By IM Doc, an internal medicine doctor practicing in flyover
Yves had asked me to write something for pledge week and it was my absolute honor to do so. Sites like this one are so rare in our discourse and I feel we should do all we can to maintain them. So please contribute at the Tip Jar!
I have followed this site religiously and daily for more than a decade. I never commented because I am not an expert on much of anything but Internal Medicine, Medical History & Ethics, and Classical History & Languages. CalPERS shenanigans and corporate malfeasance are just not in my wheelhouse. But all through those years, I read the Links and Water Coolers religiously and also the comments.
And what an amazing and rare site this is. Rational discourse between rational actors with respect and admiration for one another. And a fundamental decency when it comes to arguments. I heard Joe Rogan on podcast the other day describe Social Media perfectly. I can attest that he hit it right out of the park – “Twitter and Facebook are nothing more than a mental hospital with the inmates spending all day throwing shit at each other.” Exactly correct. The amount of work to moderate this kind of site and make sure it remains valuable I know is overwhelming and I cannot give Yves and Lambert and Jerri-Lynn and all the others too many kudos for their hard work. So don’t forget to help out via the Tip Jar.
As you can only imagine, the past two years have been incredibly difficult for myself and every health care worker in America. What really bothered me early on was the complete lack of rational discourse and truth-telling that was happening in our media. But I saw both here – and found a place where I could read links and comments and be forced to ponder – often in a manner that was just simply not happening in the medical world. And it just so happened that I am indeed a trained professional in this area and before long I started commenting.
I am not a journalist. Nor an investigative reporter. I am a physician who has done everything I can to strive to do the very best job I could for my patients during this nightmare. I also do everything in my power to be a truth-teller. It is the way I was raised. And what I was seeing on the ground in real life in my world and what was being reported in the news were often completely divergent. More concerning to me was the media and its incessant bathing in histrionics and panic porn. I could see the results of this in the psyche of my patients and felt compelled to do something, anything, about it.
The foundational figure in Internal Medicine is a physician of the early 20th Century by the name of Sir William Osler. One of his seminal works is a piece extolling what he thought was the most important characteristic of any physician – AEQUANIMITAS – which is Equanimity. The ability to stay on an even keel through even the most dire of situations. To be the Rock of Gibraltar for your patients when their world was falling apart. I have spent my life pounding that cardinal concept into the brains of hundreds of students over the years. And what I saw on TV from the likes of all the talking head doctors and our federal health officials was the absolute exact polar opposite.
Sir William Osler. The founder of Internal Medicine. The man who singlehandedly put Johns Hopkins Medicine on the map. One of my foundational heroes in life. I have spent much time the past 18 months on very dark days filling my mind with his exploits, his writing, and what his peers had to say about him. One of the most poignant statements I have found was written by Harvey Cushing MD, the founder of Neurosurgery as a profession in this country. Upon hearing of Sir William’s death, Harvey Cushing wrote the following, paraphrased from the Book of Isaiah -which later became part of Cushing’s masterpiece – Consecatio Medici. I quote:
And that man shall be as a hiding place from the wind, and a covert from the tempest; as rivers of water in a dry place, as the shadow of a rock in a weary land.
That is how Dr. Cushing felt about his mentor Sir William Osler. It also encapsulates how I feel about my mentors of Medicine and how I know they would have responded to this COVID crisis. Nobel Laureates, textbook writers, seminal medical figures of the 20th Century they were – and somehow I know in my heart that they would have been very disappointed in where we are today in Medicine.
A brief story about my very first day of internship all those years ago. My first attending was an Infectious Disease doctor. And my team had just admitted 19 patients the night before. We were slammed. The resident had to go to Morning Report – and the attending looked at me and said “IM Doc will take us to the easy patients first.” And so off we went. In those days, the intern, who had been up all night, stood at the head of the bed with the attending on his immediate left. No notes allowed. The full presentation came from memory. This first patient was a middle aged VietNam veteran with chest pain. I presented the patient in complete detail. The Infectious Disease attending looked at me – “IM Doc, please tell me how the diagnosis of meliodosis would fit in this patient.” “Ummm Sir – I never considered meliodosis in this patient. I am not really sure what that is.” And he looked at the patient and announced – “I sincerely apologize for the complete incompetence from this intern today. Believe me, we will get this straightened out – and he and I will be back later today.”
My very first patient as an intern. I just wanted to go back to the farm. But this attending did not give up. He taught me to be tough under pressure. To be confident and most importantly to tell the truth and admit what you do and do not know. It was intense. It was a trial by fire and it was a frat hazing. But treatment from him and similar treatment all year round during that year made me who I am today. And he and I became fast friends all the rest of the days of his life. He was a mentor in every way to me.
We do not expose medical students to that kind of intensity today. Not even close. Anyone doing that would instantly be branded an evildoer and ridden out of town. But that is the way it has been done for generations – and I fear something has been lost.
And I see the results of this every day in my life now. We were just a generation ago taught to be fierce and independent thinkers. To question everything. To realize that answers were a quest and authority was often the wrong place to look for help. We took the scientific method and applied it to each and every patient decision. We were taught to be comprehensive and unyielding in our advocacy for our patients and their very best outcome. We were taught that our patients were to be treated always with the utmost in care and ethical behavior.
Somehow, my profession has lost its way. We have handed over our autonomy to corporations and hedge funds. We have completely fragmented the care our patients receive. There is often no one “in charge”. We acquiesce like sheep to all kinds of suggestions from our betters no matter how imbecile they are. Doctors come and go from practices as if staying longer than two years was a mortal sin. The vast majority of us are now employees and are completely powerless to effect change no matter how important.
Many are now talking about moral injury among Health Care Workers, and this could not be more true. I hear constantly, and I mean constantly, my colleagues all around the country decrying how this whole COVID situation has gone down. But yet they are up to their eyeballs in debt – either from school loans or their million dollar homes – and can simply not afford to question or make waves. I am absolutely certain a reckoning for my profession is on the way, and it cannot came soon enough.
I however do not feel all that trapped. Because of sites and sources like Naked Capitalism, I long ago realized that personal debt was one of the big sins of the American way. I long ago realized that our current neoliberal and corporate culture was almost in every way driven by motives that were the exact antithesis to ethical behavior. And I planned my life accordingly.
I am in a position where I can speak out, even anonymously, and I have felt morally obligated to do so. I have felt the absolute compulsion to speak for those in medicine like my mentors who have already gone on. And I will be eternally grateful for Yves and Lambert for allowing me to speak freely. There were times this year I was reporting to them things that were completely in a different universe than what the CDC was saying. Even I was beginning to question my sanity. But they never wrote it off. They doubled down on getting accurate information out there. And I can tell you as a member of the COVID brain trust – just how much crazy they sift through every day. They have my undying respect.
Mrs. IM Doc has been very concerned about me lately. I have aged years in just the past 18 months. This entire thing has taken a huge personal toll on me and indeed all of my colleagues. I now understand the mental and spiritual toll that questioning the dictates of authority can cause. I saw this in my attendings during the AIDS crisis – and now it is my turn. Their one overarching lesson – is to not stray from the truth – and when you are wrong immediately admit it.
As is happening all over the country, in my community, two primary care physicians have announced their very early retirements in just the past few weeks. Their thousands of patients will now have to be cared for. There is just simply not enough capacity anymore. I know from talking to others that similar issues are occurring everywhere. This problem has been building for years in my profession. It has taken a crisis to bring it to the fore. I am very concerned about our immediate future.
One thing is for certain – we are not going to hear the true extent of our culture’s problems in medicine from our media and its blind loyalty to Big Pharma, Big Hospital, and Big Insurance. It is going to take sites like Naked Capitalism to fill the gap – and I urge everyone to support this site in any way possible. If you can give, give generously, the Tip Jar tells you how.
You can also contribute by telling your friends and family about Naked Capitalism, sharing posts and comments, and making comments of your own.
And speaking of commenters, my deepest gratitude for all the commenters who have put up with me and corrected me and told me when I am full of crap. The best commenters in the universe.