Lately, we’ve been hearing a lot of the usual rhetoric from the usual players regarding prospects for national health care reform. Current strategies aimed at change have been thus far ineffectual. Understandably enough, those in power hope that we continue to accept increasingly vacuous-sounding reassurances that the fundamental values of our profession will prevail, despite the grim environment in which we currently practice

I consider myself a casualty of reform fervor, a hopeless idealist (raised as I was by politically active parents in the 1960s), fairly confident that the storm clouds of crisis that were gathering on the horizon of the health care system when I was a medical student could be diverted by writing about them and by educating and informing my peers about them. I had hoped this information would inspire rallying to correct the problem. (After all, demonstrators had stopped the Vietnam War, hadn’t they?) My personal fires were editorially quelled to civility in the resulting text, The New Medical Market Place (Johns Hopkins University Press, 1993). The book permitted readers to draw their own conclusions from descriptions of the current U.S. health care system, factors leading to the health care cost crisis, and the ethical and clinical dilemmas brewing as a result of the mingling of health care, insurance, public policy and private profits. A few people read the book, but no uproar ensued. My youthful zeal and naivete were tempered, but not extinguished. What next?

Then, I wrote a series of polite papers and book chapters on the topic of mental health economics, and my fire was further tempered, this time by my wise and level headed mentor. But fierce, personal convictions remained private. By this point, touted by some as an "expert" on health care crisis. I was permitted entrance to the inner sanctum, an old boys’ club of national physicians and health care industry convening to brainstorm possible solutions to the health care crisis. Ah, I thought, here is where change will really happens.

In these meetings, we discussed policies and economic principles. Articulate orators pontificated on physician "greed and excess", which supposedly created today’s economic problems and justified strong-arm managed care tactics. Equally persuasive speakers defended physicians’ ethical principles and traditions, while condemning third-party intrusion into medical decision-making. At the time, it seemed we were fighting the good fight; these debates seemed relevant. In retrospect, however, they were nothing more than good intellectual fencing, conducted by players worlds away from the day-to-day fiascoes encountered while practicing medicine in the U.S. health care system sinking further into crisis.

There were persuasive arguments that persuaded on one, yet good meals, good rhetoric and sometimes sunny locations left the participants feeling virtuous. Even within the "inner sanctum", it still wasn’t easy to discern the degree of authenticity of those involved. The ingrained procedures and political machinery seemed to smooth away the rough edges of doubt so subtly that participants were unaware of their indoctrination into a timeless process geared to perpetuation of the status quo. Regardless of the reasons for the stagnation in professional debate as an avenue for change, the reality was that nothing was changing. What next?

The answer must lie within the political process. When offered the opportunity for hands-on political reform as a member of the President’s Task Force, I accepted. I threw myself into the job ful force, optimistic that finally the time for real change had come and that this was the pathway to it. We fought hard for what was right, for fair care for all Americans, for equitable coverage for the mentally ill. But my colleagues were understandably skeptical, as well as ambivalent, of the Task Force process - feeling caught between an untenable present and an unknown and frightening future. Wasn’t it right to fight the current system? Wasn’t this system unjust? They challenged my motives, and I lost some confidence.

When the Task Force ultimately failed to accomplish its goals, a victim of both the political process and its own muddled process, its failure reinforced my own. Full of doubt, struggling with political and personal defeat against an unbeatable opponent, I was left with the sense of overwhelming futility. What next?

I went back to basics. Becoming a physician has satisfied my dual needs for intellectual challenge and service to others. This calling and ever-present needs of those suffering with mental illness were consistent forces throughout my turbulent fight for a just health care system. With relief, I re-donned the mantle of full time clinician.

Now I fight from the trenches, participating with managed care plans, not because I have to, not because I agree with what they are doing, but because people still think that buying insurance should get them some health care for their money, and I intend to uphold my end of that expectation. Involvement in what seemed to me the fruitless activity of top-down change doesn’t cut it for me anymore. Now I advocate for my patients on the front lines of today war. I skirmish with those who represent managed care, using my available weapons of compliance, challenge, and sheer endurance until they surrender and agree to provide the promised insurance coverage. These managed care battles are more depleting than any clinical struggle, but I refuse to back down, to capitulate with shifting my career, retiring early or identifying with the aggressor by becoming one of them.

My first hand glimpse inside the U.S. political machine demonstrated that much of the apparent fervor and intensity pushing health care reform is but fluff. Most of us cautiously dance around this fact, too polite to risk offending, too proud to risk rebuking, too principled to abandon the challenge as long as any hope for success remains. But all the convening, debating, power breakfasting, resolutioning, cocktail receptioning, round tabling, conference tabling, tete-a-teting, dealing, bargaining, resolving, discussing and so on aren’t getting us anywhere.

To the contrary, nothing is changing, but there is deepening morass of regulations and profiteering into which we clinicians are slowly but surely sinking, spiritually and financially. The forces weighted in against us are so powerful that not even a mandate from the American people, like that demonstrated by the election of President Bill Clinton in 1992, could sway them. Money is clearly the primary form of political currency in this war - not ideas of what is morally right, not what is good for the American people.

I am reconciled that one can be defeated despite good intentions, that being right doesn’t necessarily mean getting one’s way. Serenity comes from knowing that my days are filled with meaningful work that makes a difference to identifiable others. I have made peace with the paradoxes inherent in practicing medicine in a crazy patchwork nonsystem from which dollars are unscrupulously scooped out by profiteers - and I play their game anyway. To me, being a physician leader at this time means taking care of my patients with integrity.

Having sidelined myself from the intellectual and political arena of health care economics and reform, I now observe the ongoing fray from a safer emotional distance. My eyes usually glaze over as I skim the impotent statements that regularly emerge from American Psychiatric Association and American Medical Association leadership. By now we can all anticipate their content, and we have learned that their leadership doesn’t lead anywhere. Yet despite the vagaries of politics and the probably wisdom of a pessimistic stance, isn’t it nevertheless comforting to know that our leaders remain involved in the politics and process of reform? We simply shouldn’t expect our leaders nor our professional organizations, good as they are, to fix too much of it. Although their paternalistic stance can understandably cause us to react in a regressed and childlike fashion and expect too much, their perhaps inevitable failures have generated much of the anger reflected in the membership today. Let’s not be angry, let’s be realistic. It is one tough fight, but we should stay hopeful of victory, meanwhile each finding our own way if fighting for our profession and for our patients.

To bring my tale to closure, this fallen soldier in the war for change takes comfort in the ongoing courageous fighting and the candid reports from the heady fronts of the battle for justice in our health care system. From this fellow comrade, and from others both fallen and still standing, I thank you.

Dr. Stoline is director of Women’s Mental Health at Mercy Medical Center, Baltimore.