So much has been said about healthcare reform in America. Much of it is political. Anything as big and complex as our healthcare system is subject to our particular worldviews.
But we’ve been fooled. We’ve been misled about what the crisis in medicine is. We’ve been told it’s poor access to care, the lack of good quality measures, the wide variations in medical practice, or the lack of technology in health records. These are important, yes. But the real crisis in medicine isn’t any of these things.
The real crisis in medicine is a crisis in the erotic. Everything else follows from this.
Now please stay with me here. I was born in America, but I come from a fairly traditional Indian family. The word “erotic” wasn’t used in our household.
Remember those book covers you were given to put on your textbooks in school to keep them clean? One of mine from high school had “Erotic Exotic” on it, for a reason I can’t remember. But I can remember it made me squeamish.
And that’s precisely the point. In our modern world, we’ve exiled the erotic to one thing: sex.
Sex, of course, can be erotic. But the erotic encompasses more than sex. Way more.
Erotic here is a reference to Plato’s concept of eros. The life energy in love. The aliveness, the crackle, the loadstone of life itself.
The joie de vivre.
You may feel that what’s driven evolution is a series of random mutations, naturally selected and without direction. I won’t belabor that position here. I feel what drives the whole of evolution is eros. From the Big Bang until now.
But the exile of eros to sex alone destroys the recognition and cultivation of eros in all aspects of life. Which then deadens every other calling.
It’s the exile of eros from medicine that is the greatest challenge our calling faces.
To understand this better, let me tell you some of my story.
My dad’s father died when my dad was just five years old. He was raised in India by his widowed mother. He studied medicine in India and then came here to America with my mom in 1969. He left his whole family behind, including his mother. He worked really hard in medicine. He did it for the challenge and the prestige — but most importantly he did it to secure a good job and raise his family. I’m not sure that medicine was his “calling.” But you know what? He continues to practice at age 75. And his patients love him. Why? Because they feel loved by him.
So what is love here? It’s not really an emotion — it’s a way of perceiving. It’s a verb. To love is to see, and to be seen. And by seeing, I mean to see and be seen with the eye of the senses, the eye of the mind, and the eye of the heart.
We all just want to see and be seen. And to see others the way we would want to be seen. (This has become my version of the Golden Rule: SEE into others as you would have them SEE into you.)
When we see deeply into each other, when we love, we plug into eros. We feel erotic.
For my dad, his family is what makes him feel erotic. We’re what makes him feel alive. We’re how he feels seen. He didn’t need personal vacations or big personal toys to feel that way. It enlivened him to know that through medicine he was able to provide for his family, wife, and four kids. Medicine was just his vehicle to allow him to feel erotic, to love. Importantly, by tapping into eros, he benefited the patients he cared for.
And any hardships in medicine, he didn’t really care about. He just sucked it up and did it, because that was the only way he felt he could fulfill his role. Most everybody of his generation has that mindset.
Me — I’m different. As a first-generation Indian American, I had more opportunities than he did here. I chose medicine like most other Indian kids of my generation — because your parents wanted you to pursue a secure, prestigious profession, the same one that rewarded them so well.
But I had a mid-medical-school crisis. My theory is that this happens to all medical students at some point.
Mine started right after I hit the wards. Obstetrics was my first rotation, and the residents in labor and delivery crushed me. They were overworked trainees, and they projected their own miserable experiences to us students.
I thought, is this it? Is this the career I’ve resigned myself to? It was unsettling.
So I thought about finishing up medical school and then getting a law degree. I pictured myself defending the downtrodden physician from frivolous malpractice lawsuits. But I didn’t want to take the LSAT entrance examination and write a bunch of briefs (as if I knew what lawyers actually did).
So I dropped the idea and put my chips in with medicine.
And as I went through residency and then fellowship, I felt stimulated (though tired). It was the love of new learnings, and the friendship and community of a band of intrepid residents. We spent days and nights toiling away on the wards and sharing cool cases. And then we socialized over bars, clubs, movies, dinners, and football when we had the time.
Love goes through stages. This was love at its first stage: falling in love.
You know — raindrops on roses, and whiskers on kittens. At this stage, I was loving the romance of a career in medicine.
Then I went into private practice as a solo gastroenterologist. I entered the world of the business of medicine.
It was an eye-opener. This was the side of medicine which you don’t get exposed to much during training.
As a gastroenterologist, I’d sometimes be seen as a mere technician, someone who was valued ultimately for my ability to scope and not for my faculty of reason. The hardest part early on was the lack of community. It was really to each his own, and this was starker as a solo practitioner. I had no other gastroenterologist to share interesting patients with, to talk to as a soundboard for tough cases, to release my fears to.
It was good that my dad was with me. I started practice in his area. But what would I do?
I would complain to him incessantly about what I was seeing. The absurdities of the practice of medicine in the real world. The waste-of-time consults that amounted to little more than I’ll scratch your back if you’ll scratch mine, and we’ll churn this healthcare wheel for all it’s got. The lack of deeper thought and rigor to what labs, imaging studies, procedures, medications, surgeries, and all kinds of other interventions were most prudent for a patient. A unique patient, with a unique family, in a unique environment, and at a unique time. The “cookbooking” of medicine. The wasted opportunities to influence the health behaviors of sick people whom we would patch up and congratulate ourselves for, only for them to continue the same underlying patterns that would lead them to becoming sick again. So we could patch them up some more and congratulate ourselves again. And the burdens of running a medical practice in a climate full of regulations, which ultimately revolved less around caring for a patient than around coding and billing for reimbursement.
It was all so full of apathy. So lifeless. So bereft of eros.
These absurdities wouldn’t bother my dad as much as it did me. Eros was intact for him, because it was driven by something different. Eros for me was not.
My life force was steadily being sapped from me. I was beginning to burn out. I was a rat, in a cage, scurrying along on the healthcare wheel.
I didn’t feel like I had enough time with patients, that I was meeting their needs. They had problems that no amount of upper endoscopies, colonoscopies, imaging studies, and surgeries could fix. But they kept getting them, because that’s what the system incentivizes. And primary care physicians would keep consulting you for things you know that the system is just providing a stopgap for. Even more, you would be viewed by your colleagues and even patients as an eccentric if you didn’t really play by these rules. It was harder on me not to scope someone than to scope them, because that’s what was expected of me. When referring physicians consult you as a gastroenterologist, they almost expect you to scope. So does a patient. And if you don’t, well then you’re not playing the game right. At least that was my perception.
This was frustrating me. I had reached the second stage of love: falling out of it. Where you disagree with your beloved on just about everything and just want to create your own space.
I felt imprisoned by the acronym wardens of American medicine: MU, PQRS, EHR, ACA, MACRA, MIPS, ACO, and ICD-10.
I started getting heartburn. How ironic, a gastroenterologist getting heartburn! And the more I railed internally against the system, the more my heart burned. I then truly appreciated how inadequate the conventional medical system is in addressing something like heartburn in a healthy way. Because the system just has you taking powerful antacids called proton pump inhibitors forever. Really?
Eros had been exiled from my practice of medicine. And I realized that eros has been exiled from many other participants’ relationship to medicine.
Everyone — from doctors, to nurses, to therapists, to social workers, to patients — is having difficulty seeing medicine with erotic eyes. And they aren’t being seen.
Why, for instance, are rates of burnout and suicide so much higher in physicians than in others? Because of a crisis in eros. We’re not cultivating love in medicine. So we try to fill that existential void in some other way — working long hours for money, having affairs, settling for secure jobs with big healthcare systems. But this is all pseudo-eros. And we ultimately find it wanting. It won’t fulfill the void. Because we’ve exiled eros away to something much smaller than what eros actually encompasses.
Nurses and other caregivers in the hospital aren’t tapping into eros with regularity. For example, they are increasingly burdened by the entry of structured data, which is manna to administrators. But the structured data isn’t necessarily leading to better patient care. And when caregivers responsible to those patients feel that disconnect, they become deflated.
When doctors and other caregivers are no longer feeling eros in medicine, guess who hurts the most? Our patients. We spend on average fifteen minutes with them, when they may have waited many times as long for us. And our healthcare policies are forcing us to cater more to what we’re doing for them and how to do it, rather than why we care for each other in the first place.
As Simon Sinek said it best in a talk that’s become famous, it’s first and foremost about Why. Great leaders inspire the people they serve to understand first Why they exist.
The biggest crisis in medicine isn’t How or What, it’s Why. Eros drives that question, Why? And we feel erotic when we play out the question, Why? The How and the What flow from Why.
Why do our patients get inspired by us? Why do we get inspired by them? Why are we doing what we’re doing in medicine? What’s it all about? Isn’t it about support, kindness, empathy, and compassion for the suffering? Isn’t it about love?
This is the biggest failure of Obamacare. It focused too much on the How and What of healthcare, not on the Why. And in the process, it’s banishing eros from medicine.
It’s dumbing us down based on lowest-common-denominator quality measures that aren’t really capturing quality. It’s homogenizing us through standardized expectations that don’t capture the uniqueness of every healthcare situation. It’s forcefeeding us bloated electronic health record systems that become elephants in the room, not transparent devices that help us in the background. It’s commoditizing us. And this is dehumanizing, to both us as caregivers and our patients.
None of us feels seen. We’re not feeling erotic, we’re not loving.
But isn’t the existing system selfish? Doesn’t it fail to care for everyone? Wouldn’t it let Grandma die on the streets? Don’t we need a system that increases access to care, so Grandma can live? One that aims for healthcare for all? This has been at least one refrain of supporters of Obamacare.
Well, I want healthcare for all too. I want universal health care. I am Bernie Sanders! Who wants poor Grandma to die on the streets? That’s ridiculous.
But access to WHAT? Healthcare absent of eros? Does this give Grandma access to something that’s worthy of her? That truly improves her quality of life?
If doctors are burning out in droves, and patients’ premiums are going up because of a system that will break down because of all this “access,” and patients are waiting in longer lines because of the inevitable healthcare rationing…if patients are getting ripped off, and there’s no love in medicine anymore — is this universal healthcare?
Look at that phrase again: UNIVERSAL HEALTH CARE.
Bogus! It’s not “universal” (with rationing), it’s not aimed at lasting “health” (with hollow stopgaps for the sick), and it’s not care. The entire proposition becomes nonsensical.
This is “nonuniversal sick herding,” not universal health care.
And if you have an increasing shortage of doctors because doctor parents are telling their kids not to enter into a healthcare system devoid of the erotic anymore — then what? What happens to all those well-intentioned attempts to increase access to healthcare? You have a bigger crisis.
Then you bring in physician extenders and Walmart clinics, right? But now you’re just replacing burned out doctors with soon-to-be burned out other people. You did nothing to rebirth Eros.
This is not my idea of healthcare for all. This nonuniversal sick herding is morally wrong.
The real crisis in medicine doesn’t involve quality measures, standardization of practices, meaningful use, precision in billing with ICD-10 codes, pay for performance sticks, and Big Data crunching. It’s love, stupid.
How do we rebirth and cultivate love in medicine? How do we rebirth the erotic?
I think the answer lies in the idea that love isn’t an emotion, but a perception.
You see, we don’t really choose emotions. Emotions are states that pass through us, like clouds passing through the sky.
But perception, we get to choose. We can choose how we perceive things.
If we see love as just an emotion, then we’ll fall in and out of love. And we’ll be tossed and turned through repeated cycles of these first two stages of love.
But if love is actually a perception, then we get to choose. We have the option to stay in the relationship. Not to stay in a relationship of abusive bureaucracy. But to stay in our dear and sacred relationship to healing itself. Uncomfortable as it has become.
It’s staying in the relationship that graces us with the opportunity to reach the third stage of love — sweetness. Not the saccharine sweetness of a fickle puppy love, but the sweetness of that which is pure and eternal.
To an outsider, this third stage of love may look like the first. But we know that our love for medicine has persevered through all the discomfort of the second stage. And that perseverance rekindles the flame of eros in us.
I am now starting to enter the sweetness of love’s third stage. Eros is reigniting itself in me. And I’m feeling alive again.
I’ve left the third-party payment system because it wasn’t serving what I truly want to do in medicine.
I want to honor the sanctity of the patient-doctor relationship. I want to practice a medicine that’s not just about biology, drugs, and procedures. It’s also about community, the interior, and the social. I want time to spend with patients. I want to help them discover the root causes of their illness, through addressing nutrition, mindset, stress, and what is of ultimate concern. I don’t want my son to be burdened by the massive debt we’re ringing up through a healthcare system that doesn’t deeply alter the trajectory of a person’s health. I want transparency of prices in medicine. I want to be seen for the value of the guidance I provide in multiple ways, not just by way of procedures.
I want to be seen, through my practice of medicine, in my totality. And I want to see patients with those eyes.
If third parties recognize all this in the future, I will return to that model. In the meantime, I want to continue to write about the journey.
As a fellow caregiver in our healthcare system, you might be following the same arc as me. You might have started school having fallen in love with medicine. And then, sometime during school, your training, or your career, you fell out of love.
But whether you’re in the thick of your training or out in practice for a while, there’s a grand opportunity I see for all of us — to practice this healing art with sweetness. Not by dumping the current relationship and craving for an old fling. But by staying in the relationship and kindling something simultaneously old and new.
Every one of you has to find your Why. What sparks eros in you? What, frankly, do you find erotic? What is it that encourages you to give your unique gift, the gift that nobody else can give but you?
I’m a sucker for sports movies. Remember this scene from the movie Rudy?
The scene is electric for me. It’s erotic!
What have you been ready for your whole life?
The patients need you to find this. If you don’t know your Why right now, no big deal. But if you’re apathetic to your Why…or if you think other things are more important than your Why…or if you’re content with letting third parties define your Why for you — get out. Get out now.
Your patients don’t deserve that. They need more from you than that. If you don’t take them out on the field, they are at a loss. And you will burn out.
The Why is what will light you up. What you’ll remember.
You’ll remember your kinship with your patients, not what you did for them or how you did it. And they’ll remember that of you. They will forgive you for mistakes in the How or What, as long as you connect with them in the Why. And even if you’re perfect in the How and What (mind you, an impossibility), they will not forgive you if you mess up the Why.
This is what’s compassionate, this is what’s morally right, this is what caring for the poor, the disadvantaged, the unhealthy looks like.
A system doesn’t do this. Erotic, loving people in an accommodating system do this!
Find your Why. Don’t worry so much about the How and What. Find what makes you erotic. Love, outrageously love in your practice of medicine.
And when we all do this together, our healthcare system will crucify and resurrect itself from the inside out.
Virtually everybody agrees that our healthcare system has serious flaws. But we’re focusing on the How and What, not on the Why. We’re not realizing what the primary crisis really is. The exile of eros from medicine.
We can debate endlessly about whether healthcare is a right or a privilege. I think it’s neither.
Healthcare is a sacred obligation for each and every one of our unique selves to actualize. And the health of the whole thing depends on the rebirth of eros in medicine. That has to be the central expression at the heart of medicine. That has to be what drives medicine’s evolution.
This is our greatest challenge, and our greatest opportunity.