Prayer

Healing Faith

Dr Bob

cliffsA reader named Katherine recently e-mailed me. She had lost her husband, a man some years older than she, to multiple myeloma and Alzheimer’s disease. She is a Christian, and is struggling to make sense of his death, and the difficult questions of why God allows suffering. She writes, after giving me some details of his life, death, and fine character, and asks:

Why does God allow such terrible illnesses to such a kind person? I know there is really no answer as I know all about Job. The thing I am really afraid is that I prayed for his healing, and it did not happen. When I became a Christian back in the 80’s, the health and prosperity gospel was big at the time, and I guess it really influenced me more than I care to admit as I now know it is false. Even though I know it is false, I have become obsessed that God did not answer my prayer because of not being able to get rid of all the sin in my life (as if this were possible to do). One of the teachings of that movement was that if your prayer for healing went unanswered it was either because of lack of faith or sin in your life. I kept thinking that I don’t always put God first in my life, and that I spent more time reading secular magazines than reading my Bible and listening to more secular music than Christian music. These were my “main” sins, at least in my mind and thinking. Can you shed some light on this for me? I would be very appreciative.

The problem of suffering and evil is an ageless one. It poses a particular challenge for Judaism and Christianity, because of the seemingly insoluble tension between a world filled with suffering and evil, and the belief in a God who is good and all-powerful. Solutions to this dilemma, both adequate and inadequate, abound. It is the desperate hope of the atheist that this logical incompatibility proves beyond question the nonexistence of God. Others, less willing to ditch a Divine order, have concluded that God is good, but impotent; or that God is detached and uncaring, or capricious, or moody, or sadistic — and therefore not good.

It must be said plainly that answers to this paradox are neither simple nor entirely satisfactory. The dilemma as it stands may be solved in a global and satisfactory way — as has been done by both Judaism and Christianity — but invariably the lofty principles seem to break down at the moment when a solution is most needed: in the time of crisis when we ourselves experienced the depths, hopelessness, and irrationality of suffering in our own lives. CS Lewis, whose tightly reasoned treatise The Problem of Pain provides an extraordinarily deep and thorough discussion of this dilemna–later in life nearly repudiates his faith and sound theology after the death of his wife, a process painfully detailed in his diaries, A Grief Observed. It is indeed unsettling to watch Lewis discard all of his carefully reasoned and theological understandings of pain and suffering in the brutal crucible of unbearable pain and loss. Nonetheless, he ultimately comes to terms with the paradox, and undergoes an embracing of this profound dilemma far deeper than the intellectual by means of his own trial of fire.

At the heart of this difficult issue lies the human heart. God undertook a vast and dangerous experiment when creating man: He wanted, not merely another animal — of which there were countless — but an animal capable of something He alone understood: love. He gave this exalted animal vast intellect — but this was not sufficient to engender love. He gave His creation powerful emotions, the capacity for both creation and destruction, which He alone had possessed — but this also was not sufficient. For love — the utter, uninhibited emptying of self for another — required that most dangerous license of all: free will. Having created us thus, designed with the capacity to love, we must of necessity be utterly free to choose — for choice is the very heart, the very essence of love.

It was, by all visible measures, an experiment gone wildly awry. Having given this creature the extraordinary capabilities required to love fully — intellect, emotion, passion, empathy, the ability to feel intense pleasure and pain both physically and spiritually — he set this creature free to love — first of all Himself, and then others of like kind. And the first choice of this masterpiece of creation was the decision to turn away: to replace the intended objects of love with the sterile altar of self. Thus was unleashed the monstrous liability of a truly free creature: the ability to hate, to cause pain, to kill, to destroy.

A world in which God eliminated evil would by necessity be emptied of all mankind.

If we are to be honest, much of the pain and suffering which comprise the evil of the world is due to nothing more than this: that man, having been given the ability to choose, chooses wrongly, and uses the gifts and abilities given for the purpose of love to instead elevate himself at the expense of others, often in ways stunningly malicious and utterly wicked. Look around you, at the world both near and far: pride, selfishness, greed, lust, rage, jealousy — all these things manifest themselves in our lives and those of others, causing great pain and endless suffering. The child abused; the wife abandoned; the drive-by shooting; the greedy CEO who bankrupts the company and rapes the stockholders; the serial killer and the rapist; genocide; wars of conquest; torture; senseless massacres: these are the actions of men and women putting self above others — and each of us does it, to a greater or lesser degree, though we minimize our own roles to justify our own actions. We all wish for a world where God would eliminate evil — but all assume that we ourselves would be the only ones left standing when His judgment is delivered. A world in which God eliminated evil would by necessity be emptied of all mankind.

Yet there also exists those evils which have been called, in days past, somewhat ironically, “acts of God” — those circumstances or events which cause pain and suffering, not directly engendered by human evil. Thus the child is born with a severe birth defect; hurricanes, earthquakes, and tornadoes cause death and destruction; chronic and devastating diseases fall upon those who seemingly deserve a far better fate. It is with this, this seemingly capricious evil, with which we struggle most earnestly, straining to understand, yet to no avail.

Judaism and Christianity both imply that some such evil may be consequential, the result of punishment or predictable consequences for the malfeasance of man. A more robust theology is less accusatory and thereby more coarsely granular — maintaining that such evil has entered the world because of the fall of man. Under such design our divine divorce has corrupted not only behavior, but our very natures, and all of creation. Yet such theology is of little comfort to those who are the objects of such seemingly random evil; we demand to know of God, “Why?” — and in particular, “Why me?” Yet there is no answer forthcoming, and we are left assuming a God either powerless to stop such evil or unwilling to do so.

Yet the problem of a good God, an omnipotent God, and an evil world of His creation is not entirely insoluble. Much lies in our projection of human frailty onto the nature of the Divine, and the impreciseness of our definitions of good and omnipotent. When we say God is good, we tend to mean that God is “nice” — that he would never do anything to cause us pain or suffering. Yet even in our limited experience, we must acknowledge that pain and suffering, while not inherently good, may be a means to goodness. We choose to have surgery or chemotherapy, though painful and debilitating, that our cancer may be cured. The halls of Alcoholics Anonymous are filled with men and women who, having faced both personal and relational destruction, have used their former liabilities as a gateway to a new, more fulfilling life — one which could not have taken place apart from their harrowing journey through alcoholism. To a misbehaving child, the discipline of a loving father is not perceived as good, but such correction is essential for the development of personal integrity, social integration, and responsibility.

Our inability to discern the potential for good in pain and suffering does not by necessity deny its presence; there are many who, when asked, will point to painful, difficult, and unbearable times in life which have brought about profound, often unexpected good in their lives, unforeseeable in the midst of their dark days. There surely is much suffering which defies our capacity to understand, even through we strive with every fiber of our being to find the goodness therein. But the fact that such inexplicable suffering exists, and that answers are often lacking, does not preclude the possibility that God is good, or that such suffering may ultimately lead to something greater and more noble than the pain endured.

We are … not merely imperfect creatures that need improvement: we are rebels that need lay down their arms

In our egocentricity we often neglect to look for the benefit in our suffering which comes not to us, but rather to others. Caring for someone suffering unbearably provides an opportunity to the caretaker to experience selfless love, compassion, tenderness, patience and endurance — character traits sadly lacking in our selfish world, which routinely turns its back on suffering to pursue an untroubled life of self-fulfillment and self-gratification. It is not inherently evil to be called to give beyond our means and ability — as caring for someone suffering always demands — for in the exhaustion and inadequacy thus revealed, we may discover unknown inner strengths, and come to a richer, and more fulfilling dependence on God. We are, as CS Lewis so accurately described, “not merely imperfect creatures that need improvement: we are rebels that need lay down their arms” — and finding how shallow are our reserves of love, compassion, and strength, we may through this brokenness seek to acquire them, humbly, from their Source.

But surely an omnipotent God has the power to stop suffering — is He not either impotent or evil when failing to use such power to remove our suffering? The omnipotence of God, like His goodness, is but dimly perceived. For the power of God is in perfect harmony with the purpose of God, and is thus used to advance these purposes for the greater good. Thus, the good deed of creating man with free will — and thereby capable of love — by its very nature restrains the omnipotence of God to violate that free will. The evil of the world exists in large part, if not wholly, because this free will has been abused. Yet the abuse of free will must be permitted, that the proper use of free will — the laying down of arms, the surrender to the sovereignty of a wholly good God — may take place, freely and unfettered as required by love. God must tolerate the existence of suffering and evil, that all may have the freedom to choose the good — though many will refuse to do so.

Yet he does not merely tolerate the presence of suffering, but provides for its very redemption: that suffering, though itself evil, may ultimately produce good. Thus pain, suffering, death, and evil need not triumph: they may provide the means that some may turn toward the good, or bring forth further good for themselves or others. This is redemption: to buy back that which is destructive, worthless, of no value, evil, and make it worthwhile, valuable, even priceless.

Christianity, throughout its history, has struggled with and largely resolved the problem of pain, within the confines of the mystery of God. Yet Christianity in its many doctrinal eddies has sometimes chosen the wrong path and the wrong answers to this challenge. Such errors generally fall into two broad categories: the concept of suffering as punishment or retribution from God, and the manipulation of God for man’s gratification. The first of these runs counter to the core doctrine of the cross: that God has chosen to provide in Christ a sacrificial lamb — that Christ, through his suffering, may bear the justice of God, so that we may see the mercy of God. Our suffering is not a punishment for sin, as such punishment negates the purpose of the cross. Correction, it may be; discipline, it often is; opportunity, it always is; punishment, it never is.

The countering position — that of God as divine opiate, ever present to kill our pain — is a variant of the faith which has become perniciously widespread, feeding on a culture of ease and self-gratification which creates God in its own image. Thus God becomes a font of wealth, of health, of prosperity, of a trouble-free materialistic lifestyle, a divine vending machine whose coinage is faith. Faith, however, in such a worldview is no longer a profound trust in a God who is beyond understanding and infinitely wise, but becomes instead a means of buying from God all which we demand. Hence, we may be wealthy, if we only have enough faith; we may be healed, if our faith is sufficient; we will not suffer if we will but strengthen and enlarge our faith. Our faith must be prefect, lest our pleas go unheard. The strength of faith matters more than its verity; we charge the gates of heaven with the bludgeon of self-will.

The perniciousness and destructiveness of this perversion of historical Christian faith lies in removing from the hands of God decisions of life and death, health and illness, wholeness and suffering, while burdening us with the hopeless demand that we steel our faith to impossible heights to coerce and manipulate the will of God. That such efforts are typically fruitless seems self-evident: God most surely is capable of healing — and does indeed do so often, even dramatically at times — but most surely does so in accordance with his divine wisdom and will. Should His wisdom dictate that suffering, poverty, brokenness, even death and despair would better serve the purposes of drawing men to Himself, what measure of human obstinacy and recalcitrance will change this will? When such “faith” proves futile, it destroys trust in God, and not infrequently leads to utter loss of belief, a bitter agnosticism born in false expectations and misplaced hope.

We demand of God that which we alone deem to be good, then blame Him when He pursues a greater good beyond our understanding

Hence, we demand of God that which we alone deem to be good, then blame Him when He pursues a greater good beyond our understanding. This is the struggle to which Kathleen is alluding, as she questions the goodness of God in failing to heal her husband, blaming her own “sins” for his untimely demise. To us, such a healing seems only good — in so far as it mitigates our pain and loss, as well as that of those we love — but like the surgeon’s knife, sometimes such pain must not be withheld that evil may be conquered by the good. Were he healed, and restored to full health, would he not then face death on yet another day? Our lives have both purpose and a proper time: we live for that purpose, and we die when that purpose is fulfilled. That those who are left behind cannot grasp that purpose — and appropriately suffer profound pain and loss at this separation — does not negate that purpose nor impede its culmination.

We live in a time when our expectations of health, of prosperity, of a pain-free life are increasingly met in the physical realm, while we progressively become sickly, impoverished, and empty in the realm of the spirit. Despite our longer lives, we live in dread of death; despite our greater health, we obsess about our ills; despite our comfortable lives, we ache from an aimlessness and purposelessness which eats at our souls and deadens our spirits. Though we have at our command the means to kill our pain–to a degree never before seen in the history of the world–yet we have bargained away our peace in pursuit of our pleasure. The problem of pain has never been an easy one; in our day, it has not been solved, but rather worsened, by our delusions of perpetual comfort and expectations of a trouble-free life.

Until we come to terms with suffering, we will not have comfort; until we embrace our pain, peace will never be ours.

Almost Cut My Hair…

Dr Bob

Almost cut my hair,
Happened just the other day.
It was gettin’ kinda long,
Could’ve said it was in my way.

But I didn’t and I wonder why,
I feel like letting my freak flag fly,
And I feel like I owe it to someone…

I’m suffering from whiplash — perhaps I should call one of those attorneys whose ads I see at bus stops and on the back of grocery carts…

In a recent post, I waxed euphoric about a big transition in my professional life, wherein I would move from being a solo practitioner to a hospital group employee, working predominantly in an inpatient capacity, with a much reduced load of office paperwork and business responsibilities, with the expectation of significantly more free time. I was truly excited about these possibilities, and felt great relief at the promise of unloading the crushing burden of paperwork, compliance with endless government regulatory demands, intrusive and abusive audits, and a host of other ugly and unpleasant parasites which suck all the life out of the profession of medicine.

More pay, less work — what’s not to like?

That was yesterday. And this is today: I have decided not to pursue this course — or perhaps, more accurately, this is not the course chosen for me to pursue.

The decision is, in a way, rather shocking, a wrenching change of direction for which I was wholly unprepared, and which is still deeply unsettling. I feel in some ways like the shipwreck sailor, watching a passing ship — recently his only hope of salvation — sail slowly into the distance, as he floats, unseen and unsaved. At yet there is a certainty that this sudden change of course is the correct one — though I’m quite in the dark about what comes next.

So what changed?

Nothing whatsoever about my current situation: private solo practice, as it is now configured, has become an enormous burden in so many ways. It’s ugly — and getting uglier in a hurry.

Much of the non-medical world seems dimly aware, if at all, of the tectonic changes occurring in health care. Patients are beginning to notice that their doctor’s practice name has changed to something like “Big Hospital Medical Associates”, but otherwise see little change: they can still see their doctor, the staff is, by and large, the same familiar faces, no worries, carry on.

Behind the scenes, however, the changes are enormous. As of 2009, 65 percent of established doctors were in hospital-owned practices. That percentage is growing rapidly, as physicians and other providers, such as nurse practitioners, flock to the perceived safety and security of large groups and hospital-owned practice affiliations.

The attraction is undeniable: offloading the burden of burgeoning administrative and regulatory requirements; attractive first year salaries and sign-on bonuses, combined with the promise of more free time and predictable schedules; and the lure of better reimbursement for services due to a large organization’s greater heft in negotiating contracts with insurance companies. It’s easy to overlook the potential downsides when the eye candy is so attractive.

After much happy talk and eagerness from the hospital recruiters and medical administrators, the process of merging my practice with the hospital group moved like continental drift. Months passed with no action; emails and phone calls were answered slowly, if at all. My frustration was enormous, but the delay proved a blessing in disguise.

The bad news trickled in slowly, as I waited, impatiently. A large local hospital group announced layoffs of nearly 400 people, for starters — no administrators or middle managers, of course: only the clerical and support staff that keeps a practice running. A busy surgical practice with an incompetent scheduler could not fire her (her race guaranteed a discrimination lawsuit), so they simply eliminated her position — and now they have no permanent scheduler for a year. Other schedulers were moved offsite, far removed from the physicians and practices whose lives they controlled. A former associate, a true workaholic who routinely saw 50-60 patients a day, had his salary cut because he wasn’t productive enough(!!). Highly-trained support staff were told they could not perform certain procedures because the hospital legal department decided their license did not permit them to perform them — although the procedures themselves were not restricted under their state licensing privileges, and they were far more highly skilled and experienced at these procedures than those “credentialed” to do them.

Big picture insights also came into play:

Hospitals lose $150,000 to $250,000 per year over the first 3 years of employing a physician — owing in part to a slow ramp-up period as physicians establish themselves or transition their practices and adapt to management changes. The losses decrease by approximately 50% after 3 years but do persist thereafter. New primary care physicians (PCPs) contribute nearly $150,000 less to hospitals than their more-established counterparts; among specialists, the difference is $200,000. For hospitals to break even, newly hired PCPs must generate at least 30% more visits, and new specialists 25% more referrals, than they do at the outset.

Chained to the oar, the galley master pounding out the cadence…

After 3 years, hospitals expect to begin making money on employed physicians when they account for the value of all care, tests, and referrals. … Outpatient office practices of employed physicians seldom turn a profit for hospitals.

Interesting — most private outpatient office practices are profitable, although less and less so.

Hospitals are willing to take a loss employing PCPs in order to influence the flow of referrals to specialists who use their facilities. In the 1990s, hospitals usually guaranteed physicians nearly 100% of their previous year’s salary during their transition to hospital employment. This arrangement invariably led to losses, since drops in productivity were coupled with higher overhead expenses and less-effective revenue-cycle management. Today, aggressive hiring of PCPs is returning, in part because hospitals fear physicians’ becoming competitors by aggregating into larger integrated groups that direct referrals and utilization to their own advantage. Hospital-employed PCPs generally direct patients to their own hospitals and specialists affiliated with them. In addition, by employing physicians, hospitals retain maximum flexibility in the market, should health plans change their reimbursement structures to require providers to bear risk and manage population health…

Though hospital employment may offer physicians some protection from system reforms, it comes with more performance management than it once did, and the option of reverting to independent practice later may be far less attractive in the future. Employment choices that physicians make today may not be able to be undone.

The hospitals hope to make up for their physician employment losses by improvements in productivity and “performance management” [read: controlling physicians’ decision-making based not on quality, but on cost]. That these economic “efficiencies” are largely illusory — and will harm patient care — will become evident in time. This scenario played itself out in the early 90’s, when hospitals bought up practices in anticipation of Clinton Care. They proved financially untenable and ultimately imploded, after massive cuts in support staff and physician salaries made continued hospital group affiliation untenable. The enormous economic pressures soon forthcoming through ObamaCare and ACOs (more on these anon) will invariably result in similar scenarios — with far fewer escape hatches for increasingly unhappy physicians. They will be locked down by highly restrictive regulation and “care standards”; locked in by non-compete clauses and the insurmountable hurdles to starting or returning to practice; and locked out completely of the decision-making processes which control their lives and their profession. Expect a tsunami of early retirements and career changes when this is fully implemented.

And in the unlikely event the hospitals succeed economically at this venture, through the will to power, you may be assured that the vultures will soon descend to strip the pink flesh off their bones:

The consolidation wave [hospitals acquiring practices] is raising red flags among some regulators, researchers and health insurers, who warn that bigger health systems can use their leverage to push for higher rates. “We’ve always been concerned about combinations that are being done to increase prices,” said Karen Ignagni, chief executive of America’s Health Insurance Plans.

These factors made for a long and poignant pause in my rush to employment. But the final straw proved to be the realization that my reconstructive infertility specialization, built laboriously over 30 years with much hands-on care and effort, would die on the vine under hospital management. I would lose control over pricing; lose control over my superb supportive employees who are masters at communicating with patients an the many issues involved in these cases; and lose the freedom to provide discounted and charity care when the Spirit leads.

So my “Dear John” letter went out, two weeks ago. My employees were ecstatic at the news, my wife enormously supportive of the decision (she had previously been a major force prompting me to seek the security of hospital employment, and has now done a complete 180), and I have an enormous peace with the decision in my own soul. Perhaps, like Odysseus, I have been tied to the mast, lest the Sirens lure me onto the rocks of disaster.

Of course, the problems of sustaining and surviving in the hostile environment we now inhabit in health care remains; thus it becomes now a journey of faith.

Ah, faith: not the blind confidence in the unbelievable, but trust in the eminently Trustworthy, without the clarity of vision one might wish, but with the vision of hope based on experience. He has never let me down; He will not do so now.

It should be a most exciting journey.