The Annals of Family Medicine November 2022, 20 (6) 566-567; DOI: https://doi.org/10.1370/afm.2879

“Contemplating retirement after 38 years as a family physician has, for me, been an uncomfortably revealing process. I can’t help but remember the few patient-care regrets that still upset me after all these years, and I find myself wishing I could go back in time; do things differently; conjure up better outcomes. I can’t, of course, but those memories of individual patients eventually led me to consider my entire practice life, the legacy I might leave, and my role in a health care system that has changed so dramatically over the course of my career.Far too late, I have realized that while I was singularly focused on “taking care of patients,” I neglected an even greater responsibility: to advocate for myself and my patients and push back against an endless series of misguided policy decisions that have adversely affected the health and well-being of my patients and made my job so much more difficult and stressful.American health care is experiencing an existential crisis, and I regret that it has happened “on my watch.” By not speaking up as a physician, I enabled others to speak for me, others with far less knowledge, understanding, or commitment to patient care. I regret that most of all.In this article I try to come to grips with why I was mostly silent, and I share what I am trying to do now at the end of my career to effect change and find my voice. Better late than never, I am speaking up for my colleagues and patients. Now, more than ever, I hope that we physicians will insist on being heard

MY ROLE IN HEALTH CARE’S EXISTENTIAL CRISIS

I have been considering retirement for a few years now. After 4 decades as a practicing family physician and some recent orthopedic challenges, the timing finally feels right, but the soul-searching process of becoming retired has been unexpectedly difficult and revealing. So many memories to catalogue, and so many questions to ask: Did I make a difference? Would my mentors be proud? What lessons have I learned? What, if anything, do I regret? I can’t help but revisit the patient-care regrets that stick with me: a diagnosis I should have made sooner, the phone call from a distraught family that I forgot to return, a resuscitation that went poorly. I will have to live with those. I will very much regret not being a doctor anymore, not being there for patients and colleagues, but I think I can eventually accept that, too. Painful as regrets can be, I can take comfort that, over my career, I have acknowledged my regrets as lessons learned and used them for growth. The one exception, to my dismay, is one that I hadn’t considered until recently, here at the end of a long career. It is a lesson that I have learned far too late, and it troubles me to this day.

I now recognize, and lament, that I stood by while, over the last 20 years, the influence of physicians to positively impact the lives of their patients, and their own lives, has been methodically and dramatically eroded. I remain quite proud of my patient-care decision making over the years, but I do not remember deciding that it was a good idea to schedule patient appointments every 10 minutes. I don’t recall having input on a communications system that essentially guaranteed that patients would never be able to speak with their health care professional. When did I agree (during COVID) that it was ever acceptable to deny a wife permission to see her dying husband in the hospital? Did I vote on placing a computer terminal between me and my patients? Every single one of these policies, and countless more like them, have had a demonstrably negative impact on the health and well-being of my patients, and yet they somehow became policy without any substantial pushback from me or, as far as I know, from most of my peers. These erosive and arbitrary policies were allowed to happen on my watch, while I was too busy “taking care of patients.”

Hippocrates believed that a physician should be more than just a fount of knowledge or a skilled technician. He urged physicians to practice medicine with dedication and respect, and advocate on behalf of their patients and community with passion. Now, at career’s end, I worry that I didn’t do enough of those “big-picture” things for my patients: advocating for them, fighting for them, and making sure that our health care policies are designed around their needs. I am remembering the times that I, or my colleagues, would say “I’m too busy to get involved,” or the classic “I just want to take care of patients.” In the spirit of lessons learned I have tried to look back and understand my hesitation to speak up, to engage. As an independent family practitioner, I often felt isolated and “out of the loop.” Later, as an employed physician, it was easy to feel complacent and subordinate. Always, as a hard-working clinician, a “foot soldier,” I saw myself as less businesslike and informed than the policy makers, executives, or middle managers in their suits and ties. I’ve realized now how lazy and wrong those perceptions were, and how much my hesitancy enabled the lazy and wrong decisions of others. When I failed to fully engage on these issues and speak up, when I hesitated to take the lead on advocating for myself and my patients, the nonphysician decision makers felt ever more empowered to fill that void.

And how is that going, abrogating our big-picture responsibilities as physicians? At every level of our health care system the answer is: not so well. In 2021, the United States ranked dead last among the world’s highest income countries in overall health care performance,1 and over 70% of patients polled thought that our health care system had “serious or crisis level” problems.2 Patient satisfaction has declined across all aspects of health care,3 only to be outdone by plummeting physician satisfaction scores. The year 2021 saw the highest percentages ever of physician burnout, depression, and early retirement, and a full 70% of doctors surveyed stated that they would not recommend medicine as a career.4 Perhaps the stresses and uncertainties of COVID have had a recent impact on how the health care system is perceived, but these indicators were already spiraling downward prepandemic. COVID just ripped the band-aid off a nonhealing wound.

So, as I struggle with my own professional legacy, I am confronting the idea that American health care itself may be struggling to find direction; experiencing a collective existential crisis. Adrift together in a sea of stifling bureaucracy, declining trust, and loss of autonomy, patients and physicians harbor a growing suspicion that no one is looking out for them. Who is at the helm? At a time like this, when clearly our love of medicine is being tested, I am confident that Hippocrates would point to physicians as the ones to lead the way. In the 2,000 years since he practiced, the one constant, the soul of medicine, has always been the doctor-patient relationship. No one is better situated to positively impact the welfare of patients than a practicing physician, and no one can address this existential crisis with more passion, trust, and responsibility than a physician who cares for patients. Every “big issue” that ails the health care system is writ small in every physician’s practice, every day.

Fortunately, my slow walk towards retirement has allowed me a second chance to reconsider my big-picture role as a physician. Better late than never, I have tried to raise my voice and advocate for my colleagues and my patients. I have purposefully taken on medical directorships that give me meaningful input on policy decisions that could hinder patient care or make a physician’s job harder. I have started reaching out more to other medical directors, chief medical officers, and fellow physicians to engage (and push back if necessary) on the real-world implications of those misguided policies that harm our patients or burn us out. I am paying far more attention to networking with my colleagues to hear their concerns and to see how they are coping, and I look forward to rejoining some of the professional societies that will help keep me informed. With an intern’s enthusiasm, and the gravitas of a senior physician, I am speaking up more forcefully for my patients and their needs. Finally, I am trying to write about it. Better late than never.

I will always regret that I never pushed back hard enough on the incremental policies that negatively impacted both me and my patients. I am convinced that physician’s voices, if raised, can reverberate throughout an entire health care system, effecting positive change. Our patients’ health, and the health of our profession, may well depend on it.”

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