It’s 2015. Where am I? I have no idea anymore. The state of American medicine is less predictable and arguably more adversarial than ever before.

Quality of care and (when possible) good outcomes aren’t the benchmarks they used to be. In the modern era of pay for performance, we’re graded on things such as reducing stroke risk, blood sugar control, whether we use a meaningless computer system instead of one that works, and how many patients we can cram into a fixed time frame. Things that we can’t control, such as patients continuing to smoke or flat-out refusing to take their medications, are often considered to be our fault, even though we’ve clearly emphasized the importance of our advice.

Rate-a-doc” sites continue to proliferate. Any of us can be given a terrible review by a patient who is upset that we didn’t give them enough Percocet, didn’t like our office building, or never even met us and is upset that our kid made honor band and theirs didn’t. And we’re powerless to respond with the truth. Yet, a frightening number of people trying to choose a physician will base their decisions on such sites.

Most of us are going to get penalized by our government (you know, the one we support with our taxes) because we can’t afford to upgrade to an electronic health record program that does nothing to improve quality of care. Based on my experience with them, I’d have to say they make things worse. Instead of telling what’s going on with the patient and showing the physician’s reasoning in the case, they give you a list of check boxes for negatives and positives, and an unhelpful string of ICD codes. In my opinion, it simply continues the degradation of a patient from a person to a number.

My salary has gone down every year since 2007. My staff hasn’t had a raise in that time, either, and I’m grateful they’re still with me. All my other expenses have gone up. Besides the above-mentioned penalty, the year starts (as all do) with threatened large-scale cuts in Medicare (and, by extension, all insurance payments). Hopefully, they’ll get canceled quickly as they are every year, but you never know. It’s been easier for the last 15 years or so for the government to simply slap on an expensive bandage than to actually fix the problem, and so the overall cost of a real repair keeps going up. The shift in Congress this year likely won’t change anything as our patients, careers, and livelihoods are simply ping-pong balls to those in power, bounced back and forth to score political points against each other.

A year ago, I didn’t know I’d still be here when 2014 ended, but, battered, I am. Like other doctors, I’m trying to see more patients and find other ways of supporting my practice and family, but no one is increasing reimbursements to keep up with inflation or adding more hours to the day. I can’t predict how 2015 will play out any more than you can. But I hope it will be better. My wonderful staff deserves a raise, and my family needs me more than my office does.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.