Exile of Eros: The Real Crisis in Medicine.
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? His patients loved him. Why? Because they felt 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.
This is such a beautiful message and hope that more healthcare providers reflect inward and find the “why” within themselves.
I believe its the same for teachers, and many other professions. The government is zapping the passion right out of so many important professions!
so beautifully written and so very true. Wish this was a course in med school so that every person in the field,and in others for that matter,could realize their patients are all individual,with different illnesses,different backgrounds,and yet the same need. My Dad always said the patient was the customer. I have seen many times where this was not the case.
I can see how there can be burnouts, and the business part of it has caused the patients to suffer. You seem to have a good handle on the cause and possibly the solution. I hope that your message can be spread to everyone in the medical field because it seems to be growing,a clinic on every corner,hospitals only expanding,so many people getting sick.
So much appreciate your desire to help change things-you are an inspiration.
Nonuniversa sick herding…….you’re brilliant Dr. Julapolli, just brilliant! You’re able to put into words what so many of us think and feel but are unable to communicate. Eros to you! Keep up the great work.
As a fellow physician your words hit home hard. You speak for many of us, albeit more eloquently than most.
My father and his father before him were physicians. My father’s brother was a physician and his son is a physician.
The tradition stopped there. I talked my daughter out of medicine and she is thankfully starting her 2L year at Penn Law. My other daughter will also pursue a career in law after she graduates from college. My doctor cousin’s kids also opted out of medicine.
I wish that your wish could come true. However, I am saddened that you and I are part of a vanquished breed of M.D.s…………modern American culture will not allow your dream to be much more than just that.
American medicine will soon be as cold and automated as McDonalds or Walmart and from the next generation on, no one will even notice.
Thank you for your comment. It pains me every time I hear a physician talking his or her family out of medicine. I can’t begrudge your decision with your kids. The suicide rate for physicians is among the highest of all professions. But my brother and I will not accept this. That’s why we’re going to continue to do what we’re doing.
Good observation. If you don’t have eros you have unchecked stress…which is a contributor to many health problems.
Thank you for the feedback. Loneliness, which stress tracks with, is the #1 cause of death in the world.
I applaud you for being able to communicate such a worthy cause. As a retired teacher I experienced some of what you are expressing. I hope others would come to realize that eros is an important factor in professions. Thank you for being you.
Thank you for the feedback. Teachers like you whom I’ve talked to say the same issues have been plaguing their world.
Outstanding piece — too bad all physicians don’t take similar attitudes toward their chosen profession. Even my nephew, now a cardiac electrophysiologist, only considered monetary numbers in his search for a position within a group, and now he’s going to Billings instead of NYC, or Chicago, or Houston, or L.A., etc., where he’d reach, in my opinion, greater professional heights and serve more people, but que sera, and it’s his choice, of course. I’ve consulted with more than two dozen physicians in the past five-and-a-half years and I must say that you, Dr. Julapalli, are the most (by far) intellectual, open-minded, and broadly well-versed in life’s issues than any I’ve encountered, and that includes four within my family. Kudos, and keep spreading your messages, and hopefully even beyond your local patients. You are truly the epitome of a “good man”. May I see universal health care for all U.S. citizens, and even others here, in my soon-to-be-over life, but I doubt it. Maybe for my 35 y/o son, my two grandsons, and everyone, thereafter? Thank you, sir.
What a kind response, Art…I take this to heart. I have a lot to learn — we’re going to keep at this.
In my case, I was able to focus more on the style and beauty of the piece. Enjoyed reading it very much. Thank you.
You see, my life has already been changed by your approach to my health issues, so for me, it was really a beautiful articulation of an ugly problem. After years of suffering with acid indigestion and intermittent bowel problems, your patience in dealing with my initial skepticism persuaded me to follow your guidelines, which have enabled me to enjoy good meals once again for the past few years.
The ever-encroaching modular approach to everything, from medicine to the arts may be reducing life to a mere centrifuge of problems with broad solutions devoid of original thought. The human spirit is not elevated.
When it comes to health care, I think a one-size-fits-all approach is many times more out of place, as it can literally end us long before our time.
Thanks for being my doctor.
After reading this piece, I feel a sense of guilt, almost ashamed. You see, I am one of those patients that asked you to do an upper endoscopy on me because my primary care physician had recommended it and because I was fearing that my then symptoms were due to some abnormality in my esophagus or stomach. But you knew, you knew better. You knew that I didn’t need an endoscopy. You told me I didn’t need it. And you were right. I always wondered how you knew!!!
But I promise I never doubted your faculty of reason or saw you as eccentric. I guess I was being reactionary and fearful.
You practice medicine with a heart. As you so aptly call it, CONSCIOUS MEDICINE.
You want to do this thing right. Right by your patients. Right by your own conscious.
We need more doctors like you. There are a few out there. Maybe there are quite a few out there. For one thing, I know that many patients, like myself, read reviews on doctors before calling and making appointment. We are looking for someone who listens. Someone who does not rush you in and then out. Someone who genuinely cares.
You are that doctor.
Patient care, as you rightly have stated, should be more than a system of codes, claims, guidelines and protocols.
I believe doctors are genuinely caring individuals. It is a noble profession–medicine. Years of schooling followed by residency and fellowship. Many sleepless nights and long work hours. Making self sacrifices. And a six-figure price tag education that takes years to pay off. With one goal in mind. To care for the sick and make them well again. But maybe that is where the fault lies. Caring for the sick. Western medicine is all about sick care. It is all about treatment of disease. Don’t they teach about preventive care and importance of nutrition in medical schools? I have no idea.
Is there much joy in always treating the sick? Especially when you the doctor find yourself buried under the weight of systematic factors? No wonder doctors find themselves jaded so early on in their practice!
A system that does not incentivize quality over quantity will at best be a practice in mediocrity. If you choose to remain a part of such system, you have to either learn to self-preserve (at any cost) or ultimately you will self-destruct.
It seems to me, Dr. Julapalli, you have made the conscious decision to choose what’s behind curtain #3. You value your time with your patients and you see your patients worthy of your time. Patient respect–that is the name of your practice.
Thank you, Dr. Julapalli.
There is no reason to feel any sense of guilt. We make decisions, together, for any number of unique reasons. Sometimes we get aggressive, and sometimes we pull back. Each decision is based on the uniqueness of that particular situation. At least, that’s how I see it.
This is such a heart-felt, well written piece. I wish I had the ability to compose something that could respond in kind.
A not entirely subjective opinion: Dr. J has described much, if not most of society, not just medicine. Law, Education, Business, Sports, Politics (it doesn’t necessarily have to be a dirty word, but…), even Organized Religion all can be freely substituted.
From a very personal, subjective perspective: I’m lucky to have been sick enough to go through many doctors in many specialties until I found Dr. Julapalli, who is and remains one of the greatest blessings in my life.
I am touched by your comment. You are exactly correct, about all the other domains. And you, my friend, are one of the greatest blessings to me.
Beautifully written views about our medical system. Agree, patients often get ineffective care with excessive meds, and without addressing the root cause. I am looking forward to seeing you, and get off meds.