February 10, 2022

This is the first evening for weeks when I haven’t had a pile of things to finish before bed. It feels a bit odd. There’s still a lot on the to do list but it’s all optional and non deadline stuff that can wait for the weekend, or next week, or next month so I took a little time for myself and did some reading, watched the video of the recent 9 to 5 so I could finally tell what some of the scenes were actually about, and ate a few more jelly beans than I probably should of. (I’m going to put those fifteen pounds back on if I don’t watch it…) It’s very hard for me to do nothing and relax. I think it’s the medical training. One of my colleagues wrote an essay on this recently which I posted as I found it quite profound. Physicians have enormous expectations placed on them by their patients, their peers, their systems, and themselves and there is sense of pride instilled early on in the training at the being able to power through, no matter the challenges, the sleep deprivation, the physical health, or the emotional state.

We all went into the pandemic with an adrenaline charge and with that sort of thinking imbued in us for our entire professional careers and it certainly sustained us in those initial uncertain months of lockdowns, unknowns about the disease itself, and need to change pretty much everything about how our jobs operate within weeks. The vision of the vaccine on the horizon sustained us that first year and, when it became available, a mere ten months or so after the first US cases (a medical miracle), we all breathed easier thinking things would improve and wind down. I don’t think any of us had counted on the ugly politicization of health care that rose up in the spring, ensuring the continuation of the pandemic and unsustainable working conditions. Now, two years in, with the politics firmly entrenched, even the waning of the fast and furious omicron crisis evokes no joy in Mudville.

There’s a lot of speculation about how much more the American health care system can weather before it breaks down. I think that’s the wrong question. The American health care system is already broken at this point. We’re just driving the car on a couple of flat tires and hoping that the pistons don’t give way. How is it broken? The selfishness of a certain portion of the American population, putting their need to belong to a certain political ideology ahead of their health, their neighbors’ health, or societal needs, put a system, that was designed to run close to maximum capacity with just in time ordering in order to maximize profits and minimize expenses, into overload and I’m wondering if it can recover. Currently, American health care can’t do its most basic job, which is treat curable disease. Elective surgeries are postponed. Screening tests don’t happen. Getting a new primary care provider is nigh on impossible. Rehab facilities can’t get staff. Nurses are leaving floor and clinic jobs for the astronomical salaries being offered in understaffed Covid units. A friend of mine, who works per diem nursing at a local hospital, worked a weekend shift recently. She walked on to her ward and found one of the patients working as the unit secretary. There was no one else to do the job.

The biggest driver of the breakdown is, like with so many other social movements, the Baby Boom generation. Aging in good health, many of them had been working well into their sixties and early seventies. Covid and its stresses have caused many of them to reevaluate their life priorities and to retire and leave the work force all at once. Retirement of people over age 60 is the biggest driver of the Great Resignation, not government payments. Women leaving due to childcare issues is a distant second contributor. In health care, that means those with the enormous repositories of clinical experience are departing. There is a phenomenon in human learning and intuition. When you work in a field for decades, you become so attuned to the nuances that you just know things. You can’t really explain why you know, but somehow your memory banks are comparing the current situation against decades of prior experiences and the answer is just there. I’ve been finding this happening more and more frequently to me personally over the last decade or so. This is my 38th year in medicine so the data bank is vast but it took me decades to build it.

Losing those senior people as providers and nurses and therapists and pharmacists and all of the other myriad professions that make the American health system go round is going to cause issues for years because it’s going to take years for younger people to amass that sort of knowledge base. Seasoned people don’t just pop out of medical or nursing school. They require years and years of nurturing and exploring and occasional failure. And, this loss of these individuals is just about to collide with the aging Baby Boom turning to the health system for the problems of aging. Their first impulses, given their generational behavior to date, is going to demand that the system fix them so they can keep what they view as their eternal youth. It won’t be possible and the tensions that are going to develop between them and health care are going to rise significantly. No health system is ready for this. They’ve been kicking that particular can down the road for decades and now Covid issues have become all consuming. The lead edge of the boom starts turning 80 in less than four years.

I’ve poured nearly a quarter century, most of my adult career, into making geriatric medicine viable within the UAB system. It will continue to work as long as I carry it, but the teetering system is taking its toll on me as much as it is on the pulmonologists who man the Covid wards. Will I be able to do this for another two years? Another five? If I step down, who steps up? US medical graduates continue to avoid training in geriatrics like the plague. These questions haunt me sometimes at night. And then I remember what I figured out years ago, the world is not saved all at once, but rather one patient at a time. Focus on the work in front of you, not the potential work that is not yet yours. And do the health system a favor. Wash your hands. Get your vaccines. Stay home if you’re sick. Carry a mask with you and put it on when appropriate. It’s not that hard to be part of the solution.

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