February 8, 2023

I’m having one of those periods where I’m feeling disconnected. I assume I’m not alone in having those. It’s as if I were almost an observer in my own life. There’s nothing particularly wrong but I’m still just sort of going through the motions, almost as if it were someone else’s existence while the part that I feel is most truly me sits curled up in a corner of my brain just watching it all unfold. I’ve always felt like the person looking in through the window at the party rather than the person who’s in the middle of the dance. It might explain why I love Sondheim so much; most of his art revolves around outsider characters who never quite belong and that ends up being their tragic flaw and source of dramatic conflict. It may also explain my affinity for ‘Cabaret’ – the whole ‘I am a camera’ thing that infuses Christopher Isherwood’s original Berlin Stories.

I don’t feel bad or depressed when I get like this. I’ve had true depression before, fortunately not for quite some time. When I have it, it’s a true physical feeling and it takes all the energy I can muster to get out of bed and meet my obligations. I’m feeling normal, other than the post inflammatory reactive airway cough that continues after my nasty respiratory virus of last month. I’m getting up and greeting the day in my usual way – which is often accompanied by a few curses and a couple of raps on the snooze bar. I am not a morning person. But as I spend my time with patients and in rehearsal and coping with all of the usual vicissitudes of life, nothing is feeling quite real, as if I’m marking time, waiting for something new to begin.

Perhaps this is my next phase of post-pandemic recovery. I went through the exhaustion and sleeping too much phase and now I’m in the detached and protect myself from the craziness phase. My life isn’t particularly crazy at the moment but I can’t say the same about society. Politics seems to be more about self-aggrandizement than improving of society. Education appears to be falling into thousands of little pieces. Economic life continues to descend into late stage vulture capitalism. My own little world of medicine continues to reel from the forces unleashed by Covid and there’s no end in sight.

I read somewhere this week that over the three year period of 2020-2022, coinciding with the pandemic, roughly 115,000 US physicians retired or otherwise left the practice of medicine. The number of active physicians in the country runs just under a million (roughly 940,000 at last count from the statistics I’ve been able to find). That’s 12.2% of the physician work force gone in three years. All is not lost, during that same period, 40,000 new physicians began their careers after graduating from training or through immigration so the net deficit is only about 8%. It’s no wonder that none of us can get an appointment in any sort of timely fashion. The design of the US health system to run lean and mean and pretty much at full capacity without any fat in the system means there’s no elasticity when 8% of the work force suddenly disappears.

Another news article that came to my attention this week reported that fifteen Alabama hospitals are insolvent and in danger of shuttering this year. That’s out of 126 total. That’s a similar 12%. The hospitals in danger are predominantly smaller, rural, and often the economic engines of little downs being one of the few employers offering stable positions and good wages. Alabama is one of the Republican dominated states that has refused to expand Medicaid under the PPACA legislation and, twelve years later, disenfranchised populations will pay the price. They’ll lose local health care and doctors. The wealthy populations of Birmingham, Huntsville and Mobile won’t be inconvenienced. But those poorer folk who have lost their local emergency department will still need care and will have to go somewhere and they’ll start occupying beds in communities where the system still functions leading to more shortages and so it goes.

These existential crises of manpower and economics should be making the C suites of health care companies sit up and take notice. They are, but not necessarily in the way you might think. American health care has drifted away from patient care to care of the quarterly balance sheet. More and more decisions are predicated on the profit motive than on the societal good motive. Health care providers of all stripes are waking up to this basic fact and the cognitive dissonance being created in the wake of the war between their ethical and clinical mission and the corporate rules under which they are forced to live are creating a bit of a moral crisis in the profession. It’s becoming more and more obvious that the flow of funds, which for clinicians boils down to data collection and signing of forms and choosing the correct codes of various stripes is far more important to the powers that be than empathy and active listening or even accurate diagnosing. After all, if you don’t get it right the first time, there can be more tests and more charges. I’m probably being unfair as most of the hospital administrators I know are good people trying to do a good job and they’re probably just as frustrated by what’s happening in their own ways.

Suffice it to say, that I have come full circle in my professional life. My first grown up job, in 1977 at age 15, was as a keypunch operator. (My younger readers will have no idea what a keypunch is – they’ll have to resort to Wikipedia). Basically, I was doing data entry. And now, 45 years later, I find myself again employed as a data entry clerk. And God forbid if I hit the wrong button or choose the wrong code because when I do and the form won’t go through or the note is kicked back because something is outside the computer’s understanding, the nasty grams start arriving in the email to make sure I fix it quickly because the funds must flow.

I’ve made a pact with myself. On the day I retire, I’m taking one of the computer terminals out of the office, carrying it out to the three story glass atrium, and drop kicking it off the top level to shatter on the marble below. There would be something immensely satisfying in seeing all of its electronic guts spread across the floor, winking in the fluorescent light. When I was in college, I came across a great way of stress relief finals week. Head off to the thrift store, buy some real cheap porcelain dinnerware, and heave it off the roof of the dorm into the dumpster. The sound of shattering crockery could bring even the highest levels of anxiety down a notch. I’ve always had to be controlled in the destruction of things as I don’t like making a mess. Neither Tommy nor Steve was that way. If they were in high dudgeon, they would often reach for the nearest object and fling it in a fit of pique without regard to its value or fragility. More than once I had to look at them and say something along the lines of ‘Clean that up. I’m going to bed.’ I’ve got far too many things stuffed into this condo. Maybe I ought to break a few of them. Maybe it’ll get me out of my head and reconnected.

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