Taking Death For A Test Drive

 

Just now got home from work, for the last time.

I carried a cardboard box filled with things which belonged to Cathy, my secretary/office manager out to her car in the parking lot and she said, "I thought I was going to be sad. But, somehow, I'm not." She looked at me for a moment and said, "I won't miss that mob back there, not for a second." 

The corporation we had worked for over the prior 11 years had gone bankrupt, and the new company which acquired us almost immediately alienated us, but most of all, that mob was clearly incompetent, and Cathy and I had looked at each other as one might look at an airplane pilot reeking of alcohol, who staggers toward the cockpit. 

"Uh-oh," this cannot end well, we said. 

When I resigned from our clinic 90 days ago, I did so only after I checked with her.  I would not have resigned if she wanted to stay on. But she told me she was turning 70 in April and she planned to retire, so that gave me my free pass.

Medical School Class 

Today, she went to talk to the administrator, who had suggested that even after I left the clinic, they "might have something" for her, i.e., a job in another doctor's office but when she stepped in the office, the administrator handed her severance package all prepared for her. She was a little shocked, but not really. She can get unemployment and some other benefits, so she is not exactly bereft. 

Cathy is the person you would dream up if you wanted the perfect health care worker: No patient's request was ever dismissed, delayed or ignored. She would hound me, advocating for even the most uncooperative, desultory patient, making sure prescriptions, lab request forms, letters to employers got done.  Every day was filled with patients at the end of the day who Cathy felt needed "squeeze in" appointments. Patients always had grievances about the medical system, billing, prescriptions not filled correctly, but nobody ever had a complaint about Cathy.  Every patient, doctor, co worker who ever dealt with her loved her and told me so.

Housestaff: Residents and Interns and Faculty

When I arrived home, I thought, well maybe I should be sad. And I did feel that empty feeling I felt after exam week in college, when I had studied constantly, completed long to do lists for each course and then walked out of the door of the last exam and realized I now had absolutely nothing to do. The idea of free, unscheduled time was hard to fathom.

And now, tomorrow I will wake up and not have to leap out of bed and get my day going in order to get to work. 

I have been told by my Merrill Lynch gurus that there is no reason, financially, for me to work. They claim I can live to be 100 and not hurt for money. They may even be correct.

When I resigned my job, I knew that there was not another endocrinologist from York, Maine to Portsmouth, New Hampshire all the way up to Hampton. I could open an office anywhere along the Seacoast and have a busy practice within a month.  

But, after 27 years of signing leases, responding to the various crises of running a small business, Xerox machines breaking down, staffing problems, hikes in malpractice insurance, I was thrilled to leave all that behind and get a W-2 form and become an employee.

The problem with being an employee though, is you need a willing boss who wants to hire and maintain you--and the only bosses hiring doctors in Seacoast New Hampshire to the upper reaches of the Merrimack Valley are big corporations, and they are not hiring, at least not now. Recession is coming. Mass General/Partners is laying people off.

So, I am, somewhat unexpectedly, retired.

When I stepped into my house and put down my briefcase, I realized this journey had been 52 years. I started my career, with my freshly minted MD in 1973, age 26. And now it is over. Over that time, I had never been out of work. There had been a month off between jobs, or that slow period when I first hung up my shingle and started private solo practice in Washington, D.C., coming from a medical school in New York City and with no network of friends and colleagues acquired in medical school. 

Who Was That Guy? After a Night on Call

But I had never stopped being a doctor. I never started a company, never shifted over to hospital administration.

I did get one offer from the CEO of a hospital in Washington, who told me, "Nobody is going to be able to survive just seeing patients in the office for much longer. Come work with us at the hospital."

I hung up the phone and looked out the window of my office, and the faces of faculty members from years before, at Cornell, flashed before my eyes. Give up medicine! It was like leaving the priesthood. Worse than that. I developed acute angina, my left wrist tingling and spasming--what I took to be coronary artery spasm, which took a moment to resolve.

Over the years, we'd heard of some doctor or another who had "gone Hollywood," i.e., who had given up treating patients and gone to work for a drug company or who had left medicine altogether to start a software company, some spin off of medical practice, developing an electronic medical record or something like that, parlaying an MD into an MBS related career and we always smirked a little. Gave up medicine. Chased after the almighty dollar. How embarrassing.

But now, younger doctors who have enormous student loans, earn back that investment and build up a nest egg and get out of medicine as soon as they can. They shift jobs every two years, looking for salary increases. And they leave medicine. Women, especially, leave medicine, for motherhood, or for jobs which are less demanding in time and energy.

And, truth be told, in some ways, I've mentally checked out of medical practice over the past few years, in some ways. I've been practicing in an underserved area, where patients have little education, a load of financial and personal problems, are non compliant--they don't go for their tests, don't take their medications, don't keep their follow up appointments and don't go to the consultants I've recommended. And so, not having changed what they are doing, they do not achieve improved results for their diabetes or high cholesterol or thyroid disease.

And the things they say! I've learned from my patients that vaccines are a vast government conspiracy, that vitamins cure cancer and that lowering cholesterol causes more problems than its worth.

But, I've never, not even for a moment, been anything other than grateful to have had the chance to become a doctor, to have been trained at the New York Hospital, where we all believed we were in the best medical center in the world, and were very lucky to be a part of it.  The Marines had nothing on us for group pride, and a sense of purpose.

One of the professors at Cornell was named Aaron Feder. He made rounds in the early morning at the hospital and again after seeing patients all day in his office, he'd come back to do his evening rounds.  I heard he was found dead in a hospital stairwell at age 63. He never took an elevator. Everyone smiled when they heard how he had died. "That's Aaron Feder," they said. "Died with his boots on. Died as he lived. That's how a real doctor dies."

A Dressing Down

 It’s not just at restaurants that the dress code has become more relaxed; it’s pretty much everywhere. People don’t dress up for the theater, the opera, work or travel. Sometimes airports look more like giant sleepover parties than transportation hubs. And it’s been that way for some time.

This lack of formality, or interest in occasion wear, has prompted some complaining, especially among those in the baby boomer generation who see it as an erosion of public standards. I think that the right way to look at it, however, is as an expression of a much larger and more significant social and cultural shift. One that has been taking place over decades and essentially says that we all have a right to dress as we want. It’s a shift that reflects the prioritization of the individual over the institution.

--Vanessa Friedman, The New York Times

One way to know you are getting really old is when you start looking at the younger generation and you  find yourself shaking your head and saying, "What twits!"

Waitresses, who are otherwise polite and engaging but festooned with nose piercings, so at first glance they look like something really nasty is dripping out of their nostrils. Nurses whose arms uncovered by their short sleeved scrubs, covered with tatoos. 

People at airports looking like they are planning for a sleep over with their adolescent daughters.

What's Wrong With A Little Formality?

Men at expensive, fancy restaurants, where the waiters dress in tuxedos, but as customers they look like they are Mark Zuckerberg wannabes, with just a knit shirt, a hoodie or, at best, a collared shirt but no jacket or tie. Used to be if you tried to get into a fancy restaurant without a jacket, the restaurant provided you with one.

Which is not to say, dressing down is always a bad thing. In 1975, a woman invited me to see Baryshnikov at Lincoln Center, and never having seen a ballet, but knowing it was Lincoln Center, I wore a summer suit and a tie.

She wore nearly nothing: sheer white, form fitting slacks  and a diaphanous robin's egg blue shirt. No jewelry beyond simple earrings. She was 22 years old and the forty something women, who were dressed in evening dresses, jewelry and some with tiaras, looked at her with frank envy: She had a 22 year old body, and she outshone everyone in the place except for the ballet dancers, and she could have passed for one of those on a bus man's holiday. 

I felt uncool and ungainly, and I realized I had seen her boyfriend wearing a simple Brooks Brothers shirt and slacks when I had seen them together. They were cool and avant garde in their simplicity.

I was out of it.

But today, I find myself still cleaving to jacket and tie. I'll never be cool, that's a given. But it's me.

Learning from the English National Health Service

 

One of my fantasies about how I might send my post retirement days, once I can no longer work in the clinic seeing patients, is a job working for someone, maybe the Department of Health and Human Services (if it were run by someone other than RFKJR) or some foundation, doing a survey of how other countries do healthcare, because, Heaven Knows, the United States healthcare system could use some help.

Canadian discoverers of insulin

Whenever I get off the boat in some European (especially Scandinavian) country, I head right to the nearest clinic to look around at what they are doing. My wife is off looking at some cathedral, and I'm spooking around a clinic, until the security guys throw me out. I do look suspicious.

One of the first things you notice entering any clinic in Europe is there is no secretary sitting behind a computer ready to grab your insurance card, or throw you out. There is usually just a nurse, ready to take you back to an examining room.

I spent 2 months in England when I was a fourth year medical student on an elective in cardiology at The Royal Brompton Hospital for chest diseases, seeing how they did cardiology in England. The hospital itself looked pretty modest, red brick, six bed wards, but fifty years ago they were doing cardiac catheterization through the brachial artery in the arm, and it wasn't until just 10 years ago we started using that technique in any widespread matter here in the USA where we have the world's best medical care, or so we are told. Using a smaller artery is safer, as you don't put the entire lower extremity (foot, leg) at risk and there is an arcade anatomy in the hand which allows for greater safety.

On weekends, one of the local doctors who made rounds at the Brompton invited me and a couple of other American students out to a smaller hospital in Uxbridge, where we were dumbfounded about how medicine was practiced.

The most dreaded admission for an American intern in those days was the "GI bleeder." This was before the advent of proton pump inhibitors reduced the incidence of gastric and peptic ulcers to near nothing, but in those days the GI bleeder was very common. If you were the intern, you spent all night running up and down to the blood bank getting units of packed red blood cells and after you had transfused the patient with 15 units, if the patient was still bleeding, you called the surgeons to haul him off and cut out part of his stomach or duodenum. 

In England, they transfused 2 units and put the patient to bed and then they came around on rounds the next morning to see if he was still alive. 

We Americans were pretty horrified.

But, the thing is, the patients usually were still alive. They bled down to a certain level, and their blood pressures dropped and they stopped bleeding. 

At least that's the way I remember it.

The other thing I remember is talking with patients who were admitted to hospital and asking when they expected to see their own private physicians make rounds on them. The patients were stupefied. "Why would Dr. Jones see me in hospital?" they asked. In America, you expected your own doctor to see you in hospital, to get you past the worst experience of your life, in person. Not in England. In England, the patient was taken care of in hospital by the hospital doctors and once they were home, the general practitioner got a full report.

Forty years later, that is what we do in America--hospitalists now care for patients in the hospital, just the way they did forty years ago in England. The hospitalists are there 24/7 and take way better care of patients than a GP trying to see patients in his office and then, after office hours, driving some distance to try to figure out what was going on with the patient who got admitted to the hospital, issuing orders over the phone for a patient he had not seen since the day before, if at all.

Sometimes, I think what we are doing in American medicine now is catching up to where England was 40 years ago.

England is where the CAT scan and MRI originated, after all. That much disparaged "socialized medical system" has been responsible for as much or more innovation than our much ballyhooed free enterprise, for profit American system.

Canadians discovered insulin. The English did all the big innovations in diagnostic imaging.

But America, we have always heard, is the pinnacle of medicine. At least, we are the pinnacle of bragging about our medicine.

So, my fantasy is to be sent over to England, Scandinavia, Germany, France and to be allowed to spook around those clinics and hospitals, to make rounds with the doctors, to hear the complaints from the nurses and the patients and the doctors--and surely those systems are well known to be underfunded and beset with problems, but we can also learn from them, I suspect because they have learned to innovate owing to cost constraints and they made decisions not based on considerations of profit, but because they have been looking for greater efficiencies in a cold eyed way.

Even if I were part of a team sent by who knows who, what are the chances anything we discovered about better practices would ever stand a fighting chance of changing things back her in the US of A, where we think nobody has anything to teach us?

But dreaming costs me nothing. 

We can always dream

What Should College Be?

 Reading the New York Times in New Hampshire is always something of a magic carpet ride. But this piece on how careerism is ruining the college experience threw the Phantom for a loop.

The author, a young woman, now in law school, described her disappointment to learn that college was not about good times and bull sessions, but about competition and hard work.

"When I pictured myself in college, I envisioned potluck picnics and late nights listening to Taylor Swift, overanalyzing class crushes. Maybe even joining a Quidditch team.

I never daydreamed about hiding in the library bathroom crying because I had just been rejected by an undergraduate law journal."

Sophia Macy

A few years ago Sophia Macy, the 18 year old daughter of movie stars, was caught up in a cheating scandal, when her mother was found to have paid to have her SAT scores altered and she remarked that she never studied for her SAT's or, for that matter, much at all, and what she really thought going to USC was about was going to football games and sorority parties. That of course reinforced the idea of fecklessness.

Isabella Glassman

Now we have this twenty something, Isabella Glassman, complaining about competitiveness in college.

Everyone wants to work for Goldman, Saks or McKinsey or go to Yale Law, Glassman laments.

Quel dommage!

315,126 applicants vied for 2,700 positions at Goldman Saks in 2023!

Undergraduates at the University of Pennsylvania cut each other's throats trying to get into the Wharton School of Business. 

People study long hours and stress out about failing.

Of course, what undergraduates are now competing for is not so much places in medical schools--as medicine is no longer a ticket to avoid the military or even to the upper class, but simply a sort of trade school, where, if you are interested in money, you have to compete for places among the radiologists, opthalmologists, anesthesiologists or dermatologists (the ROAD to happiness.) Or surgeons.  Outside the ROAD, most doctors are making salaries just below or just barely into 6 figures. 

No, undergraduates have become too sophisticated to want to be doctors or engineers--they know the big dollars are in finance, venture capital and all that jazz.  So let the games begin!

Of course, in the 1960's, when Ivy League schools began admitting students of modest financial means, a sizable proportion of these strivers wanted to go to medical school, or to become engineers. The only people more miserable at college than premeds were the engineers, the wags said.

These students took difficult courses and competed to be higher up on the grading curve with a bunch of equally determined and motivated kids.  

Nobody thought about potlucks, football games or Quidditch teams, well nobody who came to college to get ahead thought about any of that. 

Of course, there were still those who majored in French literature or Medieval History, who did not seem to worry much about launching into a job, much less a career after college. They somehow thought life would take care of them as it always had.

But then the Vietnam War blew up, and just about every male on campus suddenly got interested in what lay beyond graduation day, because getting drafted was more likely than not, and every biology, chemistry and physics major suddenly discovered that medical school looked like a very good idea. Medical School was an automatic deferment between 1967 and 1974, and law school could sometimes be finessed into the judge advocate general corps, which was not a bad way to become a veteran without getting shot at.

After the draft ended, maybe things got back to hedonism and fecklessness on campus, but if Ms. Glassman is any guide, kids paying big tuitions may have decided a return on investment is in order, and Goldman Saks looks good.

But, if you are female, not worried about the draft, come from money, you can drift through college, party hard, and if you are still unmarried at graduation, go off to the Sorbonne or the London School of Economics and maybe picnic in Hyde Park, and drift along and maybe get a job in publishing or an art gallery or something toney, and why should college be hard work, or stressful or challenging?

College once upon a time was not about fun but about survival, competing and moving on to the next stage.

Pre meds, engineers and even some pre law students are now "careerists," and much gnashing of teeth happens over the loss of liberal education, the demise of departments of English, art history, Egyptology, philosophy, sociology, history and classics. 

When F. Scott Fitzgerald went off to Princeton, there were no SAT exams and the idea of meritocracy was that your father had gone to Princeton or your family was exceedingly rich.

Now it is all about grubby competition.

After all, if college is not a safe space, where does a girl find a safe space?

Real Life

As Thomas Hobbes noted, if you read Hobbes in college, life can be a drag:  "No arts; no letters; no society; and which is worst of all, continual fear, and danger of violent death; and the life of man, solitary, poor, nasty, brutish, and short."

IF THERE WERE JUSTICE ...

 

You have heard this song.

Arlo Guthrie made it famous. When he does it, the audiences all sing it in harmony, in the refrains.

Willie Nelson, Cheryl Crowe, Glenn Campbell, John Fogarty everyone has done it.

But Steve Goodman, who I have never heard of, and who I bet you have never heard of, wrote and performed it, and listen to his guitar!

He wrote the song, as Arlo Guthrie clearly told the story, and Goodman's version, for my money, is by far the best ever done. But who has ever heard him do it?

https://www.youtube.com/watch?v=e4ztWNJYFrU

Reunion

 

We graduated when we were 26 years old and now 51 years later, about 40 of 90 graduates of the Cornell University Medical College convened at the University Club, in New York City, for dinner.

Each graduate, and if present, each spouse, was asked to get up and summarize his career, fate, life since we last saw each other. (I can use the proper "his" because there was only one woman graduate and I'm sure she'll forgive my antiquated grammar.) Dinner was getting cold, waiting to be served.

A man at my table had returned to Montana/North Dakota, become chief of Obstetrics at the then new North Dakota medical school where he still serves today, although he stopped delivering babies at age 70. Along the way he bought and sold a few banks, built hundreds of homes and office buildings as a sideline.

Another became plastic surgeon to the stars in Hollywood.

A few did most administrative stuff: one had organized the government's efforts to deal with HIV, as he worked first at the CDC, and later in the American program to fight HIV globally. Another reshaped medical school curricula, and helped organize and found a new Canadian medical school.  Someone else made an infectious disease career in the diabetic foot, but that took him to a professorship at Oxford and he authored numerous books and papers. Two others became founding fathers of Emergency Medicine--when we graduated there was no specialty of Emergency Medicine--one in Arizona and one in Washington State. The latter organized a company to sell Emergency Medicine groups to hospitals and today many hospitals contract out their ER departments to his organization, which is the largest employer of ER doctors in the country. The same guy got an MFA from the University of California and made a documentary about ER medicine. 

There was an astonishing story about the one woman: She was the wife of a Cornell first year, and she was attending NYU medical  school, and she wanted to join her husband and she was told that because one of the 5 women in the class was leaving, there was now a "woman's spot" available. Looking back at the classes since 1945, there had always been either 4 or 5 women in every class of 90. During the war years, the classes had 50 women but then reverted to 5 after the war ended. The men who ran the admission committee had no qualms about quotas. Until the 1960's there were only 5 Jewish names and 1 Black. When you think about the ills of "affirmative action" you have to consider how many years there was affirmative action for White Christian males.

As it happened, I was the last doctor to speak and all I could say was that I was inspired to go into Endocrinology by a pediatric endocrinologist named Maria New, who everyone there knew, and Maria, having come from a family of professional musicians, realized that unless you are the very best, there is no point in trying to be a musician, so she chose medicine because that's a field where even if you were mediocre, you could still do a lot of good and make a decent living. (Of course, coming from Maria, that was funny, because she was among the very best of pediatric endocrinologists, and did several ground breaking studies.) So, I said I had practiced endocrine, first in private practice, and now for a corporation, and I presided over a mediocre practice, although I've gotten progressively better at it, but after more than 50 years of practice I've probably done more good than harm, in a mediocre sort of way.

What was more impressive to me than the curriculum vitae of those who attended, was the fate of ten classmates who could not attend because they were dead. Some died young, one from suicide, one from an accident, others from causes unknown. Several of their wives, who I remembered clearly from medical school days, had died young, one from breast cancer at age 39. 

Most had made enough money for beach homes, pied-a-terre apartments in New York City, and only one I could identify practiced, as I do now, in an underserved area with patients who are at the bottom end of the economic strata. 

There was a lot of talk about how we were taught to provide the best type of care--the importance of laying hands on the patient, of establishing a connection with the patient, all things which are now considered mere "theater," things which are unnecessary and self indulgent, because, after all, you can see a thyroid, examine a thyroid way better with a sonogram than with your fingers, so why bother touching a patient's neck?

A neurologist spoke of having patients presented to him by young doctors who never bothered with a physical exam, once so essential to figuring out where the brain tumor was, but instead now they present the brain CT or MRI, and never mentioned whether the patient was hemiplegic. 

One doctor told how he had been told to evaluate a patient at Cornell, as a student, and he had done what he thought was a complete history and physical exam but after he presented the patient to his professor, the professor asked if he knew who the patient was, or what she did in life and he had to admit he did not. He knew she had pneumonia. And the professor said, "The patient is Aretha Franklin. Next time don't forget to do the 'Social History' (SH) part of the work up." (It is the SH where you ask where the patient was born, grew up, got educated, what kind of work they did and marital status and where they live now.)

Now, of course, that "Social History" is given short shrift, and young doctors refer to it dismissively because it takes time, and when you are trying to see 30 patients in eight hours, that means roughly 15 minutes a patient and there are a lot of labs and imaging studies to review during that time.

When I arrived at my job in New Hampshire, I found there were no examining gowns. How was I going to examine a woman's heart without an exam gown?

"Why would you want to listen to her heart?" I was asked. "You're an endocrinologist!" 

I really had no answer, other than that's the way I always had practiced medicine, the way I learned it, and I really could not remember why. 

Well, now I know why: because that's the way I was taught. I might be the only doctor to see that patient for a year, and why miss a high blood pressure, atrial fibrillation or a melanoma because you were supposed to focus on just her thyroid, and then move the patient on to the next doctor--who she would likely never bother seeing? That in the flesh encounter is your last  chance to actually do the patient some  good.

At least now, I know where I got most of my bad, inefficient, self indulgent habits.

Trump Will Eat Your Pets!

Everybody's saying it. And I saw it on TV, so it must be true.

All those ketchup ladened French Fries thrown against the wall, were part of a special "Cat and Dog" dish he likes.

And there are miles of caravans, thousands of criminals and insane asylum escapees headed your way, especially if you live in Michigan, Pennsylvania, Georgia or Arizona all because they want to go to his massive rallies, which are bigger than any rallies in the history of the world and definitely not boring. 

Those are the best places for out-of-staters to feast. Ohio was just the beginning.

South Carolinians are crossing the border into North Carolina and not the best ones--they don't send their best; they send the pet eaters.

And don't get me started on Maryland, which is where, you know, the Wire happened, and all those bodies wound up in the vacant houses and Hannibal Lecter had a field day. Jodie Foster was lucky to escape with her life. Oh, lovely Jodie. Poor Jodie, you know she was a child hooker before she became an FBI agent? Very sad. And Maryland shares a border with Pennsylvania: Marylanders are just pouring across that Southern border into Pennsylvania by the thousands, looking for pets, and women, White women. They eat the pets and rape the women in Pennsylvania. 

Is Hillary out of jail yet? You know we didn't lock her up long enough. I bet she's headed to Springfield right now. She has a taste for a certain type of cat, I don't know which type, but she's a very nasty woman with a big cat appetite.

Did you know he could shoot someone on 5th Avenue and nobody would blink an eye and his fans would still vote for him? Everyone says so.

 He's done worse, really. Raping that woman, who was definitely not his type, in the back of that store and we won't even talk about Jeffrey Epstein, but you'd be surprised what we are finding out about him! That was the Clintons who did Jeffrey, who was a very nice guy. A good friend of Alan Dershowitz, you know.

And Alan just changed parties: He's no longer a Democrat. He couldn't stand being forced to eat dogs, which is what all Democrats do. But Republicans don't stop at the cats and dogs--they go after the children, or at least White children. White Christian children.

But the best part is, if you vote right, you'll never have to vote again, ever. Which is such a pain. Having to wait in line with all those foul, stinky immigrants the Democrats imported to vote for them but are now voting for Republicans, which is just so perfect. Really.

Really, I don't know why I bother. 

You can take a bullet for Democracy and all you get is complaints.