Where was this supposed to be, this place where he found himself? Time might tell, but it seemed to be a thing he should know. His not knowing didn't just make him uncomfortable, it amused him. Not funny-ha-ha amusing, but amusing nonetheless. Looking up he saw the sky, blue, clear, cloud,less, like the sky everywhere else. Around him trees, the worn narrow path he found himself on, rocks, grass, dirt. Any where, and here. A deep breath, clean, fresh, cool air. The smell of the woods. He could see his breath... late fall. He had the sense he was late, for what he did not know, but he was late. He was pretty sure it didn't matter.
He had not moved. He realized he had not moved. He was tense, stiff, but not fixed in place. He made his shoulders relax, and took a deep breath. He turned around slowly taking it all in. He knew this place. It was where it all started. He felt a moment's angst: I do not want to live this again. He was suddenly anxious. Very anxious. Pulse quickened. Breathing quickened. He did not know what was next. Another deep breath. A pause. He calmed. Now was not the time to panic. He was not the panicking type.
He took a step forward. He knew it was forward. This time it might be different, but he would need to remember.
And remember he would.
He started running, and he grew confident. He had no idea what was next, but he knew he was smarter, aware, and that he had done this before.
This time, he knew.
Tuesday, February 18, 2020
Tuesday, February 4, 2020
Dead Doctor Walking
Night passed; the day came. He awoke into that haze that narrows your world to what you can touch, giving way slowly to what you can see, and he lay there with a moment’s peace. Soon enough that haze lifted and the wider world intruded, slithering into awareness, bringing its anxieties and fears in a slow moving wave drowning him, the stress rising up within him squeezing his heart, taking his breath away. It was a matter of moments, but he was suddenly seized by the realization life was killing him, and inside he began to cry from the pain. He closed his eyes, rolled into a ball and stuttered a deep breath, slowly releasing it, washing some of the anger and fear away. The alarm softly began is crescendo chime, he reached out and silenced it, wishing it was that easy to silence these emotions that raged within him. He rolled back and stared unseeing at the ceiling, then stretched, hard, quelling the anxiety to the point of lightheadness, relaxed, and found a cat who was acutely annoyed at his having disturbed him. With a deep breath, a sob really, he sat up, stretched lightly, and looked sleepily around for his slippers. The cat had stirred, meowed and was now hugging him in that cat way, tail up, purring, head bopping him gently, as if encouraging him to get up, which he was, to compel him to feed him. He knew quite well that the only reason he was still alive was cowardice, the cats, and his family, probably in that order. Man, how he loves his cats. Or maybe it was love, and intense jealousy of the cats? As every cat owner knows, a cat’s life was the win.
He was nauseous. He tended to be in the mornings, in part nerves, in part medications. It waxed and waned, and would settle. He had taken to skipping breakfast because of this, and by the time he remembered he hadn’t eaten it would be well after noon because of the pace in the urgent care clinic. What happened to him really doesn’t matter. Work consumed him, and it was the poison that would kill him. Make no mistake, he loved his work, and those he worked with. It had taken a lifetime to find himself here. He loved his patients, almost all of them, especially the kids. But he hated the bubble that contained it all. He hated that piercing fear that seized him when a patient raised an eyebrow, or a voice, signaling something he asked or said, something he had done a thousand times before, annoyed this one, though his asking it was why they were there. His fear was not the confrontation, though that was certainly fueling the angst, it was that when they judged him, and they would be asked to judge him, their psychology would be the tool of measure, this moment of customer dissatisfaction, not his medical advice, would be the fault, and the bubble would squeeze him for failing to avoid the annoyance, for creating unhappiness.
This pressure was changing him, from being a good clinician, to being the vending machine, a provider, an awareness that made his colleagues happier for having accepted it. HE need not be there. The customer asked, demanded, directly or through the subtleties of the dance, and his was not to judge the appropriateness, the safety, but to find what they wanted and provide it. He wasn’t to be a clinician, but a provider. The bubble even made it a point to call him that to remind him of his place, and to criticize his lack of wokeness for suggesting he was, in fact, a clinician, not a provider. Maybe that was what they meant by “moral injury” that was literally killing his brethren, the struggle between working all your life to be a strong clinician, to learn how to compassionately and professionally make medical decisions, and only to learn that was not respected, not desired, in fact, it endangered you. In these times he only needed to know what the customer wanted. It was coming to terms with understanding you are a placeholder, the least among you is equal to you, their ignorance was better than your knowledge in these transactions. None of your decades of preparation, your struggle, really matters. The uneducated customer had become superior to your years of education, experience and knowledge, and all that mattered was what that customer wanted. You are not measured by any tool for the quality of your medicine, your ability to weigh the evidence and solutions, picking the most suitable one, but solely on the happiness you gave to customers, your ability not to displease.
This, the bubble was coming to realize, was why you could be replaced by someone with far less qualification and experience, that they would be called your equal, because the medicine doesn’t matter, the cost does. And if you found this offensive, you are not woke. It was the fragility of it all, that a “customer complaint” for not making the customer happy could destroy him, his medicine would not be relevant, and he would be chastised, punished, with no one to defend him, no voice. No one held the accuser accountable, they are the customer, and when profit is the goal, that is the superior role. He failed to create happiness. The bubble made it clear, his was to accept the bullying, both from the customer, who short of shooting him was never wrong (perhaps not even then), and then from the bubble, for making the bully bully him. He wondered, who apologized to him?
It was not at all why he had done this, any of this. He did it to take care of people, and to tell them what they needed to know, give them what they needed, not necessarily what they wanted. He did it to protect people from mythology and snake oil, to make things better for everyone. That was all upside down. He was a provider, a means to profit, not a clinician, a practitioner of medicine. He had to strip all of that away. His job was to be another invisible cog, and stay employed. Every part of his character, integrity, and being, all that had made him an exceptional man and clinician, rebelled this need to ignore all of that to survive. All that he did, from the encounter, the testing, the EHR record typing, to the prescribing, and finally, the piece de resistance, the coding, in minimal time, was all about profit. He was not here to do medicine in the traditional sense, that was just the theater of it all. “Entertain the patient while the body heals itself!”, Voltaire had revealed. The price of survival was decaying all that he was.
Most of his days passed well, he succeeded somehow finding a balance, and he would enjoy those days making a difference for those receptive to learning and understanding he cared about them, hoping to relieve their suffering, even if only a bit. But all it would take is one customer who knew more than he, who wanted what they wanted, for whom it was his duty to provide, and he failed them, despite himself. There was that moment when the abuse was too much, and he, bubble forbid, pushed back against the bullying. He raised his voice. The complaint would be dramatic, histrionic even, and the more so, the more “egregious the allegations”, the more injury upon him. The accuser had met the enemy, head on, and was holding him accountable. Its basis in reality doesn’t matter, there was likely a kernel of truth, but the goal wasn’t to create awareness, it was to damage him, to punish him, and only strong, dramatic, pious re-creation would do. He had committed the ultimate provider crime: he created unhappiness. For that, he could lose everything, and be cast out, the years he had dedicated to being here would become instantly valueless, and his life would be over. He would be formally labeled, “A Maker of Unhappiness”. A provider who created such customer unhappiness was not welcome anywhere. His medical acumen has no power here. He had no value anymore.
That is why so many of us physicians chose to end our lives. That pain, the daily deep seated fear and corrosive anxiety, that abandonment, that powerlessness, that lack of representation, leverage, that having nowhere else to go, that inability to take care of our families, the humiliation, the confusion for it all being wrong… that is the pain that could only end by taking our lives. No one sees this, because everyone averts their eyes when they see the smoke, lest they be next, be tainted by it, be an accessory, or be seen by the bubble as conspirators, and because we are never sure until we are there ourselves, at that last breath. Stay employed. Lose your job, lose your life. Hung by our Golden Handcuffs, literally. This dumbs down the medicine, and they get away with it, it costs the bubble no profit to lose another one, we are fungible. It creates victims, survivors, out of amazing people. As a result, there are fewer and fewer physician clinicians, the gaps filled with providers, but even they are becoming sparse. One day there will be no clinicians left, and maybe no one will notice. But the money in Ferengi Medicine is good, and that is the point of it all.
That’s when the coffee kicked in. He suddenly was aware he had arrived, not quite sure how he got there, walked into the clinic, and felt the warmth of those he worked with, those in HIS bubble within the bubble. They could not protect him, they probably wouldn’t even if they knew his suffering; they had their own issues inside the bubble. His disappearing would meet with a moment’s sadness, a momentary ripple where the finger left the bucket, and then it would be like he was never there. Some words of sadness and regret on his behalf. No injury to the bubble, so it didn’t really happen, it didn’t matter, really. Only the bubble matters. Another day in the machine, another day making someone else’s dream and desires happen on his back with no awareness nor concern of the cost to him, the actual value to the bubble he is. We are just employees, to be bouyed by corporate “vision statements” of inclusion and caring, smiling at the cheerleading as team players, all the while being excluded and ignored. The “successful” had come to terms with this, and were “happier”, but at what cost, to them, to us, to society? At this point, he just wanted to weather another day without a complaint, without scrutiny of his ability to provide happiness, to stay employed. And in that, being a good clinician really didn’t matter, in fact, it was a character flaw. He was becoming a provider, with all its damaged ambiguity, mediocrity, and isolation.
And maybe, today he didn’t kill himself, you know, for his cats.
He was nauseous. He tended to be in the mornings, in part nerves, in part medications. It waxed and waned, and would settle. He had taken to skipping breakfast because of this, and by the time he remembered he hadn’t eaten it would be well after noon because of the pace in the urgent care clinic. What happened to him really doesn’t matter. Work consumed him, and it was the poison that would kill him. Make no mistake, he loved his work, and those he worked with. It had taken a lifetime to find himself here. He loved his patients, almost all of them, especially the kids. But he hated the bubble that contained it all. He hated that piercing fear that seized him when a patient raised an eyebrow, or a voice, signaling something he asked or said, something he had done a thousand times before, annoyed this one, though his asking it was why they were there. His fear was not the confrontation, though that was certainly fueling the angst, it was that when they judged him, and they would be asked to judge him, their psychology would be the tool of measure, this moment of customer dissatisfaction, not his medical advice, would be the fault, and the bubble would squeeze him for failing to avoid the annoyance, for creating unhappiness.
This pressure was changing him, from being a good clinician, to being the vending machine, a provider, an awareness that made his colleagues happier for having accepted it. HE need not be there. The customer asked, demanded, directly or through the subtleties of the dance, and his was not to judge the appropriateness, the safety, but to find what they wanted and provide it. He wasn’t to be a clinician, but a provider. The bubble even made it a point to call him that to remind him of his place, and to criticize his lack of wokeness for suggesting he was, in fact, a clinician, not a provider. Maybe that was what they meant by “moral injury” that was literally killing his brethren, the struggle between working all your life to be a strong clinician, to learn how to compassionately and professionally make medical decisions, and only to learn that was not respected, not desired, in fact, it endangered you. In these times he only needed to know what the customer wanted. It was coming to terms with understanding you are a placeholder, the least among you is equal to you, their ignorance was better than your knowledge in these transactions. None of your decades of preparation, your struggle, really matters. The uneducated customer had become superior to your years of education, experience and knowledge, and all that mattered was what that customer wanted. You are not measured by any tool for the quality of your medicine, your ability to weigh the evidence and solutions, picking the most suitable one, but solely on the happiness you gave to customers, your ability not to displease.
This, the bubble was coming to realize, was why you could be replaced by someone with far less qualification and experience, that they would be called your equal, because the medicine doesn’t matter, the cost does. And if you found this offensive, you are not woke. It was the fragility of it all, that a “customer complaint” for not making the customer happy could destroy him, his medicine would not be relevant, and he would be chastised, punished, with no one to defend him, no voice. No one held the accuser accountable, they are the customer, and when profit is the goal, that is the superior role. He failed to create happiness. The bubble made it clear, his was to accept the bullying, both from the customer, who short of shooting him was never wrong (perhaps not even then), and then from the bubble, for making the bully bully him. He wondered, who apologized to him?
It was not at all why he had done this, any of this. He did it to take care of people, and to tell them what they needed to know, give them what they needed, not necessarily what they wanted. He did it to protect people from mythology and snake oil, to make things better for everyone. That was all upside down. He was a provider, a means to profit, not a clinician, a practitioner of medicine. He had to strip all of that away. His job was to be another invisible cog, and stay employed. Every part of his character, integrity, and being, all that had made him an exceptional man and clinician, rebelled this need to ignore all of that to survive. All that he did, from the encounter, the testing, the EHR record typing, to the prescribing, and finally, the piece de resistance, the coding, in minimal time, was all about profit. He was not here to do medicine in the traditional sense, that was just the theater of it all. “Entertain the patient while the body heals itself!”, Voltaire had revealed. The price of survival was decaying all that he was.
Most of his days passed well, he succeeded somehow finding a balance, and he would enjoy those days making a difference for those receptive to learning and understanding he cared about them, hoping to relieve their suffering, even if only a bit. But all it would take is one customer who knew more than he, who wanted what they wanted, for whom it was his duty to provide, and he failed them, despite himself. There was that moment when the abuse was too much, and he, bubble forbid, pushed back against the bullying. He raised his voice. The complaint would be dramatic, histrionic even, and the more so, the more “egregious the allegations”, the more injury upon him. The accuser had met the enemy, head on, and was holding him accountable. Its basis in reality doesn’t matter, there was likely a kernel of truth, but the goal wasn’t to create awareness, it was to damage him, to punish him, and only strong, dramatic, pious re-creation would do. He had committed the ultimate provider crime: he created unhappiness. For that, he could lose everything, and be cast out, the years he had dedicated to being here would become instantly valueless, and his life would be over. He would be formally labeled, “A Maker of Unhappiness”. A provider who created such customer unhappiness was not welcome anywhere. His medical acumen has no power here. He had no value anymore.
That is why so many of us physicians chose to end our lives. That pain, the daily deep seated fear and corrosive anxiety, that abandonment, that powerlessness, that lack of representation, leverage, that having nowhere else to go, that inability to take care of our families, the humiliation, the confusion for it all being wrong… that is the pain that could only end by taking our lives. No one sees this, because everyone averts their eyes when they see the smoke, lest they be next, be tainted by it, be an accessory, or be seen by the bubble as conspirators, and because we are never sure until we are there ourselves, at that last breath. Stay employed. Lose your job, lose your life. Hung by our Golden Handcuffs, literally. This dumbs down the medicine, and they get away with it, it costs the bubble no profit to lose another one, we are fungible. It creates victims, survivors, out of amazing people. As a result, there are fewer and fewer physician clinicians, the gaps filled with providers, but even they are becoming sparse. One day there will be no clinicians left, and maybe no one will notice. But the money in Ferengi Medicine is good, and that is the point of it all.
That’s when the coffee kicked in. He suddenly was aware he had arrived, not quite sure how he got there, walked into the clinic, and felt the warmth of those he worked with, those in HIS bubble within the bubble. They could not protect him, they probably wouldn’t even if they knew his suffering; they had their own issues inside the bubble. His disappearing would meet with a moment’s sadness, a momentary ripple where the finger left the bucket, and then it would be like he was never there. Some words of sadness and regret on his behalf. No injury to the bubble, so it didn’t really happen, it didn’t matter, really. Only the bubble matters. Another day in the machine, another day making someone else’s dream and desires happen on his back with no awareness nor concern of the cost to him, the actual value to the bubble he is. We are just employees, to be bouyed by corporate “vision statements” of inclusion and caring, smiling at the cheerleading as team players, all the while being excluded and ignored. The “successful” had come to terms with this, and were “happier”, but at what cost, to them, to us, to society? At this point, he just wanted to weather another day without a complaint, without scrutiny of his ability to provide happiness, to stay employed. And in that, being a good clinician really didn’t matter, in fact, it was a character flaw. He was becoming a provider, with all its damaged ambiguity, mediocrity, and isolation.
And maybe, today he didn’t kill himself, you know, for his cats.
Me and Zaphod, Zaphod and me.
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