Delay. Deny. Depose. Being Surprised and Somehow Not Surprised.
Photo by Usman Yousaf on Unsplash
Ugh. Who wants to talk about this? But it's important, so here we go.
The detail about the message left in the words etched on the bullet casings from the killing of the United Healthcare CEO is what most surprised me, and since I started writing this piece Monday, it’s painfully clear that detail caught the attention of a lot of people. The release of preliminary information since the arrest of the suspected shooter is piecing together a motive for a murder that appears to have been an assassination. When I heard about UnitedHealthcare CEO Brian Thompson’s death, I was simultaneously surprised and not surprised. I want to talk about the not surprised part and ask you and all doctors to consider your not-surprised experience, but before I do that, I want to acknowledge how horrendous and misguided it is to make the human being Brian Thompson the carrier or personification of toxicity that belongs to a much larger phenomenon, especially since all of us have a hand in creating and perpetuating that larger reality.
The surprised part (to say it and move on) has to do first with the enactment itself—which appears to be a material and violent expression of roiling discontent about the healthcare industry and, potentially, the economic challenges of life in the US; second, with the targeting of UnitedHealthcare versus other healthcare industry giants; and third, how it’s possible to imagine a long list of individuals and organisations that could have a motive for a crime like this, including physicians. This leads to the not-surprised part, which is keenly aware of how dysfunctional and seemingly monolithic the healthcare industry is and how profoundly this impacts individual patients, families, and practitioners. Doctors may be more secure about the financial rewards of practice in the era of industrial healthcare because so-called “downstream revenue” can be captured to bolster physician salaries, but this has come at great expense to the intelligence and soul of practice: things money can’t buy.
During the last ten years I’ve sought to define and help resuscitate what is beautiful and essential in medicine. I founded Metamorphosis Medicine to create and curate more resources for physicians to choose to practice medicine in personally sustainable, ethical ways. I also created The Seed House as a pilot project, a multidisciplinary wellness centre designed to support the wellbeing of providers of care in the ways we intend to support the wellbeing of others. The number one complaint virtually every doctor has about practice is dealing with insurance. Even so, many people who hit a wall in clinical practice bail out to employment by the primary architects of the transactional healthcare industry. Corporate healthcare has little in common with relational, archetypal Medicine. We swallow terms of practice that are misaligned with our original dreams and intentions, accrue moral compromise in order to safeguard our employment, and then we write off the moral residue as being the unavoidable consequence of being “mature” or “realistic.” We admire and seek to emulate colleagues who make that disavowal of self look effortless. We have even sacrificed the freedom to express our professional opinions, concerns, and experiences because they are regarded by corporate employers as insubordination that can mark us as “difficult” and unemployable.
There have always been secrets in medicine, significantly because of our covenant to hold our patients’ information in confidence but also because of conflict about how to maintain accountability for physician performance within the profession. Perhaps some of these habits of secrecy inadvertently pave the way for buckling under pressure to remain silent about institutional requirements that lead to moral distress. We also, as a group, are inclined toward making sacrifices in order to serve a greater good, and the survival of medicine itself may seem bound to the healthcare industry. Not letting our personal interests contaminate our service to patients has been a core issue in the healing arts for as long as there have been healing arts. It demands real strength of character.
The healthcare industry uses physicians and all medical practitioners. Physicians are corporate healthcare assets that are occasionally propped up as symbolic leaders and the “face” of the industry. The truth is that while we uniquely hold personal accountability for care delivered that the healthcare system administrators do not, physicians have ever-diminishing authority over the care we provide. The irony of working in a system ostensibly built around the service we provide and and whose reputation depends on physicians’ and other clinicians’ integrity in which physicians feel increasingly invisible and powerless to effect change is not lost on us. Patients count on physicians to be uncompromised in our medical opinion and recommendations. We know the entire project depends on trust.
The reason why it’s important to attend to the not surprised response in ourselves and in the public to the murder of a healthcare industry executive is because it tells us how deep and pervasive the sense is that something is terribly wrong with healthcare. The not surprised is a dystopian wake-up call. When we fail to consciously address individually and collectively things that are egregious, rage and discontent can rupture the veil of rational control in ways that are chaotic and destructive. Put another way, early symptoms when ignored worsen until they cannot be ignored. Making change is hard, especially when it entails personal risk. High-achieving, personally accountable doctors almost always internalise feelings of anger and discontent even while seeming to blame the system and the medical profession. The net result is a kind of paralysis, which I can say from personal experience doubles down on the other feelings of shame, failure, and disappointment. This makes a toxic, self-perpetuating cycle of being simultaneously complicit and outraged. I 100% believe that it’s possible to make change, beginning right now, at a personal level, starting with micro changes that do not have to upset an entire way of living. I also know how difficult it can be to discern those courses of action and trust their validity or to find constructive conversation about them. Asking what else is possible can seem like opening Pandora’s box. It’s a damn shame and a form of personal violence to disavow our dream and calling, and it shutters down a magnificent source of energy for the work of doctoring. If we fail to honour our own path, so eventually will everyone else.
Now for upcoming changes. Last month I started the process of establishing Metamorphosis Medicine as a nonprofit organisation. I've also been working on securing CME credit for intensives and other activities--still a work in progress. Contact me if you would like help remembering your dream and outlining actionable steps to increasing alignment between that intention and your day-to-day work. I promise you there are a zillion ways to realise this. Being a doctor should not make us sick or sick at heart. Something else new is that I will be moving my writing to a platform I'm calling Close to the Bone to tell a more personal and Jung-inflected story about my journey, drawing connections between aspiration, practice, and analysis. Another email is forthcoming about that shift in the next few days. If you would like to be sure you don't miss an installment of Close to the Bone or would like to have it sent to a different email address than this one, let me know by replying to this email.
Being stretched too thin to think about the implications of this crime or the reactions to it or feeling hopeless about prospects for improving the terms of practice are symptoms that the soul needs help confronting formidable challenges, not signs of weakness or personal failure. As painful or frightening as it can be to register the deeper structures of meaning underlying Brian Thompson’s murder and the spectrum of responses to it, authenticity and healing lie on just the other side of turning to face the distress. It may not be easy, but it is worthy. My goal as a physician, whether in the operating room or through work like this, is to live as vivid and generous a life as possible and to help others do the same.
