In the Doldrums

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.

The doldrums.

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.

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11 thoughts on “In the Doldrums

  1. Trust not in thine own understanding Doc…
    I had to give up my doctorate because of chronic pain. So, I often wonder what would’ve happened as I live my life relating to the poor woman whom you described. There is one thing that I am reminded of frequently and often; and that’s Romans 8:28. Even if you don’t happen to see it at the moment He will make it known in time.
    May God’s blessings fall on you like rain and sunshine.

  2. Articulate, passionate, thoughtful, empathy provoking words. Makes me want to send a heartfelt thank you to my Dr. He has seen my through the death of my mother, my husband, a still born baby and my own health issues for the last 20 years. I always knew he cared…
    I am certain you have also been such a blessing in the lives of so many. Thank you for allowing us to view this insight into your profession.

  3. I am sending this to our good physician who, in addition to providing excellent care, also prays for his patients. He will be retiring soon, I fear. We will miss him.

  4. Hi Dr. Bob –

    I just wanted to say that I enjoy your blog.

    I am a nurse and you are one of the few sources I have that lets me sit and think about what we do in a quiet, thoughtful fashion.

    I will pray for you and hope that your lawsuit turns out ok. Even if it does, it won’t make up for the angst you have already been through.

    So often, I wish I could bring people to the hospital and have them follow us throughout the day to get a glimpse of what goes on. People have no idea. Yes, there are horrible doctors (and nurses!) out there – so foul, arrogant, what have you. But then there are those who are amazing in spite of the pressures that exist in a hospital.

    Blessings to you, Dr. Bob.

  5. I am so sorry you have to bear such burdens. Healing is a ministry and to be assailed by the malpractice suits and the heavy insurance demands must be awful. I will pray for you, that God will revive your spirit, and strengthen you, so that you may continue to minister to your patients.

    In our family, the only physicians of ours who have not either left the profession or left town (we live in a place infested by the litigious and the entitled feeling) are mine, who is a devout Christian, and the doctor who delivered our children, who is a devout Jew.

    Our God can bring those whom he loves through anything, and will not give us anything we cannot bear, although (as Mother THeresa famously observed) sometimes one “wishes He didn’t trust me so much…”

  6. This could have come straight from my own pen, right down to the lawsuit. It’s why I have applied to rejoin the Navy, why I’m looking at “medical tourism” sites like Costa Rica, why I’d love to get out of Medicine altogether if I could get out from under my debts. And our patients haven’t the faintest clue what it’s like.

  7. I’m so sorry this is happening to you. Thank you for your service as a doctor.

    I’m reading everything I can find about how doctors are coping. More and more patients are waking up, I think. We watch eagerly for doctors who signal that they’re ready to opt out and try something different — retainer service, no insurance, Costa Rica, whatever may work. Lots of us are looking for alternatives, too. We need each other to make it work.

  8. Dr. Bob…here is the one thing you will learn to be ever grateful: The Lord God is the biggest gambler in all of existence or out…He gambles on Himself and risks it all, gambles that His love will be greater in you than your pain and trial and doledrum.

    Fret not at the removal of all things…they are as
    nothing, and in the final analysis of it, you will discover that you stand on a rock, and not because of your own stuff, or your own acts. To the degree that it is up to you, you are building on sand. But the Lord God knows that it is up to Him, and He only builds on the Rock, and you shall see that and rejoice in deep humble joy, knowing that He contended for you and lives evermore contending yet for you.

    Oh Great God, show Bob that you have lifted him up out of the miry clay and set his feet upon a rock, and put a new song in his heart.

    Show him that sweet surrender to you is the ONLY thing you desire, all else is settled, finished and only waiting to manifest through yielded vessels.

    I would have lost heart, unless I had believed that I would see the goodness of the Lord in the Land of the Living. WAIT in faith on the Lord;
    Be of good courage. And He shall strengthen your heart; wait, I say on the Lord!

    You will indeed rise up over this. And you will know the freedom Solzhenitsyn proclaims of the man who no longer has anything to protect or to lose.

    Your words in the past lifted me up from the pit…and the Lord Himself will lift you from the pit of protection to the sweet serenity and victory of surrender.

  9. Whew! I thought the industry my husband and I own a business in was bad. We keep wondering how much longer we’ll be able to stay one step ahead of the endless regulations and lawyering. You’ll be in my prayers!

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