Uncertainty and Complexity in the Practice of Medicine: What Keeps Us Going?

I ran across a blog post by Psych Practice which speaks to the tolerance of uncertainty which so many of us, including yours truly, find difficult to tolerate. This coincides with my efforts to wrap my head around the complexity of being a doctor these days and the fear and loathing the field seems to ignite. And an interesting post about psychiatry as a profession by my colleague Dr. George Dawson also fits because it highlighted the optimism of one psychiatrist regarding our specialty. And then I had an opportunity to compare this to another provocative story about the practice of medicine nowadays which provoked a storm of comments. I’m trying to compare and contrast them and invite readers to do the same, using the tweets below for convenience:

I don’t know about you, but I was struck by the disparity in the number of comments after the two articles. There seemed to be almost no interest in Dr. Fischbach’s piece about the rewards of psychiatry as a profession. On the other hand, there was a blizzard of comments in response to Drake’s article about what a terrible time it is to be a primary care physician.

There were a lot of comments after the Drake piece about doctors being reduced to little more than cogs in a vast machine and the many political, social and economic forces that contribute to that perception. It reminds me of a fiendishly complicated article with a plethora of legalese arguments about the medical profession [1]. One quote from the author:

“Nowhere does the IOM (stands for Institute of Medicine) suggest that doctors should function as solitary islands in the stream of health care. In both To Err Is Human and Crossing the Quality Chasm, physicians are expected to work as a cog in the wheel (bold-face type mine) of an interconnected, interactive health care delivery system. Further, corporations are regarded as an inevitable part of the health care delivery system.”

That “cog in the wheel” image probably irks us even more than the bewildering complexity surrounding the practice of medicine in our times. I’ve tried to express my stance in a post about how I chose psychiatry. I keep going because I love what I do.

What keeps you going?


1. Huberfeld, N. (2004). “BE NOT AFRAID OF CHANGE: TIME TO ELIMINATE THE CORPORATE PRACTICE OF MEDICINE DOCTRINE.” Health Matrix: Journal of Law-Medicine 14(2): 243-291.
Discusses the negative impact of the state-based corporate practice of medicine doctrine on the health care delivery systems in the United States. Historical background of the corporate practice of medicine doctrine; Failure of the corporate practice of medicine doctrine to improve quality, efficiency or accountability of medical care; Reluctance of physicians to participate in Medicare and Medicaid; Need to allow physicians to practice in an integrated environment that will benefit patients and facilitate the continued development of this integrated health care delivery system.




  1. Jerome Kagan, one of my gurus, notes that the need to resolve uncertainty is almost as important and feeding and f——. He also points out that if resolved by blaming others then anger results; by blaming the self depression results; finding not one or nothing to blame then despair results.

    I think three things must be making life very difficult for MDs in general, but psychiatrists in general. (1) The drastically changing market place as noted above. (2) the rise of technology which may ultimately leave MDs behind the scene in terms of diagnosis and treatment. (3) The onslaught of so much information including gobs of mis-information thrown at not just doctors, but all of us. Number three really hurts psychiatrists as everyone and their cousins think they know better.

    How to cope? Of course, trying to stay abreast of all the advancements. But for me, the trick has been knowing that the person to person part of psychiatry or therapy in general heals the most and cannot be machine replicated.

    Just a cranky old lady’s thoughts. Thank you for all you do.

    Liked by 1 person

  2. Foolishness is a good word. I would add prior authorization, utilization review, and managed care to the list of foolish enterprises that we have all been forced to engage in. When I first started working there was plenty of time to read about medicine and even do a little research on the side. For years I had lunch almost every day with a number of Internal Medicine specialists and we would discuss movies and the medical problems of the day.

    No more – everyone is huddled in their little cubicles doing paper work for managed care and the government – hoping to make it home by 8PM. Nobody has time for a collegial conversation.


  3. Jim – I think economics and sheer fortitude keeps most docs going. I have not met many docs who have told me that they would not retire immediately if they were able to. I think that attitude contrasts greatly with my mentors in medical school and residency training – many of whom were active into their 70’s and 80’s. I think a lot of that comes from the Drucker concept of how knowledge workers get treated as opposed to how production workers or cogs get treated. In our current society it seems that only electrical engineers are treated like knowledge workers and even then there has been evidence that large IT companies conspired against them to prevent them from moving to different companies.

    American society has devolved to the point that business has too much of an advantage and the best case in point is how they stole the medical profession from physicians and turned it into a production job.

    Liked by 1 person

    • George, what you say makes perfect sense. I catch myself dreaming wistfully about what retirement would be like. I nearly gave up membership in the APA and the AMA last year. I’m ambivalent about renewing again next year. Teaching is still fun, but expensive foolishness like the MOC and MOL are eroding my enthusiasm.

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      • James O'Brien, M.D. says:

        Here’s my take: physicians don’t like conflict but love the classroom where they shine. In peaceful times, this works out fine. But while the science of medicine may be like the classroom, the business and politics of medicine are like the playground, where smart contemplative types don’t fare so well. Quite frankly, Jim, APA and AMA remind me of the Simpsons character Martin Prince on the Springfield Elementary playground, protesting his bullying and wedgies with statements like, “How can my membership in Honor Society and years of hall monitor service be so unappreciated?”. As the bullies just laugh and pile on.

        We are under siege from politicians, PPOs, insurance, ABMS, Press-Ganey, HIPAA, hospital bureaucrats, EHR etc. Marcus Welby and APA/AMA types might be nice fellows but I don’t want them at a proverbial gunfight. Give me a son of a bitch like Clint Eastwood or John Wayne. Or the AAPS who is saying no and taking these people on.

        If you can’t identify the sucker at the negotiating table, you are the sucker. Doctors have to realize they’ve been weak saps and played as such. Recognizing the problem is the first step, it will be tough turning them into fighters. Maybe some of the aggression that doctors hammer each other with can be turned outward.

        Liked by 1 person

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