September 8, 2023 

Dear Interested Readers,

 

Moving On With My Story

 

In retrospect, internships are a transition from mostly watching as a medical student to progressive hands-on doing. The residency years were a surprise to me because I had to back away from the direct patient contact that I relished to accommodate the next new batch of graduates who as new interns were eager to have their turn at the bedside. The grind of a mostly every-other-night internship was over. As a junior resident, most of my rotations were every third night. The other new angle was that we had two rotations in other hospitals, Cambridge City Hospital and the West Roxbury VA Hospital. 

 

The West Rox VA had a totally different rhythm than any teaching hospital that I had ever experienced. Patients often stayed for months, and at times very strange things happened. I only heard the story and can not verify its truth, but I was told that not long before I arrived a veteran had been taken by stretcher to the dental office for treatment. By accident, he was returned to a surgical ward where he stayed for six weeks before someone on the medical floor recognized that he was missing and went looking for him. The most bizarre event of my entire career is described below and serves as the perfect example of the alternative universe of medical care in the VA system of the early seventies.

 

The medical service occupied the fourth floor of the building which looked more like a “Georgian” architectural style college building than a hospital. To fit into the external picture, the windows on the front of the fourth floor stretched from the ten-foot ceilings down to about a foot above the floor. They were the size of large doors. A large common bathroom at the front of the building contained two or three of these windows. The bathroom was used by the patients who were ambulatory. 

 

One of the patients admitted to our floor had suffered a pulmonary embolism. He was treated with an “umbrella” that was placed in his inferior vena cava. Like many of the other elderly veterans, most of whom had served in World War II, with even a few from World War I, who may have suffered from excess alcohol consumption or just the impact on the central nervous system of a difficult life, he must have had some problems with orientation after dark that we didn’t fully appreciate. After he was better and ambulatory, sometime after midnight one night, the gentleman awoke with a need to go to the bathroom. It was summer time and someone had widely opened the large windows in the bathroom. There were no screens. The plausible speculation that is perhaps the best explanation for what happened was that when he had completed his business the old veteran came out of the stall and walked straight ahead rather than turning left toward the door. 

 

Fortunately, we had recently had some rain and the large rhododendron shrubs directly below were sitting in very soft soil. I have no idea what was going through the gentleman’s mind as he quickly descended the four floors into the bushes. The descent and his landing in the bushes must have jarred him into a higher state of awareness. He dusted himself off and hobbled around to the emergency entrance where he was readmitted to the orthopedic service with a broken leg. His readmission chest x-ray revealed that the antithrombotic “umbrella” was now in his superior vena cava. A bad joke was that it was the umbrella that allowed him to float down like Mary Poppins to a relatively soft landing. Before the day was over, there were bars covering the windows in the bathroom. More than thirty years later, my wife enjoyed taking care of many veterans as a nurse practitioner working on the cardiology service at the same VA hospital where for eight years before she retired, she managed older veterans who had CHF and other cardiac issues. Her office was on the fourth floor and she knew the famous bathroom and launch pad quite well. 

 

Perhaps the most formative experiences of my residency years did not occur in teaching hospitals or even in the affiliated peripheral hospitals where we rotated. As I have discussed in a previous letter, I did a lot of “moonlighting” in local suburban hospital emergency rooms. At the end of the internship year, we took the National Boards. With a completed internship and my national boards behind me, I was eligible to practice independently, and on the advice of one of my residents, I was quick to get my medical license so that I could “moonlight.” For years Brigham residents in need of income had covered the Lowell General Hospital emergency room on nights and weekends. My resident recommended that I take his place on the schedule since he was moving to Chicago for a GI fellowship.

 

Lowell is an immigrant community that in the nineteenth and early twentieth century had many mills that were powered by huge canals constructed to divert water from the Merrimack River. There were many similar mill towns along the Merrimack River in Concord, Manchester, and Nashua, New Hampshire before the Merrimack flowed into Massachusetts where there were mills in Lowell, Lawrence, and Haverhill. In part due to efforts by former Senator Paul Tsongas, Lowell is a National Historic site. Many of the mills have now been converted into housing.  

 

Lowell had three hospitals at the time. Two Catholic hospitals which later merged served the area around the mills in the rundown areas of the city and the “Acre” which was a well-known ethnic neighborhood. The Lowell General is on the north bank of the river across from the mills. The north side of the river was where the mill owners and managers lived in more palatial homes. The name of the hospital suggested that the Lowell General might be an inner-city hospital, but it was not. In the seventies, the hospital was on a wooded knoll a few hundred yards from a bridge across the river. The area looks almost rural. I would frequently enjoy a thirteen-mile run up the road along the north side of the river toward Tyngsborough where there was a bridge that allowed me to cross to the south side of the river and run back to the bridge that connected the mill area of Lowell to the north side of the river near where the hospital was located. It was a beautiful run and a payoff for a hard day’s work.

 

The Lowell General had a fine, up-to-date, physical plant and a significant endowment. The emergency room was large, well equipped, and had a very comfortable adjacent on-call room and bath where I could sleep or watch TV when things were slow. Some of the poorer patients from Lowell did find their way across the bridge to our emergency room, but there were also more affluent patients who used the hospital which created a very interesting mix of patients from a wide socioeconomic spectrum of the area. Many of our patients were from the lovely surrounding old New England towns like Chelmsford, Billerica, Westborough, and Tyngsborough where many of the employees and managers of the growing computer industry in Massachusetts lived in large upscale homes and well-restored colonial antique houses.

 

There was a large medical practice in Chelmsford that used the hospital. Ironically, years later that practice became part of Harvard Vanguard and Atrius Health. I now drive down to the Chelmsford offices of Atrius Health for much of my own care. The pictures of many of the old docs who would send their patients to see me in the Lowell General EW hang on the walls of the newer building that now houses the multispecialty practice. Part of the merger included the renovation of a large building which was purchased when the group joined us.

 

As I said in my previous writing about my Lowell General experience, most of the time I was there on weekends and overnight on weeknights, I was the only doctor in the hospital. Doing a 24-hour weekend EW shift exposes you to some formative experiences. I treated major burns, patients with heart attacks, pneumonia, strokes, victims of motorcycle and car crashes, children with meningitis, victims of parental sexual abuse, and thousands of colds, fractures, and lacerations. It was not uncommon to have more than 100 patients on a long Saturday or Sunday. I learned a lot very fast.

 

I was in my late twenties and could fold several shifts a month into the every third-night rotation which often meant long stretches without much sleep. I didn’t think it was crazy because there were other residents before me who had done the same thing. The experience also exposed me to fee-for-service issues because most of what I earned was from billing for my services. I quickly got a billing service to help me. The collection rate was about 55%, so there was a lot of “free care.” We billed by the stitch which exposed me to the challenge of doing only what was needed. I was forced to decide to develop an ethic of doing only what was needed and not to add extra stitches to enhance my return. Years later, I was convinced that the high cost of medical care was in part due to fee-for-service billing for work and tests that did not add value to the patient’s care. I understood the temptation because I had experienced the frustration of not getting paid for work that I had done, and having the temptation to bill for unnecessary services. 

 

Back at the Brigham, I was in a different world where the most capable advisors were at hand. In Lowell, I was on my own and wondering what sort of challenging patient might be coming in the next arriving ambulance. When It was very busy I needed to learn how to triage my efforts, depend on the excellent help of experienced nurses, and finally make the call to a local doc for help. Those calls were often not well received.  

 

I continued to work at the hospital until 1979 when the chief of the medical practice at Harvard Community Health Plan gave me the ultimatum of giving up HCHP or giving up the Lowell General. By then I was well known as a source of primary care in the emergency room. I would often see patients who had no other care and who had the obvious need for some sort of disease management. I would start a med or recommend some test or treatment and then tell them that they could see me in follow-up in the EW. After a few years, the compensation changed to an hourly rate which was fine with me and shifted the uncomfortable burden of billing to the hospital. It always felt awkward for me to see my name on a bill “for services rendered.”

 

My seven years working in the Lowell General Hospital and some occasional work at the Cardinal Cushing Hospital in Brockton, Massachusetts (Now a part of Steward Health and called The Good Samaritan Medical Center.) were a great source of experience for me, but I fear that it came at a high cost for others. I had two small sons and missed much of their early years which also put a huge burden on my former wife which may be a partial explanation for why that marriage did not last. She had her own career and was often away on a business trip so occasionally I took my boys with me. They would watch TV in my on-call room while I was working. One thing that I frequently question and have rarely seen in the discussion of burnout or moral hazard in medical practice is the impact on the families of stressed physicians. Even though  I accepted my stress, I was forcing my wife and children to go along with what I could justify for economic or professional reasons. I regret that there are no complete “do-overs” in life. 

 

Unless something new or forgotten comes to mind, I will make this the last of my reflections on my house officer years. Next week I will move on to my experiences as a cardiology fellow and how it came to be that I was employed as a cardiologist and primary care physician at the Harvard Community Health Plan It’s time to move on toward the challenge of learning how to work in the social experiment of a large capitated multispecialty group practice. Life did move on on the conveyor belt of medical training. 

 

Finally, A Summer Weekend

 

About once a week, Lily, our cat, wakes my wife in the predawn hours. Lily recently passed her sixteenth birthday. She is slowing down, but she still rules. We have had two cats that made it to nineteen, but according to our vet, Lily has chronic renal failure. The vet prescribed a special diet and my wife has responded with special treatment all around although I am told that Lily will be our last cat. We have already had our last dog whose ashes sit with his predecessor’s ashes on a bookshelf in our living room. The only positive thing that I can see about Lily’s limited outlook is that I will be moving up from number three to number two after all the sadness resolves. 

 

My wife is very happy to address all of Lily’s nocturnal needs, but there is a cost to her kindness because it often means that she never goes back to sleep. The upside to rising somewhere between four and five-thirty in the morning is that she gets to take some great pictures of the early morning sky. Today’s header was the payoff for a short night’s sleep last week. 

 

Well, summer finally arrived on Labor Day weekend. This week we have had the weather that often comes in mid-July. This is the first summer ever that we have not needed to water the grass or the garden. We have had our house on Little Lake Sunapee for fifteen years. I’ve never seen the water level higher. This summer the brook that flows out of our lake toward “big” Lake Sunapee washed the road out twice. I don’t think the road has ever washed out before. I don’t think we are living in “end times,” but we are living in the “new times” of global warming.

 

As a preview of what is to come, I have been reading Kim Stanley Robinson. His 2017 book, New York 2140, paints a picture of a New York City where people live in buildings that are partially underwater after most of the polar ice has melted. The partially submerged buildings are connected by walkways like the current High Line Walkway in lower Manhattan and those buildings that haven’t toppled over now have docks to accommodate the boats that have replaced cars. 

 

The New Yorker had an interesting look at the book that gives a good picture of Robinson’s vision:

 

It’s spring in New York City. At Twenty-sixth and Park, the waves shine in the sunlight, and the breeze is briny with seaweed. Morning commuters are boarding a crosstown vaporetto. Out on the canal, finance guys in speedboats weave between the bigger ships. Workers in an inflatable raft are repairing the Flatiron dock; a superintendent, in diving gear, is checking his buildings for leaks. The super-rich live uptown, in a forest of skyscrapers near the Cloisters. The poor live downtown, in Chelsea, which is half-submerged.

This is the vision of the city in “New York 2140,” a science-fiction novel by Kim Stanley Robinson, out last month. It’s surprisingly utopian. New York may be underwater, but it’s better than ever. Sure, it was a rough hundred years for the planet: the seas rose ten feet in the two-thousand-fifties, then forty feet more around 2100, and billions of people died.

 

If that seems far-fetched, I offer you his most recent novel, Ministry For The Future, which also has a theme based on global warming that seems very plausible after this summer of fires and heat domes. A New York Times review of that book underlines how Robinson has become an effective voice for efforts to curb global warming.

 

Last fall, the science fiction writer Kim Stanley Robinson was asked to predict what the world will look like in 2050. He was speaking at the United Nations Climate Change Conference in Glasgow, and the atmosphere at the summit — billed as the “last, best hope” to save the planet — was bleak.

But Robinson, whose novel, “The Ministry for the Future,” lays out a path for humanity that narrowly averts a biosphere collapse, sounded a note of cautious optimism. Overcome with emotion at times, he raised the possibility of a near future marked by “human accomplishment and solidarity.”

 

That “optimistic” novel begins with an extreme “heat dome” over India in the 2040s that generated a lethal “wet bulb temperature” that killed 15 million people when air conditioners failed and people headed to the water in a futile effort to get relief. The event initiates a militant response that results in the CEOs of energy companies being assassinated and the Lear Jets of the wealthy being the targets of climate vigilantes. After this summer when the Northeast had too much rain and overcast chilly weekends while most of the world was being baked, blown, and burned, almost anything is possible.

Be well,

Gene