduce our work to first principles (take care of the patient to the best of our ability), healthcare can be an autotelic experience. But when our annual evaluations and feedback are filtered through leadership matrixes and layers of politics, optics, limits, and abstractions (ie, only one “role model” designation per manager per year), it reinforces the lack of objective standards. Simple answers and benchmarks for what constitutes ‘progress’ are needed. Each of us has an obligation to join the conversation and define what success means for our roles. Modern life is abstract but can’t overcome our human need for integration – so it’s up to us to save ourselves. We need to create metrics that resist obfuscation and abstraction; metrics connected to effort, skill, and outcomes. I don’t have answers yet for what these could be. Your suggestions are welcome!

Reconnecting the loop between our work and its effects will enable us to reconnect our souls to our vocation. We’re exhausted, yet rest doesn’t suffice or re-energize. David Steindl-Rast captures it best when he says “The antidote to exhaustion is not necessarily rest. It is wholeheartedness. You are so tired, through and through, because you are only halfway there”¹¹ If only half of our consciousness is present, what’s the other half up to? The other half is suppressing our internal voice so that we’re able to function day-to-day amidst the struggles described above! Recognizing this conflict allows us to begin resolving it, changing our environment and emerging from the grayness of midlife.

Midlife isn’t a problem to be solved, it’s a rite of passage and an experience that has be lived to be fully understood. Wisdom must be earned. We’re all capable of understanding, if not doing, what other humans have done- but it’s up to us to do the work.¹² I built a life on someone else’s blueprint, inside a system designed to consume me, and am only now learning to want what is actually mine. Everything has changed, yet I am more me than I have ever been. As William Deresiewicz writes of his own confrontation with identity, “I never planned to stop being myself, I just didn’t realize quite how myself I was. I came to see what I might become, and like every traveler, what I’ve discovered is who I already am”¹³. Keep developing your story. Keep persevering. Keep carving until something true remains. Keep following your intuition to find your identity and unique place in the world!

Soundtrack

“Shades of Grey”, Billy Joel

“Stone the Crow”, Down

“Hood Mentality”, Ice Cube

“Criminal”, Fiona Apple

“Ice Machines”, The National

“The Lasting Dose”, Crowbar

“Famous Last Words”, My Chemical Romance

“Bother”, Stone Sour

References

1. Hoffer, Eric. The Ordeal of Change. Harper & Row, 1963.

2. Brooks, David. The Second Mountain: The Quest for a Moral Life. Random House, 2019.

3. Sinek, Simon. Start with Why: How Great Leaders Inspire Everyone to Take Action. Portfolio/Penguin, 2009.

4. Fisher, Mark. Capitalist Realism: Is There No Alternative? Zero Books, 2009.

5. Girard, René. Things Hidden Since the Foundation of the World. Translated by Stephen Bann and Michael Metteer, Stanford University Press, 1987.

6. Rilke, Rainer Maria. “The Swan.” The Book of Images, translated by Edward Snow, North Point Press, 2001.

7. Carroll, Lewis. Through the Looking-Glass, and What Alice Found There. Macmillan, 1871.

8. Harari, Yuval Noah. Sapiens: A Brief History of Humankind. Harper Collins, 2015.

9. Crawford, Matthew B. Shop Class as Soulcraft: An Inquiry into the Value of Work. Penguin Press, 2009.

10. Csikszentmihalyi, Mihaly. Flow: The Psychology of Optimal Experience. Harper & Row, 1990.

11. Whyte, David. Crossing the Unknown Sea: Work as a Pilgrimage of Identity. Riverhead Books, 2001.

12. Twight, Mark. Poison: Sermons on Suffering. Non-Prophet, LLC, 2022.

13. Deresiewicz, William. “A Jew in the Northwest.” The American Scholar, 2011, https://theamericanscholar.org/a-jew-in-the-northwest/ . Accessed April 29^th, 2026.