August 4, 2023
Dear Interested Readers,
The Story Continues
If you have read my last two letters, you know that those letters were autobiographical. I have never resisted tossing events from my life into these notes if my personal story illustrated a point, but I have never made the story the primary objective of a post. You may ask, “Why now?” The best answer I can give is that I hope that writing a more complete description of the steps in my life that led to the current moment will be an exercise that might facilitate a deeper consideration and provide a greater understanding of the complexities that complicate this moment in healthcare.
I doubt that my story is unique. I am sure that there are elements within it that are common across the lives of many healthcare professionals. I began the journey from the perspective of a review of moral injury which some authorities believe is a more accurate explanation for the state of mind of many providers than the concept of burnout. As I have said, I practiced in a very unusual environment that effectively protected me from moral injury, but as I noted in a letter in 2015, not all my colleagues had the same experience.
Based on my own experiences, and through contact with many provider organizations, I can see that there are probably many clinicians who feel that they are being crushed by an industry that is operating in a way that is antithetical to the personal values that motivated them to go through the many steps of training that were required of them. As I implied last week when I described my psychoanalysis with Dr. Magraw, looking back has always helped me to look forward. Today there are many problems that compromise the delivery of equitable care. How did those problems evolve, and what changes might be made if we want to improve? My story only adds one person’s perspective, but perhaps it is a start. It’s all I have that I know to be the truth. I should add here that total factual accuracy is not necessary for the faithful presentation “of the truth.” My attempt to relate the story of my evolution as a doctor is as accurate as I can make it given the way memory works and the fact that it has been 65 years since sometime in my early teens, I first entertained the idea of becoming a doctor.
As an example of selective memory, as I reflected on what I told you last week, I realized that I omitted one big story, and perhaps a few smaller details. I’ll skip the small stuff, but the big story was that for most of the four years that I was in college I had a job as a nursing assistant, or as male nursing assistants were called in the hospital where I worked, I was an orderly. I talked a lot about my experience as an orderly in my medical school applications and interviews. I think the experience made me somewhat unique.
Once again my father was a significant actor or factor in my life. It was his idea that I could check out a life in medicine by becoming an orderly. Ultimately, my Dad was supportive of my being a doctor as long as I did not want to be a psychiatrist. There is some irony in the fact that he did not want me to be a psychiatrist since in the late seventies when he was preparing to retire, he took a three-year training program offered in pastoral counseling by the Worcester State Hospital and Andover-Newton Seminary to become a licensed pastoral counselor. When he did retire in 1982, he and my mother moved to her childhood home in Lincolnton, North Carolina where he built an office building next to the county hospital and opened a behavioral health practice. At the time he was the only licensed mental health worker in Lincoln County.
As an aside, the county and the town are not named for Abraham Lincoln. The names honor General Benjamin Lincoln of Massachusetts who was a general in the Revolutionary War. Lincoln was assigned by Washington to lead Patriot forces in the South and had the honor of receiving Cornwallis’ sword at Yorktown. During the war, there was a significant battle, the Battle of Ramsour’s Mill, between Patriots and Loyalists in what is now Lincolnton in 1780. My earliest ancestors in the area arrived in the 1790s, but the family that lived next door to my grandmother were Ramsours. Other significant battles nearby were The Battle of Kings Mountain and The Battle of Cowpens. It is noteworthy that a big element in all these battles was the conflict between “Patriots” and local loyalists who were their neighbors. At times it was brother against brother. We should remember in these times of intense political disagreements that even at the birth of our nation there were political disagreements that led to mortal combat between neighbors and within families.
After football season in my freshman year at the University of South Carolina, my father asked me how sure I was that I wanted to be a doctor. He suggested that I should get a part-time job at one of the local hospitals so that I could “gain some experience” that might help me be sure that I really wanted to be a doctor. The largest local hospital in Columbia, South Carolina was South Carolina Baptist Hospital which was just across the street from The First Baptist Church of Columbia where we were members, and where the convention that resulted in the secession of South Carolina from the Union had occurred in December 1860. South Carolina Baptist Hospital was where I had been admitted just a year before for an in-patient workup of my hypertension. At the time, my father was the Secretary of Evangelism for South Carolina Baptists, and he knew the hospital director whom he asked to give me a job after explaining the objective.
I never had an orientation to the work, nor was I given any formal training, but it did not take the nurses long to give me the “on-the-job training” that I needed to very quickly begin to get a feel for life in the hospital. The hospital had no house staff. Physicians admitted, worked up, wrote orders, and rounded daily on their own patients. At the time the closest medical school was in Charleston. There were no hospitalists, and I think the emergency room was covered on a rotating basis by younger physicians who were “building their practices.”
It did not take me long to begin to notice some differences among the doctors that I observed. Some were better than others, but all were interesting for me to observe when they came in to see their patients. I also noticed how they interacted with the nurses. The ones I admired most listened to their patients and the nurses. The nurses had “made book” on all of them, and when the doctors left to go to their offices the nurses were quite free with their assessments, good and bad.
I soon realized that the hospital was really the domain of the nurses. Some of the doctors were visitors from a different planet who were barely tolerated by the nurses. Years later as a house officer, I went out of my way to establish good relationships with the nurses. I learned a lot from them, and I am sure they “protected” me, especially when I was trying to get some sleep. Columbia is the state capital of South Carolina, but in 1964 its largest hospital as well as the somewhat smaller local Catholic hospital operated much like our small town and rural hospitals function today, and this is likely true in the majority of America’s more than 6,000 hospitals today where I am sure the nurses are still the key to better hospital care.
When I was hired as an orderly, I was told to wear white pants, a white shirt, and a black bowtie when I came to work. My father taught me how to tie the bowtie, and ever since then, I have been wearing bowties. During the school year, after football season, I would work weekends and holidays, and I was full rime through the summer. One of my biggest jobs was bringing large oxygen tanks from the hospital loading dock to the bedside of those patients who were on oxygen. I wheeled patients to tests, to get X-rays, and to the morgue. I carried samples to the lab, and I picked up meds at the pharmacy. I helped the nurses give bedbaths. I learned to make beds. I walked post-op and other recovering patients in the halls. I set up orthopedic frames over beds. I helped the nurses change the bandages on severely burned patients. I restrained patients or put restraints on the patients who were delirious or were in the “DTs’ when I was directed by the nurses to do so for the patient’s protection. I was taught how to use sterile technique to place male urinary catheters and recorded the inputs and outputs. I was also taught to give enemas to men. One of my worst memories from my own hospitalization was being awakened in the middle of the night by an older man who was an orderly. He told me that I had to have an enema to prepare for the IVP that was scheduled in the morning. Except for giving enemas, I loved everything about the work. I especially enjoyed talking with patients and the sense of comradery that I often shared with the nurses. It was great when I was occasionally acknowledged by a doctor.
In retrospect, the experience gave me an insight into how important other healthcare professionals are to the delivery of care and to the optimal outcomes we desire. I also observed that some doctors treated the staff like “hired help,” and did not give them the respect that they deserved as essential team members. Some seemed to be in a continuous competition with the nurses and their demeanor was a demand for deference. One of the things that drew me to embrace Lean years later was the way it emphasized teamwork and the importance of appreciating the insights of the “frontline” people who worked at the “interface” with the customer.
When I started working at the hospital, I was given the minimum wage which in 1964 was $1.15 per hour. After taxes and Social Security, I cleared about $0.95 an hour. I don’t think I ever got more than $1.25 per hour, but what I got in experience was worth a fortune. I thoroughly enjoyed all my interactions with patients and especially enjoyed working with the nurses who went out of their way to make sure that my experience would be a valuable preview of my future life in practice. Once again, my father had given me valuable advice. He said that I should be sure that I wanted to be a doctor before I entered medical school. After my experience as an orderly, I was more convinced than ever that I was “meant to be” a doctor.
My wife and I graduated from the University of South Carolina in early June 1967 and had to vacate our student apartment. It was a very nice two-bedroom garden apartment with a little backyard for which we were charged $55/month, utilities included. The day after graduation we filled up a U-Haul trailer with all that we owned and headed for Boston. As we drove north, we were listening to news accounts of the six-day war in Isreal. We arrived in Watertown Square in the late afternoon of a very chilly and overcast early June day with temps in the low fifties. It was a shock coming from South Carolina which we had left in hot and humid weather. The weather was the first of many factors that made our move to New England almost like a move to a foreign country.
In the interim between when I was accepted to medical school and our graduation, we had made a trip to Boston for my wife to find a job and for us to find an apartment. My wife was hired as a junior high English teacher in Needham, and we were able to find a “garden apartment” off Trapelo Road on the Watertown-Belmont town line which was a very good facsimile of our campus apartment in South Carolina except for the rent which was $142 plus utilities. The apartment complex was popular with married students at the Harvard Business School and Harvard Law School. It was convenient for my wife’s commute down Route 128 to Needham, and it was a doable but long commute for me and our two-year-old son to the medical school for me in the Longwood Medical Area and his daycare in Brookline.
For my first year in medical school, my son and I took a bus from our apartment to Watertown Square. We would walk across the bridge over the Charles to the trolley line terminus and turn around. We rode the trolley to Union Square in Brighton. In Union Square, we would transfer to a bus that eventually traveled down Harvard Street through Brookline Village to connect with Huntington Avenue near the medical school. I would get off the bus in Brookline and walk my son two blocks to his daycare. The walk from Harvard Avenue to his daycare was up an incline that he called a “long, tall mountain.” After he was playing happily with the other children, I would get back on a subsequent bus to complete the trip to the medical school. My wife would pick up our son at the end of the day. The positive things about the long trip were the time that I spent with my son and the introduction that the commute gave me to the working-class culture of Boston.
I was amazed at how hard the “activities of daily living” were in a northern city versus the relative ease of life in the “sunny South.” By the beginning of my second year, our name had come up on the waiting list for a Harvard University apartment in a high-rise complex on the Charles River across from the B-school. Tricia Nixon and her husband lived in our building. There were other medical students in our complex and I often rode with one of them or took the “Red Line” of the “T” from Harvard Square to Park Street Station and from there the “Green Line” out to the Medical School. Most of my classmates lived just across the street from the Medical School at Vanderbilt Hall. Between classes, I enjoyed the athletic facilities and the cafeteria food in Vanderbilt Hall. Vanderbilt Hall also housed the student health services where I had the privilege of getting care from a very famous retired doctor, Professor Hermann Blumgart the former Chief of Medicine at Beth Israel, (please read his NY Times obit) as my doctor. I saw him often because before ACE inhibitors my blood pressure was difficult to keep below 200/100. I was actually deemed 4 F when I went for a Berry Plan physical in 1972. Dr. Blumgart loved to practice and I think he thoroughly enjoyed his interactions with the students and employees who received care from him. I was inspired by and felt honored by the ability to see him. He always inquired about how things were going with me. He was an inspiring role model.
My medical experience in Boston began before medical school. Shortly after we arrived in Watertown, I got a job working as a lab assistant in a neurochemistry lab that studied cardiolipins at the McClean Hospital in Belmont which was not far from our apartment. The researcher for whom I worked did not give me much supervision. Each morning I got a written list of things to do while he sat in his office reading and listening to classical music. It was a paycheck. I was fascinated by the McClean campus and the underground tunnels that connected its buildings. At the time, I knew that some famous people like Sylvia Plath had been patients at McClean. I did not know that James Taylor was a patient not long before I worked in the lab. Other creative people who got help at McClean included John Nash (A Beautiful Mind), Ray Charles, Marianne Faithfull, and David Foster Wallace.
As a third-year medical student, I did my psychiatry rotation at the McClean Hospital, I was very excited by the experience. When I told my father that I thought I might want to consider a career as a psychiatrist his response was, “I hope that you won’t waste your medical education by becoming a psychiatrist.” I was surprised by his negativity and as I implied earlier, I was really miffed when about ten years later he retired from the ministry to become a mental health provider. He never explained his opinion or his later personal choice. My response was to always be aware of the emotional status of my patients. I greatly valued my behavioral health colleagues and frequently got “curbside” consults from them in my attempt to improve my own behavioral health skills. Some of my most difficult patients had borderline personality disorder. One of my psychiatric colleagues told me that success was just staying close enough to them that they kept their next appointment.
I remember the summer of 1967 as lasting a very long time and being the chilliest summer I had ever experienced, but I think it was good to spend the time getting settled before school started. Finally, it was September and the first day of my medical education had arrived. Despite the chilly summer, I remember that first day of medical school as being rather warm and muggy. My class was gathered in the amphitheater of Building C where most of our lectures would occur over the next two years. Dr. Ebert, our dean, welcomed us to the school and to the beginning of our professional lives. After Dr. Ebert’s welcome, we were marched down Longwood Avenue past Children’s Hospital and around the corner onto Brookline Avenue to the front entrance of the Beth Isreal Hospital. We were directed to a large amphitheater where we were to be given our first “clinic” by Dr. William Silen who had recently come to the BI as the chief of surgery. Dr. Silen was “a force” at the medical school for most of the next fifty years. Dr. Silen lived to be 95 and died in September 2022. So, he was only forty on that day in the fall of 1967.
The curriculum at Harvard Medical School in 1967 was pretty traditional. During the first year, we had lectures and labs in the basic medical sciences. I guess the idea is that we should first learn how the body worked when it was well. In the second year, we began to focus on how things could go wrong. In the last half of the second year, we got a taste of the hospital when we took a course in physical diagnosis and history taking called “Introduction to the Clinic.” The problem from the students’ point of view was that when we arrived for the first year many of us were expecting an immediate exposure to practice which was still almost two years away from us in the future. The solution that was supposed to connect what we were learning to the “hands-on” experience we craved was weekly “clinics.” Clinics were on Saturday mornings and most of them were in one of the Harvard teaching hospitals. In the usual clinic, we sat in an amphitheater and listened and watched while a senior physician would interview and examine a patient while introducing us to some disorder or procedure that was in some way connected to our recent classwork.
The walk over to the BI from the Medical School was just far enough and just hot enough to get many of us a little sweaty. Soon after Dr. Silen began his presentation the lights in the amphitheater were turned down and we were sitting in darkness. Dr. Silen talked for a while and then began to show us a film of an operation. The patient was draped. The surgeon (probably Dr. Silen) was gowned. The camera focused on the ink line that crossed pink skin in the opening at the center of the surgical field. You could see the surgeon’s gloved hand with the scalpel. The scalpel was drawn across the skin and it parted. Yellow fatty tissue was exposed and red blood began to ooze and spurt from vessels in the skin that were immediately cauterized or compressed with a gauze sponge. That was what was happening on the screen while in the darkness we began to hear thumps as several of my new classmates passed out. I think there must have been a few dry heaves, but the thumps were what I remembered because I was fighting my own autonomic symptoms. Perhaps the heat or the walk set us up, but it was most likely the incision with the parting skin edges and the blood that was the trigger. I don’t remember Dr. Silen breaking his stride. The clinic continued without a pause. It was a dramatic beginning to the long, but interesting road that still lay ahead before we would really be doctors.
Over the next four years, I would get to know most of the one hundred and twenty fellow students who arrived with me that day as well as the forty students who joined the class as transfers at the beginning of the third year. For the first two years, most of our classes were also attended by a small number of students from Harvard Dental School which was adjacent to the medical school. Almost fifty-six years have passed since that first day, and only a few days of those first four years remain vivid in my memory, but I know that the process was transformative. I am sure that by the time we graduated in 1971 all of us could have watched Dr. Silen’s little movie in a sauna without anyone fainting. Each of us had changed and had been shaped for a life of some kind of service.
I am certain that the students that enter medical schools this fall will have somewhat similar experiences to the ones that I will be describing as I continue to present my experiences. In many ways what lies ahead of them will be even more exciting than my story. I know that the classes will be more diverse. There was very little diversity in the Harvard Medical School class of 1971. About 10% of my classmates were women, and less than 5% were from non-White minorities. What I am most concerned about for our collective future is that there will not be enough new doctors in the class of 2027 to meet our nation’s needs. This last week the Kaiser News service picked up on Bernie Sanders’s statement that “tens of millions of Americans don’t have a primary physician.”
I don’t know how we will correct this deficiency without major changes in public policy about medical education. Those changes seem unlikely to get much attention in the near future given what appears to be growing apathy about the state of almost everything in America. In his last podcast entitled “Ask Me Anything” before taking a break to write a book, Ezra Klein was asked to explain why healthcare has moved down the list of our collective political concerns. Klein gave an unusually long answer, which you can find if you click on the link or check out the transcript of the show. His comments are about a third of the way through the transcript. After his long discussion, he summed up his conclusions and what he thinks many other people think by saying:
When I think of what I would want, any kind the Congress, any kind of unified Congress and presidency, to make their top priority, it is hard for me to say further health reform…It’s not that health care is great in this country. It’s not. But political capital is so limited, and enough people here are doing well enough, and the moving it that last couple of miles would be so difficult that I think, when you imagine what are the single bills you could pass that would lead to the largest well-being improvements, it’s hard for me now to say that it’s health care reform, both because its status as an economic problem has abated somewhat and its status as such like, we have this huge uninsured population, has abated somewhat.
So I think it’s just become more of one issue among many rather than the central issue that is causing both employers, and budget wonks, and normal people incredible amounts of pain.
I bolded the last sentence. My take is that Klein is saying that the ACA has made a difference, but it hasn’t solved all the problems. The ACA blunted the pain that most people feel enough that the majority of people, those who have no active health care issues, have other concerns, and they are not concerned enough at the moment about the deficiencies in healthcare to make improving healthcare a high priority. That same majority of Americans don’t suffer much from disadvantageous social determinants of health either. Perhaps, in time as “getting care” becomes a greater problem for more people, even if they are “covered,” healthcare will move up the ladder of concerns once again.
I would say that similar to the workforce shortage of doctors there are even more dangerous shortages in nursing. As was true when I was an orderly, nurses are providing the majority of hands-on bedside attention in most of our hospitals. The nursing crisis is particularly acute in small-town hospitals where there is often no doctor or only an emergency room doctor for much of the day. We have tried to augment our medical workforce by importing physicians and changing the character of the workforce to include Advanced Practice Clinicians: Nurse Practitioners and Physician Assistants. Those are all good strategies, but they are not enough to cover our needs now, and they won’t provide adequate access to care for all Americans in the future. For many years some of the Boston hospitals “imported” Irish nurses. We still import nurses, and most of the nurses we import, like the doctors we import, come from “third world countries” where there are even greater needs. Is that ethical? We have a problem that has been brewing for most of the past fifty years. We won’t solve it overnight or in the next few years, but we must start now to give it much more effective attention than it has been getting.
I will continue the story next week.
Less Rain, Cooler Days, Chilly Nights, Plenty of Flowers
I am not complaining. We have had some beautiful days this week. The rain when it comes has mostly been in the afternoon and evenings. It’s just been cold. On Tuesday it was 65 with a chilly wind. I reverted to a wet suit for my afternoon swim. During the night the temp dropped into the 40s, and I put on an extra blanket. Did we skip August? It has felt like we went directly from the sweltering days of July to sometime in the mid-fall. It has been a strange summer, but as you can see from today’s header, our flowers are loving it. Our gardens are out of control.
I really like daylilies. Hydrangeas are nice also. I once had a patient who left a lucrative career in finance and IT to become a daylily “farmer.” I think he had “made enough” and decided to pursue his passion. I think about him frequently this time of year when every yard sports some daylilies and they have spread to growing wild along our back roads.
Below is one of those roadside daylilies that must have been planted by a bird.
Daylilies are hearty, and that should be an inspiration for us all. I snapped the picture on one of my walks this week. I hope that your weekend is sunny but not too hot and humid so that you might get out and see what nature is offering near you,
Be well,
Gene
