The Epiphany

streamIt’s time for a change. A big change.

The days–once energized by the excitement of a remarkable profession, the joy of independence and self-sufficiency, the satisfaction of skills finely executed and a business well-run–those days, those same days, are increasingly a grinding chore, a tedium too often, their life-joy ever sapped by the parasites which at first merely annoy but by attrition rob their host, a few corpuscles at a time, of its very life.

I love my profession. It is a love which has changed much since the first flush of excitement in solving a difficult medical quandry, mastering a new technical skill, or acquiring the seemingly boundless knowledge and insight which medicine luxuriously provides to those who pursue it. Like a long and comfortable marriage, the excitement fades while the satisfaction deepens, sending down roots into the soul, drawing cool refreshment upward while enriching the very soil from which it draws life. The thrill of the disease mastered, the new technical skill first practiced, the immense satisfaction of a difficult surgery completed without flaw or blemish for the first time–these great joys do not pass away, but by their nature, like first love, temper themselves as mastery and repetition make their novelty fade. In their stead–though such accomplishments still bring quiet joy–comes a deeper and more profoundly satisfying sense of intimacy with the profession and the souls it touches. There is great indemnity in knowing that you have mastered the skills to tackle and conquer the challenge your patient brings to you–but far greater is the satisfaction, the deep joy and humility, which comes from having touched another soul in their moment of need, to have experienced in some measure their pain and futility, and then by skill and grace to provide a measure of relief and hope where none previously existed.

The satisfactions of this profession, now over 30 years my companion, today come in ways little experienced nor anticipated in its fervent youth. Far deeper now is the richness of a lingering conversation with an old patient, their acute crisis long passed, as we wander conversationally to common struggles and new experiences not even distantly related to health–yet paradoxically intimately bound up in it, in the well-being of us both. For to share friendship, commonality, mutual struggles, trust, laughter–this is to tap into the very heart of man as wandering pilgrim in the rich but treacherous lands we call life. Deep is the satisfaction of a surgery performed, not with the flashy cockiness of bright new skills, but with the weathered elegance of a task mastered through countless repetitions, endless subtle variations having been tested and proven to strive for an ever-receding perfection, just out of reach. It is a period of life in which one will say, at day’s end, that you have done well–having done nothing spectacular, nor been applauded by others, nor even appreciated by those who have benefited by the grace of years’ experiences, but rather have made a small difference, touched a life, changed a world.

Yet the brook which sparkles in the broken sunlight of forest trees, whose rushed whispers touch the spirit and excite the soul, both polishes the stone smooth and erodes the sandy soil with harsh, relentless abrasion. The solid ground is no match for the raging stream, which carves deep and jagged furrows in its frenzied rush downwards.

Each time an insurer sends my patient a letter, justifying their non-payment by defining my care as “medically unnnecessary,” the corrosive effects of this erosion is felt. Every time an employee repays generosity with greed, the soil is scored more deeply. Each agonizing case, fought with sleepless nights and troubled dreams, where best efforts yield bad outcomes and visions of lawyers and depositions haunt you like possessing demons, yet more of your bedrock is stripped away. Each mindless federal regulation, each legitimate payment denied and appealed, each illogical form demanded, consuming endless clerical hours without purpose or renumeration, erodes the joy and stifles the satisfaction of a noble profession, carrying you yet more distant from the headwaters which first drew you in.

The attack is relentless, as it is subtle. Physicans become “providers”; patients become “clients”; covenant becomes contract. Governments assume you are fraudulent and demand you prove otherwise. Hospital priviledges become hospital obligations, as their massive bureaucracies heap on unfunded mandates and endless requirements, camouflaged as “quality measures” but designed to utilize their indentured staff as free labor to satisfy yet another federal law or executive marketing decision. And the paper: cancer staging forms, mandated so the hospital can market itself as a cancer center; work release forms which defy logic and force square disease pegs into round punch holes; and endless mountains of charts to dictate, dictations to sign, reports to review, lab to compare and assess. Yes, much of this is the normal stuff of any job or profession–but its quantity has become so massive, and its rationale so perverse and distorted, as to starve the oxygen from all other priorities. We have become slaves of paper rather than servants of patients.

Last week, as I stared at a huge pile of undictated charts, unreviewed lab, scanned images to organize and import into the EMR, dozens of urgent emails demanding immediate action on matters trivial, and a pile of ill-organized detritus representing both wheat and chaff of running a business, I had an epiphany: something must change. Many things must change, in reality–but the process must start. I must recapture the joy, the satisfaction of this profession, no matter the cost.

Physicians are handling the devolution of their profession in many ways. Many who can are retiring early, seeking other careers, changing fields, moving to another state or form of employment. Many who cannot or will not pursue such solutions become fatalistic, depressed, sullen, and resentful, slogging through their joyless days, counting the minutes until they, too, can leave or retire to a measure of peace which recedes faster than the days pass. Others take the quick fix: the drink, the drug, the affair, the new Porsche, the trophy wife. Such measures kill the pain just before they kill the spirit, leaving nothing to give, emasculating the very energy from which the profession derives its life.

I am no stranger to many of these things: for years, increasingly disenchanted with the profession, I sought relief in dreams of new careers and the countless escapes which medicine provides through easy excuses and hard money. None satisfied, nor even came close; the more I hoped for relief, the more trapped and unhappy I became. My last epiphany came–as so many seem to–with the subtlety of a bomb, as looming disaster mandated fast change and a degree of faith and trust I had never before found within. Yet while fear can destroy or paralyze, it can also transform, and something far beyond my feeble means transported me to a new place little imagined and most unplanned. It has been a good place, a resting place, where the joy of my calling could once again resurface.

But that which is static dies–and this is nowhere more true than in the spirit, where comfort and routine deaden the heart. And so change–yet more change–must come.

Vocation–an old term, rarely used outside seminary and sanctuary today, but in truth that to which we all must all answer: the calling, the direction, the purpose which ennobles the effort, guides the spirit, and gives peace in the torrents and whirlpools of our passage down to death yet up to God. And to maintain the purpose, the calling, the vocation, there must be change. Almost ironically, to stay on course we must often change course. In my last epiphany I found in my profession my vocation–although this very profession was worn and weathered with years of purposeless passion and pointless pursuit. In this epiphany, this impending change, must come greater focus–not only on profession, but patients, and family, and friends, and spirit.

Change comes hard for most, I suspect, but particularly for those who have embraced this profession. For when we change, we change not only ourselves, but those around us–employees, patients, peers, and family must all be carried along with us, or lost in the swirling currents which can swallow the unguided and break the rigid, weak and feeble dams in their path.

And so, once again, it is time to step out in faith, to take a path whose direction remains unknown, to follow that still small voice so easily shouted down in the crush and rush of a world in such a great hurry to go nowhere, to accomplish nothing. It is a journey, like those before, of both fear and faith.

Let that journey begin.

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11 thoughts on “The Epiphany

  1. How scary! How exciting! I have great hopes for you, one of which is–of course–that you will keep us posted.

    Such change, I know, is borne of desperation, however quiet, yet only the brave will step out to follow it. You have a Guide who knows the way. He is, in fact, the Way. “Walk ye in it.”

    Blessings!

  2. Dr. Bob, I hope that you will be able to share your new journey with us, and allow us to travel along with you. I have a feeling that each of us can learn, where are today, from your thoughts and decisions.

  3. Thanks for your thoughts–one of the temptations, once you realize things have to change, is to change them–right now, hurry up, let’s get this unpleasantness over with. For me right now, the hardest thing is waiting, and listening, and taking small steps as the next step becomes apparent.

  4. Mmmm–oh, yes, been there! Waiting, listening to *nothing* except that deafening silence, until one day a quiet Voice, or just a deep *knowing,* unravels the knots in your tummy, and you know it was worth waiting for.

  5. Many doctors work in the gravest of circumstances. This is when the best interaction between doctor and patient occurs.

    It seems odd to me that paperwork is a problem when many of your peers are staring down guns and guerillas. Perhaps your spirit is yearning for that kind of simplicity?

  6. Dear Dr. Bob,
    Here is a poem I wrote for a friend who quit her job, and perhaps it speaks a bit to this “dark night of the soul.”
    LOST TRUST

    Trust unbinds
    Outside of sound.
    Grinding fragments fall in silent shards —
    Betrayal’s brittle waves
    Cutting away…cutting away.
    Good will is swept astray.
    The view’s the same
    But not the Day.

    Indifference
    Immolating Loyal Fealty
    Accumulates in hot dry tears.
    “Stands” not stood
    Expose Principles rescinded
    By discomfort/ or a busy day.

    Hollow leaders hide in slogans
    That do no good,
    Dragging their small wooden world
    Down into the quicksands of oblivion,
    Blinded to bright jewels
    That shine still as they slide past.

    Thank God for that.
    Strength does not wither under fire;
    Those loyal to principle stand fast for
    Those who trust can be trusted.
    The mystery of life evolves
    Through them
    Creating the ever present future.

  7. Regardless of where your journey takes you, on which I wish you the thrill of discovery and renewal, still where your talents today are of invaluable service (unpaid I fear but very appreciated) is in keeping us all on the right track in this war against Islamic aggression. By helping us sort out the motivations, not only of the enemy but our own angry responses, by giving us background on the dynamics of certain attitudes, it helps the layman understand the bewildering culture who’s wrath is facing us. You are our reality check! G*d Bless!

  8. I’ve never restored more than a few, if any, fellow humans to health — by personal, not-professional psychological support to family and friends — but seem to know in my heart the “grinding chore, a tedium too often” of which you speak.

  9. Ditto.
    I retired after 34 years mainly because my husband was getting frail and wished to move to a warmer climate.
    But the non medical stresses were making seeing patients worse.
    Arguing to fund things, arguing that the patient needed specialized care and could not be cared for in our 30 bed hospital, calling for permission to hospitalize Mrs. X was just getting too much.
    However, missions still could use you if you don’t mind cockroaches.

  10. “We have become slaves of paper rather than servants of patients.” How sadly true that statement is. The paperwork seems to dull the desire to serve others, because we are no longer serving the patients but the insurance companies and other bureaucracies. By no means do I have the intense workload that you do, but I find myself at the same place you are at right now, too – recognizing that things have to change, but uncertain what the steps are in order to bring about that change. God bless you on your journey.

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