April 7, 2021

I heard about another physician suicide this morning. It wasn’t someone I had ever met. I knew who he was from some of his postings in a group for gay male physicians. He was quick with a quip, had a nice sense of humor and was posting his usual bad jokes up until the day he died. It made me wonder just what the mental health cost of this past year is really going to be, especially in medicine. UAB gives us a little survey once a month to check up on our mental health. I have no idea what they do with the data they’re collecting, but no one has ever called me concerned from the chairs office so I figure they aren’t overly interested as long as I keep showing up for work routinely and vaguely on time. (I could be a bit earlier in the mornings, but ‘not a morning person’ doesn’t even begin to cover it as anyone who has ever scheduled a 7 AM meeting with me can attest).

I’m not suicidal and am unlikely to ever be. All of the bad that’s happened in my life, both personally and professionally has given me a rather deep well of resilience that I can draw on. I’ve been through the fire, survived and it’s going to take more than a viral pandemic and a societal shut down to really disturb my equanimity. I’m also of an age where I know I’m looking at the end game of my career. I don’t know how much longer I’ll continue working. It’s going to depend on a number of factors that are in constant motion but I don know I have no intention of being in my eighties and tottering around the office older than my geriatric patients. (I’m starting to get a few patients within a few years of me. That’s scary enough).

I am worried about my younger colleagues. They are giving up their 20s and early 30s to the educational treadmill, being forced into significant debt, and emerging into a health system that no longer truly values what a physician is. The corporatization of healthcare and change over into a health industry that has changed its goals from service and social mission to the manufacture of encounters and hospitalizations for the purposes of profit, regarding the physician as just one more cog in the machine. The system recognizes that the physician is necessary – laws dictate that nothing happens in the system without a physician’s order – but not so necessary that he or she cannot be replaced with a less expensive adjunct such as a physician’s assistant or second guessed by sophisticated algorithms contained within information systems. More and more, physicians in their patient advocacy role, are going to be slowly ground down by the implacable demands of the business side of the health care industry.

Covid has exposed a lot of the problems in the system for physicians. During the shut down, when patients did not want to enter health facilities for fear of exposure, falling revenue streams led to cuts in salaries just as they were being asked to step up to the plate and bring their A game to societal needs. The psychic strain on younger physicians caring for deathly ill Covid patients, many young and with whom they could identify, added additional burdens. The current cadre of young physicians is too young to remember the HIV epidemic. I was in the thick of it and sat at the bedside of a lot of young men in the late 80s and early 90s and held their hands as they died as there was no one else who would do it so those of my generation have experiences we can draw on that the younger ones don’t. The acute shortages of staff and the abrupt rise of telemedicine are leading hospitals to experiment with new ways of providing care that don’t necessarily depend on patient and physician in a one on one setting. Better information systems is leading to outsourcing of services to cheaper labor markets as in all other industries.

I had predicted, decades ago, that the late 2020s and early 2030s were going to be rough time for American medicine. This was based on demography and the aging of the baby boom. In 2030 we hit peak age with the older boomers in the early 80s and even the youngest over 65. I had not forseen Covid and its effects on American healthcare which seem to have accelerated the negative trends so that we are in the midst of this transitional time now, a decade ahead of schedule. I can tell it has hit because the demands on me as a clinician by patients and families are accelerating. The high levels of anxiety and depression engendered by the last year are starting to manifest in somatic ways and with people in constant need of reassurance. The paperwork load, with all of the transfer to telephonic and video conference services has doubled. People, now that they are vaccinated, are paying attention to body signals again in heightened ways and developing weird symptoms which need to be evaluated and followed up on. When this is in an older person, there’s always the question of whether something is a normal phenomenon falling within the ever broadening bell curve or an unusual presentation of something which could be disastrous if missed.

One of the reasons I like being a geriatrician is that so much of our work is team based and I don’t always have to rely just on myself to stay on top of everything that could be wrong with my patients. I’m human. I miss things all the time, but with competent nurses and social workers and pharmacists and therapists also looking at the picture, the missing puzzle piece is usually noticed by someone and we can work together to craft a care plan that will ultimately help. When something goes awry, I often second guess myself and wonder what I could have missed or what I should have done differently. When I was in residency and Steve and I were first together, I had a case like that where my patient died and I was kicking myself at home that evening assuming I had blown it in some way. The next day, at work, I opened up my backpack to find a rubber skull in it with a word balloon coming out of its mouth in Steve’s writing saying ‘Dr. Andy, why you kill me?’. That was Steve.

Set load in – Avondale Ampitheater

Quick switch of subjects. Pirates of Penzance has sold out. We had a spacing rehearsal in the ampitheater this evening and the show is going to work well. We are all now nervously watching weather reports as another storm/tornado front is due in the next couple of days. As long as it passes before Saturday at 2 PM we should be OK. We may have to do our dress rehearsals with umbrellas and gum boots. I must say this was one of the easiest parts I’ve ever had to learn as the majority of my lyrics are variations of ‘Tarataratara’ I had those down at the first rehearsal.

Covid numbers are not looking good. We added more than 450,000 new cases last week in the US and the British variant has become dominant. It takes roughly six weeks between your first jab and maximal immunity setting in so all of the people who have been vaccinated in the last month are still somewhat susceptible and those begining their series now won’t be good to go until June. Therefore, it remains imperative to keep up all those good habits. Wear your mask, wash your hands, keep your distance, even if you’ve had your vaccine.

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