When will doctors kneel?

The San Francisco 49ers will take on the Kansas City Chiefs in Super Bowl LVIII tomorrow night in a very much hyped game (but aren't they all?). There is no shortage of attention on this game; it has been 40 years since the 1984 Apple Macintosh commercial that revolutionized how commercials would forever play a dominant role in the spectacle and would serve to elevate the game as something worth watching, if only for the commercials. Along with amazing halftime shows and every storyline imaginable put out by the media (Taylorverse, anyone?), it beckons for your Sunday night attention.

When the 49ers lost in Super Bowl XLVII to the Ravens, Colin Kaepernick was QB and he played against Joe Flacco (who, ICYMI, played phenomenal for the Browns this season) and Jim Harbaugh (who led Michigan to a National Championship this year and is returning to the NFL) played against his brother John, coach of the Ravens. Some story lines simply write themselves.

But just a few years later after the 49ers loss, who would have imagined that CK would take a knee during our national anthem. A gesture meant to bring attention to racial injustice...and, boy, did it ever. Today CK is not signed to play with any NFL team, but his gesture remains emblematic of how a single person can draw incredible attention (both maddeningly against and captivatingly for) to an issue that cuts to the heart of our society.

Today, nearly 1 million physicians are practicing medicine under circumstances that, on any given day, can feel as though injustices are occurring right in front of them.

For the most part, physicians are well paid and are held in high regard in spite of the wild spirals of today's healthcare market (I don't believe in calling it a system; certainly not a thoughtfully designed or just one, but if you prefer that term, then as Dr. Deming once pointed out, the deeply problematic results have originated from its "perfectly designed" (wait, what??) system).

While there is growing unrest among physicians in UME (walking out in protest during white coat ceremonies) GME (union activity) and efforts appear to be increasing to mobilizing the sentiments, why don't more physicians simply take a knee? Many did so during the summer of 2020, in solidarity with other groups in the face of the death of George Floyd, but where are those gestures today? And what did they accomplish?

And, even if someone could articulate one single element of the machine to rage against, to focus on any one of the types of injustice specifically affecting physicians (burnout, moral injury, depression/suicide, financial subjugation, unfair labor practice, abortion statutes, loss of autonomy, etc. etc. etc.) that is occurring, what would happen next?

Are today's practicing physicians afraid of the repercussions of taking a knee? With nearly 70% of all physicians working in some type of employed arrangement (as opposed to a truly independent, private practice), who can blame them for keeping their head down? Who would be willing to suffer the level of shame that was leveled against CK? Who would be willing to risk all that they worked (so hard and so long) for?

There is an urban legend that at the University of Michigan Medical Center in the 1970s-80s, the medical residents wanted to draw attention to their plight (whatever it was at the time, idk) but they did not want to be accused of abandoning their responsibilities for patient care and risk their medical licenses or any sanctions by the residency program. So, they simply decided to refuse to discharge a single patient. They would continue to care for them, but not discharge them. The hospital immediately bloated, then became constipated, then became corked up entirely. No one could be admitted either for elective or urgent/emergent needs. Those patients would have to go elsewhere. No lives were lost or folks injured or harmed, at least as legend has it. The administration caved within a few days and met the resident's demands. The gesture was an inaction. Not a walkout, not a strike, not a performance. An inaction that led to an accommodation.

Finally, most physicians are simply too busy or too distracted to address the injustices of today's healthcare market, to take an action or invoke an inaction. Rather, they depend on physician leaders to speak for them. To take ownership of the problems on their behalf. To share the insults and injuries with other stakeholders. To articulate meaningful ways to make sense of the new world order in modern healthcare. To advance tools that truly unlock the potential of being the best physician one can possibly be; not to promote the golden calves that look all shiny and bright (and cost a ton) but, in the end, only seek self-adulation and adoration. And, to make matters worse, bring more "time" back to the physician so he/she can be more efficient (i.e. productive) and generate the ROI that paid for the auriferous baby bovine.

I have spent the last 18 months of my life on a personal journey. From atop a medium sized health system, to rectifying progressive health problems beyond the single bane of my existence (congrats to Dr. Burill Crohn for getting naming rights), to diving ever deeper into the realm of physician leadership and experiencing the uplifting joy of being part of medical education. All the while experiencing a prolonged reflection on the things that matter (vis a vis Four Thousand Weeks/Second Mountain/Strength to Strength) and spending a considerable amount of time meeting with and talking to various individuals who have filled my heart with hope regarding US healthcare. I have met CEOs, CMOs, COOs, all of whom are physicians; all of whom are working tirelessly, one room at a time, to fix the House of Medicine.

If leaders breathe oxygen to hope and calm into chaos, thankfully, there are many of you out there. In fact, I would posit that never before in human history have so many physicians had the amount of experience, wisdom, expertise, advanced education, and positions of leadership and influence as they do today. While there is a real problem with physicians leaving practice, there may also be some benefit as undoubtedly some of them are not so much running away from medicine, but perhaps running toward any number of opportunities to solve medicine's problems and to lead change. With credit to Malcolm Gladwell, I would like to believe that with the right context/environment, there will soon be enough connectors/mavens/salesmen and stickiness that the tipping point will come.

The Pollyanna voice says that there are too many other vested stakeholders with power and money to burn that will block any changes, and, yet, Steve Jobs (look it up) never even watched a Super Bowl prior to 1984. His product and the infamous commercial https://www.youtube.com/watch?v=ErwS24cBZPc have absolutely changed our world, both in terms of Apple devices and our version of the Super Bowl, respectively. He pushed up against massive interests in the computing world, the television world, and the world of sports. And no one counted on his impact(s) at the time.

If there is one thing that power brokers count on, it is change. For it is in opportunity (i.e. change) that they obtain both power and money. We cannot let the forces stacked against unleashing a better future stop us from moving toward that future. They should know, change is coming.

I was recently reminded by a wizened older physician that medicine is still a very noble profession. I believe that to be true and it touched my soul when he said it. While there are only a few real professions in the world (soldiering, law, clergy), medicine plays an incredible and perhaps outsized role in the life of every single living human being compared to the other professions. Not everyone needs or wants a soldier, a lawyer, or a clergyman to intervene in their life at any point, but not true for the need of a physician. No one gets out alive. And being one still requires the practitioner to avoid harm and to heal to the best of their ability. Our abilities are being pushed around. We have to begin to push back. Maybe it starts with taking a knee. Maybe not. But we owe it to our forbears, to our colleagues, and to our progeny to figure this out.

In any game, you have to play it to see who wins. And any die-hard fan of any game will tell you that it is hope that drives the passion. So, we lost today. Next time we will win! The Super Bowl is a great, audacious, spectacle that has outlived and outsized anyone's wildest imagination. With increasing physical risk to the players themselves in the form of concussions, career ending injuries, and the ever feared commtio cordis, the game continues and fans still show up. With hope for an outcome that continues into a post-game celebration, a victory lap, a visit to the White House even. And, if not, well let's bring back the Joe Flacco's of the world, the Harbaugh brothers, and even the 49ers can have another chance at another ring. They say hope springs eternal. Enjoy the Super Bowl and remember that it really is only a game. May your pick win and, if your team isn't there, or if your team loses, remember also that tomorrow is the start of next season. In this life, we only have one long season, though, so make the best of it, no matter how the odds are stacked.