By Dr. Keith Roxo, Guest Writer

I have been in the Navy for over 30 years now. About half of my career has been as a combat-rated Naval Aviator, and the other half has been as both a pilot and a physician. Aviation was always my first passion, so I trained in Aerospace Medicine, and I have worked almost exclusively within aviation-related units for my physician jobs. For much of my time as a Navy physician, I also continued to fly as a pilot.

This dual role has given me credibility within a community that loathes seeking medical care out of fear of losing their ability to fly and their associated identity. Demonstrating that I can not only treat their issues but also keep them (or quickly return them to) flying only further enhanced my reputation. This allowed me to parlay this skill set into my consulting company outside of the military.

 

The Wall of Inevitability

Having been a pilot and now a doctor for so long in the military, I find myself face to face with many senior officers staring at military retirement, and, well, many are freaking out. They come to me because they know I’m not an average doctor. I am “more like them” than the traditional “staff” officers.

What I have noticed is that many of them haven’t been living intentionally—not unlike many physicians. They just go from one set of orders to another. They rarely think about getting out of the military, even though everyone leaves eventually. Unless you die on active duty, you either quit or get kicked out. Yet it seems to creep up on them. They just keep marching toward this unseen wall of inevitability. Suddenly they didn’t promote to the next level, and they are coming up on maximum time in the military—or they only have terrible options for orders and/or duty stations that they or their families don’t want to do. These officers are typically in their mid-40s to early 50s when this happens. The wall is now visible and precariously close.

They are typically the sole income for their family. They have never had to look for a job. Officers, in the Navy at least, have to tell the military they are leaving a minimum of nine months prior to actually retiring with no guarantee of civilian employment awaiting them. It is very anxiety-provoking to them. My wife sees a lot of posts in the military spouse social media groups about people concerned for their recently retired spouse who isn’t themselves; what they describe is someone who seems to be depressed.

None of the people who have seen me have been suicidal, but I have been on base when other senior officers have died by suicide after a failure to promote to the next rank or be selected for the next level of command. Between the ones who come see me for primary care as their flight surgeon and the other things I have heard or seen occur, I have really had to think about how to respond.

More information here:

What It’s Like to Be a Military Doctor — and Is It the Right Path for You?

 

Living Intentionally

I was at the Aerospace Medicine annual scientific meeting in May. I was riding an elevator with a colleague who I have met several times at various conferences. This time his wife was attending, as well. She commented that I seemed like a pretty happy guy. I said something like, “Well, if you aren’t happy, what are you doing about it? I believe that people should be shaping their lives into what they want and not just accept the circumstances presented to them.”

I have discussed this concept with some friends before. I call it living intentionally. My short-, medium-, and long-term goals are set up to feed into one another. I do this personally and professionally, and I try to blend them together as applicable. For example, I have a 4×4 to go off-grid camping with my family. I am in the process of buying an even more capable off-road trailer to make the trips easier to do more frequently. I have built a business where I can set my own hours and even work remotely. My Starlink internet system will let me work remotely from my off-road trailer set up in the middle of nowhere—or perhaps the middle of somewhere awesome.

 

Motivation 3.0

In Daniel Pink’s book, Drive, he talks about what motivates people, and he breaks it down into three levels. Motivation 1.0 is all about survival. Motivation 2.0 is the culture of reward and punishment. But Motivation 3.0 is for those operating at a higher level, and it consists of autonomy, mastery, and purpose. You get mastery from education, training, and hard work. But what about autonomy and purpose? My intentional living is leading toward autonomy—retiring from the military and working for myself.

As I considered how to help these people, I had my thoughts on intentional living and Motivation 3.0 in mind. But it didn’t really click for me until I considered trying to come up with the opposite of what drives suicide.

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Suicidality

As I mentioned, most of the people I have seen have not been suicidal, but they are very concerned about the direction of their lives. They are having trouble sleeping. They are having symptoms of anxiety. They are having feelings of doubt and guilt about their decisions that have led to their current situation.

Not everyone going through a rough patch in life warrants a psychiatric diagnosis, but that doesn’t mean they can’t use some help. Those who have come to me have similar circumstances to people who may be in a major depressive episode or have died by suicide; they aren’t there yet, and I don’t want them to get there. As such, I felt it was worth looking at the extreme and finding a way to provide the best possible advice on how to combat the issues these individuals were facing.

The Interpersonal Theory of Suicide states that when the overlap of three conditions occurs, the possibility of suicide increases dramatically. Those three conditions are:

  1. Thwarted belongingness
  2. Perceived burdensomeness
  3. Acquired capability

Thwarted belongingness is the loss of a sense of belonging. Say you were previously part of a tight-knit group, a cadre of like-minded people with common goals and focus. Suddenly, you are no longer part of that group. A military person accused of a crime or a police officer accused of corruption may find themselves suddenly ostracized. The same could be true for a physician in a group accused of writing bad prescriptions. The taint of the accusation, true or not, suddenly puts this person on the outside.

Perceived burdensomeness is when a person believes themselves to be a burden to their family or their team. Examples include a spouse who has lost a job or a surgeon in a practice who has broken a hand. They are no longer providing to the family or team, but they are taking up valuable resources.

Acquired capability can come from witnessing death, which may be more common with military, law enforcement, and medical practitioners. It can also come from past failed attempts and the steady escalation of attempts.

If the absolute worst end state of total unhappiness could be considered suicide, what are the off-ramps from this road? How best can someone prevent even getting on this path? I tried to see if I could come up with the opposite.

I call it contentedness.

 

Seeking Contentedness

What I came up with was the direct opposite for two of the Interpersonal Theory criteria and one replacement:

  1. Inclusion
  2. Purpose
  3. Goals

In the military—and really in a lot of medical settings—it is fairly easy to find inclusion. Being part of a team (and a valued one at that) can be a major boost to personal satisfaction and enjoyment in life. But when you leave that setting, what is your plan to replace that sense of inclusion?

Instead of being a burden to others, having a purpose gives many people meaning in life. Again, we see parallels between the military and medicine. In the military, we generally have a unified purpose of protecting our nation. It's a cause that many people feel is so worthy of doing that they will voluntarily join to do very dangerous things that really can’t be done anywhere else in society. Similarly, you generally can’t go around cutting into people and taking organs out . . . unless you are a board-certified transplant surgeon. And you are doing it for the rather noble cause of saving lives. Many physicians derive significant personal satisfaction and purpose from their profession.

Many people have goals. But merely having goals may not be sufficient. An unattainable goal is going to be more of a negative than a positive in your life. Having a series of goals that feed upon each other to help aid the next level of goals to be more achievable is a good approach. What people really need are goals with a plan to achieve those goals.

Like with the Interpersonal Theory of Suicide that needs an overlap of all three criteria, these three individual criteria will not provide contendedness. Based on my ideas of living intentionally and the concepts of Motivation 3.0, I believe that by trying to align overlap for all three . . .  well, then I think you can achieve contentedness.

And if you practice this, you will be building the future that you want—a future that doesn’t have a wall of inevitability brought on by outside forces.

Are there other ways to find contentedness? How will you try to live your life once you retire?

[Dr. Keith Roxo is a Top Gun-trained adversary pilot turned Aerospace Medicine physician. He has more than 2,000 hours in a variety of high-performance military aircraft—including the F/A-18, F-16, and F-5—and he holds multiple military flight instructor qualifications. He also holds airline transport pilot and CFII certificates. His medical qualifications include board certification in both Aerospace and Occupational Medicine, and he is a HIMS-qualified FAA-designated Senior Aviation Medical Examiner. Keith provides aviation medical consulting with Wingman Med. This article was submitted and approved according to our Guest Post Policy. We have no financial relationship.]