March 28, 2023

As the world and my life continue to transition from pandemic to post-pandemic (or at least to Covid is no longer one of the top things on everyone’s mind times), I figure I’m going through one of those times of transition we all get to at some point. The old patterns and models don’t work. The new ones aren’t yet clear. Yet. we all must continue to live and work day to day without benefit of a proper map or compass which will spell out exactly what’s coming or how it will affect us. It would be a whole lot easier if I could knew what was coming for health care so that I could make some reasonable choices going into the next (and possibly the last) phase of my career. But we don’t get to know these things. We simply make leaps of faith and hope we land , if not where we were aiming, at least somewhere safe and stable.

I have two major professional responsibilities, the ambulatory outpatient geriatrics clinic at UAB and the rural piece of the house call program at the Birmingham VA. There’s some other minor things but that’s the vast majority of what I do during my work days. Both programs are beset with issues that are common throughout US healthcare and which are hardly unique to the institutions with which I work. And all of it has been made far worse by the effects of three years of pandemic. They include a lack of money in the system directed toward preventive and primary care, a system that tilts towards procedure dominated specialties, a severe shortage of qualified individuals for clinical positions, a rapid aging of the population, and a change of expectations of what healthcare should be and should provide on the part of the aging baby boom.

I’ve thought about walking away as a significant number of the generation older than I in health care has done over the last few years. But that’s not really my style. I want to be sure that the programs I have given my time and energy to over the last quarter century are capable of surviving my departure and continuing to thrive under a new generation and I don’t see that as happening quite yet. The problems are macro-socioeconomic forces far beyond my ability or even the ability of a single institution to change in any significant way. So I keep going to work day after day hoping that I will, at some point, see the sign posts that will tell me which way to go. They may already be there, but just disguised enough that I haven’t been able to see them clearly. I can be a bit dense sometime.

I believe that my way of practicing medicine, built around a team approach, a deep understanding of patients as people, and treatment of disease within the context of each individual’s life and circumstance creates the kind of care most people are looking for from the health care system. However, it’s not the kind of care that a system that becomes increasingly corporatized and systemized around computer driven treatment algorithms can sustain. And being caught between the push and pull of those two opposing forces can get quite wearisome. The system will continue to evolve, as it has rapidly under the influence of the pandemic and its changes to society. And how it will evolve will depend entirely on where the money flows. If there is money to be made in better patient care, the system will reward that. If the money is made by catering to the big data tendencies of health systems, government entities and insurance companies, that’s what will determine what happens next. I think we all know which side is currently in ascendancy. Will it remain that way? It’s hard to say.

The Baby Boom, through force of numbers, has long held sway over US social priorities. They still consider themselves young, despite the lead edge turning 77 this year. There hasn’t been any sort of wholesale grappling of the boom with the needs of aging. It’s coming. No generation remains forever young. And it will all happen within the next twenty five years or so because the boom will cease to be a social force by 2050. There simply won’t be enough of them left after that point. 40% of the boom will die in the 2030s and another 40% in the 2040s. I can’t imagine they’ll pass through the American healthcare system as they age, decline, and die off without leaving some sort of significant imprint but I have no idea what it’s going to be. Will it be towards a more personalized care or will it be towards a more technological standardized care? Will it be some new model that hasn’t yet really taken hold?

The transitions apply to my writing life as well. The last volume of The Accidental Plague Diaries should be out this summer, covering the age of omicron. I have no idea what to write next. Do I have another book in me? Do I have the energy and will to complete something significant without a world wide pandemic spurring me on? Thinking about writing thousands of words on a single subject and nurturing it through the publishing process simply seems like way to daunting a task to contemplate at the moment.

The one part of my life that seems immune to worrying about transitions is performing. There will be another symphony season. There will be another opera season. There will be more plays that require the old guy. The biggest issue there is the precarious funding for performing arts. The changes the pandemic has wrought has left most non-profit performing organizations in tight times. Theater and music companies continue to close their doors as they can no longer afford the expenses of production or because they are being priced out of available space. I’ve lived through a number of boom and bust cycles in performing arts over the years. Companies will go under but creatives have to create and there will be new companies forming in church basements or civic halls. They’ll start out small and the offerings may be of lesser polish but a new generation will get trained up and grow. It’s always been like that and always will be.

Perhaps it’s time to go back to Voltaire. Work hard without regret for yesterday or hope for tomorrow and make our garden grow.

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