I will speak for myself to say that I completely identified with, and fully agree with, all the sentiments shared by Dr. Klingberg in “A breakup with primary care.” Still, from my own life experiences, and a 30-year career in primary care solo practice, I have been forced to believe that these sentiments are ultimately narcissistic and self-destructive.
Yes, primary care medicine has become thankless, oppressive, cruel, and destructive of our ideals and our persons, in every way she has described it. Yes, I completely agree that the practice of medicine has become a completely absurd existence, and by which I mean absurdity in the manner that the mid-20th century philosopher Albert Camus defined it. As Camus put it in his opening line of The Myth of Sisyphus: “There is but one truly serious philosophical problem, and that is suicide. Judging whether life is or is not worth living amounts to the fundamental question of philosounderphy.”
In this case, we are talking about a form of professional suicide, of ending all the personal suffering and degradation heaped upon we members of a once-proud profession, upon those of us now referred to dismissively in TV drug company commercials as “prescribers” –an even lower insult than the ubiquitous (but still pejorative) word of “provider” to which we all answer now. These slings and arrows are real, and they are soul-destroying.
Professional suicide is one thing, and I will freely admit that should I ever win the lottery, I too will seriously be looking for the exit doors. However, doctors are also opting for real-life, real-death suicide. This is a horrifying epidemic in our profession, and it stems exactly from everything described in Dr. Klingberg’s article. Some doctors kill themselves all at once and are doing so at an alarming rate, and other doctors kill themselves slowly one day at a time with depression, alcohol, and drugs. Some of the latter group are lucky enough to find freedom from this despair in various recovery groups; others slowly drift down into a pit of despair, first taking all their loved ones down with them on a sinking Titanic without enough lifeboats.
So, what then is the answer to life in an absurd world? Why not commit one of these three forms of suicide, the professional, the immediate, or the long and protracted form? Where is the worth and the value of what we do anyway? Why keep this up?
The most corrosive and self-destructive form of resentment is righteous indignation. It is one thing to work through one’s own faults and emotional struggles. But what about when the world actually is wrong, and you really are in the right? How does one put up with such unsolvable injustice without eventually going mad? Even a retreat from the battlefield of medicine will not save us from the bitterness and anger, and even the PTSD, over the abuses we have suffered. We all know a few sad-case friends in our lives can who never shut up about what an ass their ex-partner was while they swill back a third glass of wine and flick through another dating app, and slur out to anyone listening about how “all men/women are just jerks.” You can quit the field, but the field will not quit you unless you can find a way to free yourself from the endless hangover of bitterness.
Stoicism was one of the most popular philosophies of the ancient world from about 300 B.C. to 300 A.D. before Christianity overtook it. Its most famous practitioner was the emperor Marcus Aurelius. Some of its wisest sages were Epictetus, a freed slave, and Seneca, the boyhood tutor to Nero, who ultimately executed him by forced suicide. These men, especially Seneca, lived in an evil world run by evil, cruel, and capricious men who held the absolute power to make them princes one day and execute them the next. It was thus an absurd existence, just as Camus has defined it.
Yet, in Seneca’s On the Shortness of Life, Marcus Aurelius’ Mediations, and in Epictetus’ Discourses, we can see how these men found that the only worthwhile meaning comes from inside oneself and that the persons, places, and things of the outside world only disturb us because it is we ourselves who are at fault for allowing these disturbances, because we have wrongly placed value in things that are beyond our control. And in fact, the only thing that is actually within our control is what resides between our ears and behind our eyes is the value we place on our perceptions — what the Stoic’s called our “reason,” which was the power that the Gods themselves bestowed on humanity which made us special above all the rest of creation.
Stoicism is commonly mischaracterized as simply “grin and bear it” or “suffering in silence” when it is exactly the opposite of that. The Stoics rejected “suffering” entirely, even in the face of imprisonment, torture, or execution. In a nutshell, these temporary circumstances imposed on our mortal coils by the world and by the cruel men in it would not be allowed to either control us or define us. They could torture or kill the body, but they would never be allowed to enslave the mind of the true Stoic practitioner. Our lifespans and our experiences in this world are so limited and finite compared to the infinite universe that these temporary misfortunes should be merely disregarded. The writings and the lives of the Stoics provide us with many examples of how these men faced cruelty, banishment, execution, bereavement, infirmity, old age, and death with aplomb.
So then, what does give meaning to one’s brief lifespan on this earth? Is it the hope that one day after we are finally dead that an almighty judge will finally settle our scores for us and give us our just rewards? Maybe so. Billions on earth find a great deal of comfort in that notion, but unfortunately, no one has yet reported back with scientific confirmation from the other side. But if this is all there is, then what is this exactly? If this is all there is, then existence is absurd, and Camus’ question remains, why not exit now? Or why not at least a professional exit?
Well, maybe you should, but I suggest it not be for the wrong reasons. If you ever intend to gain actual peace from any professional exit, it had better be on your terms and not as the sad victim of an uncaring, unfaithful, and abusive boyfriend.
The world is absurd. And the practice of medicine, especially primary care as it exists today, is a completely absurd profession. But we can survive, and we can thrive, and we can still give some meaning and benefit to the patients that we make our choices to help—because we want to.
We can accept absurdity and even learn to embrace it by changing our provenly false views that we can somehow control and mold the outside world into “the something better” that we feel entitled to — by virtue of our virtue. To the oppressors and the oppressive system we now find ourselves in, we can say “the figo for thee.” We can style ourselves on the Russian Refuseniks, or we can practice “Irish Democracy.” We can make our own daily decisions of how much bullshit we will comply with, how much we will actually only “pretend” to comply with, and how much evil we will secretly subvert and undermine to our own purposes to better serve our patients and ourselves.
We can then draw the line in our own minds, on our own terms — and we can keep the location of that line a secret to ourselves — and then we can choose for ourselves how we will use our time and effort to benefit ourselves and others. Doing that, we empower ourselves to keep pushing our boulders with the inward self-satisfaction of Camus’ Sisyphus. When that inner line is finally and irretrievably crossed, we can exit the professional stage on our own terms with our heads unbowed, as did Camus’ The Stranger.
Well, I don’t have all the answers, only the ones that I have found that worked for me. Try them if you like, or not. But please try something before it’s too late for you and your family, and yes, for your patients too.
Glenn P. Matney is a pediatrician.
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