I have often spoken of the doctor-patient relationship as a covenant. Our patients bear their bodies and souls in exchange for a thoughtful, engaged, respectful partner in navigating health and disease. This dyad, this trusted space, allows for the breaking of cultural norms and full disclosure. Proper healing is an agreement, it is a relationship.
Although often not spoken of, any successful flourishing health care system also requires another sort of covenant: one between provider and society. Let me explain.
Being a physician has changed me. For someone who naively went into this profession hoping to help people, the reality is much more nuanced and difficult. I make decisions hourly, daily, that have a profound affects on people’s lives. As a mentor once told me, each successful physician has a graveyard full of patients with their name on it. While I am not that cynical, I have no doubt that even with the best of knowledge and skill (and following medical guidelines and standards to the fullest), people have died by my hand. I am not proud of this. The thought keeps me up at night and wakes me early in the morning. It literally turns my insides.
I have to live with this. Day in and day out, my decisions, treatments, or lack thereof may have immediate and devastating consequences. There is no other profession with such a dyer moment to moment routine. Policeman and fireman spend just brief seconds of their career making such split second decisions. Judges, lawyers, politicians, even air traffic controllers rarely deal with these imminent vagaries.
This stress, this fear, breaks us. It can turn the unlucky into a cold shell of a person, a far cry from who they used to be. Those who are introspective enough to recognize PTSD can, with the right struggle and support, learn to once again become effective, emotional human beings.
Being a physician takes it’s toll. Not just on our psyches, but on our relationships, on our children. In many specialties the ring of the phone is incessant. Government regulations have become so strict that every time a patient scratches themselves, a physician gets a phone call. Birthdays, anniversaries, vacations, and graduations have all been interrupted. And what is one to say to the poor patient or family. Sorry I couldn’t answer the phone to help your poor dying husband, I was at a birthday party?
The hours are difficult. The work is arduous. And many more battles are lost than won.
But there is a silver lining, a saving grace. Along with the above outlined struggles comes something, that for many of us, makes it worthwhile. Many of us will gladly exchange the heartache and pain for what we believed was our due when we went into medical school.
Respect. We expected that society at large would understand the sacrifice of being a physician. The hours, the culpability, the stress. That instead of pointing a finger at us, blaming us for the financial downfall of our system, or beckoning us to defend ourselves in court, a hand of solidarity would be extended much as we try to do for our patients.
Compensation. The idea was that a physician would be provided for commensurate with the amount of hours and difficulty of the work. This work, a calling, should garner enough income to keep the lights and heat on.
Meaning. When governmental regulation and intrusion becomes primary, we have lost our way as a society. Physicians derive meaning from taking care of patients, trying to heal, and comforting. The flurry of paperwork, meaningful use drivel, and insurance hurdles leave no time for the best part of our job.
This is the covenant I speak of between physician and society. Physicians will do arguably one of the most difficult jobs in the world in exchange for respect, reasonable compensation, and the freedom to use their skill in meaningful ways.
Dr. Aaron Carroll believes that some physicians are crying wolf.
I believe the Medicare data dump, meaningful use, and the SGR mess are signs that the covenant has been broken. Maybe physicians are not dropping Medicare yet, but they are retiring early. They are choosing specialties outside of primary care. They are emotionally divesting from their lives work and leaving the patient confused and unsupported.
They are turning their pagers and mobile phones off when they leave the clinic, and letting someone else handle the mess.