Down dropt the breeze, the sails dropt down,
‘Twas sad as sad could be ;
And we did speak only to break
The silence of the sea !
All in a hot and copper sky,
The bloody Sun, at noon,
Right up above the mast did stand,
No bigger than the Moon.
Day after day, day after day,
We stuck, nor breath nor motion ;
As idle as a painted ship
Upon a painted ocean…
Her lips were red, her looks were free,
Her locks were yellow as gold :
Her skin was as white as leprosy,
The Night-mare LIFE-IN-DEATH was she,
Who thicks man’s blood with cold.
Samuel Taylor Coleridge, in his epic poem Rime of the Ancient Mariner, depicts the dread of all ancient sailors: becalmed, abandoned by nature and fate, powerless to move forward and at the mercy of vast forces and spirits beyond their control.
In some measure, these have been days much like that. The past few months have been some of the most difficult of my professional career. There has been a sense of fatigue, of purposelessness, of weariness with the routine and the rush, the frustrations and failures inevitable in any life pursuit, but perhaps nowhere more so than in the practice of medicine.
It is a high calling, this profession — words which, while true, seem fatuous and hackneyed in an age marked by hard science and even harder cynicism. It is a vocation fraught with paradoxes and contradictions: compassion and cold steel; empathy and enervation; arrogance and humiliation; deep satisfaction and bone-wrenching sadness. Its rewards, while rich, seemingly come at the cost of your very life, as the slow extravasation from countless battle wounds weaken the spirit and shock the soul, sapping your strength, leaving but an empty, fractured vessel, gloriously engraved on the outside but pervious and parched within.
It is no one thing, this weariness, but a score.
It is the two hours spent filling out a mandatory online recredentialing form for an insurance company, insisting on intrusive and irrelevant information (“What is the mailing address and contact phone number of your high school (required)?”) so that their marketing department can claim they only use the “finest” physicians.
It is the three hours spent dictating charts after a 10-hour office, missing no detail that might lead to an insurance denial, a government audit, or a later lawsuit — and knowing you will be back before sunrise to finish those charts you no longer have the mental or physical energy to complete.
It is the mandate to comply with the endless and every-engulfing tsunami of government compliance regulations, demanding coding quality assurance, privacy protection, identity fraud, or pay-for-performance “programs” which would overwhelm entire QA departments at Lockheed-Martin or Raytheon, but which you are expected to implement, by yourself, for free, in your spare time.
It is the countless hats you wear every day: employer; small business owner; conflict resolution manager; IT consultant; accountant; complaint department clerk; therapist; social worker.
It is the garrulous patient who talks endlessly but never answers your questions, while you run ninety minutes behind schedule; the sullen patient who refuses to fill out your history form or answer your questions, demanding you “get that information from my other doctors”; the demented patient from the nursing home with no records, accompanied by an aide who knows nothing about her or why she is here; the angry patient who blames you for their disease, refuses to follow your advice, and who is certain that you are only seeing his sorry ass to make a buck off him; the uninsured patient who needs major surgery or expensive medications but has no way to afford it.
It is the patient in intractable severe pain, incurable by every means modern medicine has to offer, who sits weeping before you, her shriveled life constricted to never leaving her home or getting out of bed, who begs you for answers you do not have. It is the insurance company who refuses her next treatment because it does not meet their “treatment guidelines.” It is the state regulators who harass and threaten you as you manage her severe pain with carefully-managed, medically appropriate chronic opiates while they perceive you as an addict-enabling criminal.
It is the perfectly-performed surgery with a disastrous outcome; the excellent outcome that leaves a bitter patient because it did not meet their wildly-unrealistic expectations — which you told them it would not and could not meet; the out-of-town and out-of-touch daughter who demands everything be done for her dying father’s terminal cancer to assuage her guilt, hating you almost as much as she hated him.
Add to these the seemingly-daily debacles the freakonomics of health care in the new millennium: overhead costs spiraling at multiples of the inflation rate, as income dives inversely; ever larger numbers of legitimate treatments and services denied or criminally underpaid by government and the insurance industry cartel; the ludicrous notion that you can somehow provide the highest quality (or even barely adequate) care while being reimbursed substantially less than the costs to provide it; the horrifying freak show in Washington where corrupt and prevaricating politicians shamelessly conspire to destroy a noble profession and an extraordinary health care system to line their own pockets and acquire perpetual power and control.
And then there are the lawyers — aah, the lawyers.
I spent the better part of twenty years in the practice of medicine avoiding their clutches. I came to believe that careful, conscientiously-practiced professionalism, a willingness to spend substantially more time than my peers teaching and communicating with my patients, constantly striving to treat them with dignity, kindness, and respect, would prove a bulwark against the woes my professional peers suffered at the hands of an out-of-control legal system.
What a fool.
My first two malpractice suits came within a year of one another, now over ten years ago. Both were frivolous, and were tossed out of the courts for lack of evidence — after tens of thousands of dollars were spent on their defense. Both, incidentally, were triggered in large part by inappropriate comments by another physician (anyone who thinks physicians cover up for their peers is badly misguided — we are an arrogant lot, shooting our wounded and eating our children). During this same period, several other suits were threatened but never filed. Small comfort, indeed.
It is difficult to express the personal devastation afforded when accused in a medical malpractice lawsuit. It is an existential crisis, cutting to the heart of who you are as a professional, challenging motive, integrity, and competence. Anger, betrayal, self-doubt, fear, and sleeplessness become your daily bread. Every patient becomes a future litigant. An invisible attorney sits in the examining room on every visit, condemning and second-guessing your every decision and action, as you wildly check off every test and x-ray you can imagine to defend yourself against his future judgment: “Doctor, could you explain to the jury why you did not order this study, which could have diagnosed her disease before it became so advanced?” Check. “Doctor, could you read page 1235 of this medical reference — which you stated you have in your office — which points out how all patients with this disorder should be evaluated thus?” Check. “Doctor, isn’t it true that you dismissed his complaints as nothing to worry about, when in fact his cancer was eating away at him and you ignored its warning signs?” Check.
My current litigation, scheduled to come to trial this June after nearly three years in process, of course cannot be discussed here; perhaps I will discourse on the lessons learned therein — for they are legion – when it is resolved, one way or the other. Suffice it to say for now that it involves a child, and that the damages sought exceed the limits of my malpractice coverage by multiples of seven figures.
Sleep well, Doctor.
In truth, why would anyone choose to go into this profession today? Why would any sane man continue to practice medicine in this environment? Why, indeed, do I continue in this insanity?
As a man of faith, a Christian physician, the answers to these questions are far from simple. They cut to the very heart of free will in the service of God and man; of matters of purpose in life and submission in faith; of trust and obligation, gratitude and motives, prayer and practice. The high-sounding principles of pew and pulpit are now tested in the fiery crucible of life, and you discover that lofty ideals and strong convictions alone are insufficient ground on which to stand. The dark night of the soul strips away your props and annihilates all your pretensions; will there be anything left but ashes when the flames have died out?
Time will tell, I suppose, whether I stand on rock or sand.
May God be with me. May God be with us all.