Yesterday was the perfect storm.

The combination of articles printed over the weeks seem to give me a morose outlook on the medical profession.

Article 1: A specialist had reasoned the medical world was in shambles because “specialist” try to rule the world with unnecessary obscurity. His example was acid reflux and how addressing it was a failure in delivering simple remedies. My throat was bitter with betrayal.

Article 2: An insurance company threatened to set an example with a new policy to deny payments for ER visits if a visit was deemed unnecessary as “a primary doctor could have addressed the problem.” Patients with no primary care due to fluctuation in coverage or patients with complex issues without a readied system to address them laid possible victims of idealistic visions of seamless arrangements. The failure was invariably placed on doctors.

Article 3: Another insurer gamed the system as an “advantage program” by mandating the listing of comorbids it then uses to bolster the capitated fee and thus reflect “savings” when said patients are doing well. Profits are had but not by patients. Efforts to relay medical complexity for the sake of fiscal analysis.

Day after day, article after article.

The combination of such headlines spells distrust and the demotion of doctors as leaders. It becomes all rhetoric to negate the physician-patient relationship and physician motive and value.

Doctors are in the way. They are muddying the new world order. I stand ready as a proponent of careful, compassionate care in the middle of a noisy street. I feel tired each day to execute the needed measures and still deliver the thoughtful, heartfelt elements. I rally the profession to be intelligent, diligent, and tender.

Insurance companies make money each year without fail. Doctors are in the way of this prime directive. It seems clear who wins. Insurance companies raise copays, deductibles, premiums and decrease reimbursements to physicians and deny coverage if they deem care “not needed” or “wrongfully delivered in an ER.” It seems clear who wins. Doesn’t it?

Then CMS holds a meeting and measures millions of data points and claims, “It’s working!” They claim they are succeeding in delivering care with financial responsibility. They are balancing the budget, and all they need is more control and fewer doctors running rogue. The doctors detached from the trenches agree that all is well.
I feel I am in the way of a boulder coming. My sentiments are not only not important, but they are also misconstrued. I am in the way, and I must, therefore, not want millions to have health care. There will be no validation of the romance of medicine nor the valor of doctoring. There is no algorithm for it, and the boulder is coming. I am made to feel like a silly child coming to the meeting to talk of loving humankind.

So, I go to bed very broken, very sad about my purpose and worth. My entire life working to become a doctor relegates to zero effect with zero distinguishing attributes. I think I should quit medicine and find that thing that is hard to do that saves people and champions life and owns authority bought with hard work and intelligence and nobility. I wonder what profession does that in the new world order.

“It was hard to study through the night year after year,” I recall only faintly because I am being conditioned to inflate my journey.

The next day, I feel exhausted to go to do the work of hoping for nothing exceptional. I wonder what dogma to espouse today that will be fiscal. Medicine in America has no room for the kind of craft and glory I thought defined hope in humanity. It is becoming a factory for widgets, and I am now not a person with experience, judgement or intelligence. I am a drone and replaceable by a model made makeshift another way.

Doctors are in the way.

I don’t look at my office list ahead of time, and one by one they come and very quickly I realize what they are. These patients are all the byproduct of careful negotiations and crafting. One after another, they defy the rules of biology and fall off the margins of algorithms. They are the 40 percent that would have been lost to judgment in a world made orderly by data. One by one, they come in laughing and better. They are the total of over a decade of doctoring under one guideline: Do the right thing.

I forgot how strange Mr. Johnson was coming off dialysis. I forgot how incredible Mrs. Tallessman needed only 1/2 a tablet of a drug twice a week. I forgot how I pushed for Mr. Sands to complete a test that lead to a call the following Monday for a kidney transplant. I absolutely forgot about how Mrs. Edwards almost died three different times until her granddaughter rolled her eyes because that “old woman” is still alive after being given six months to live 10 different times. I forgot about twins for the lady with lupus and discitis with paralysis in the Parkinson’s man who is now walking. I forgot, and I tell each patient how I forgot and that I thank them for being tangible when the intangible thing I am trying to explain cannot be described.

The boulder is coming, and the best we can do is lift it up and over us as we protect our discipline and calling for the good of humanity. We must continue to doctor above algorithms and with the one weapon we have, experience. We must go to do the right thing bar none because one day such sentiments will be what is left to distinguish us from anything, not a doctor.

Doctors are in the way, and thank God we are.

Jean Robey is a nephrologist who blogs at ethosofmedicine.

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