Equinox

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Spring in the Midwest often doesn’t arrive until summer, when rain and gloom abruptly change to searing heat. School lets out and the Devil acquires an abundance of idle hands to tempt. Fuses get shorter as the mercury rises, making some people downright mean, doing and saying things they would normally consider inexcusable. Even the sun is belligerent, a festering, crimson boil when setting behind air so saturated it suffocates rather than nurtures.

September is a seasonal sigh of relief; the interlude between the contentious summer and the brutal winter. The Canadian highs that we’ll be cursing in January sweep out the humidity, bringing sharp blue skies and a nocturnal nip to the evening air we call “good sleeping weather.” The rising and setting sun is once again warm and welcoming instead of withering.

The kids go back to school, having traded T-shirts and shorts for T-shirts and jeans. It’s not like the old days when we dressed in new school clothes of fall colors—red, yellow, brown and orange. The Devil heads to the other hemisphere and waits for their idle hands to reappear. Summer gear goes back into the garage. The anal among us start thinking about Christmas shopping.

Autumn implies decay and decline for many but paradoxically, for me at least, it is a time of realignment and renewal. It is, after all, the season during which we celebrate the uniquely American ritual of Homecoming and the conflicting emotions it brings. We live vicariously through our offspring while reflecting upon own lives: the victories and defeats; opportunities taken or lost.

But that Home is often mythical, having eluded some of us during our early years. Decades later, Aaron Copland’s Two Pieces for String Orchestra granted me safe passage to a place in which I never lived but have known forever:

 It’s late in the afternoon, just before dinnertime. Evening comes sooner these days but the sun is still a comforting disc in the sky, bathing the green leaves with a golden tint, a preview of the more spectacular and permanent change to come. Sometimes the setting sun highlights the dark grey clouds of a past storm on the east horizon. What’s done is done.

Windows and front doors are open and anyone on the sidewalk can hear the muffled voices coming from the black and white TVs in the living rooms: Moms are in kitchens, frying chicken, whipping potatoes or baking biscuits, wrapped in a floral apron nothing like Mrs. Cleaver’s cocktail dress and pearls. Dads are sitting in living rooms, smoking Luckies, listening to Chet and David or Walter, their somber voices relating the news; warning us rather than entertaining us. You won’t know about the Cuban Missile Crisis for another year or two, and the war in Southeast Asia that will take some of your friends is another five in the future.

This is a good time, when you found comfort nestling in Mother’s bosom.

In the coming weeks darkness will arrive earlier and earlier. The furnace will kick on for the first time, filling the house with that familiar, slightly musty scent, resurrecting memories of time long past. It will be a time to be alone with your thoughts and your soul; a time to be grateful for what you have and not mourn what you’ve lost. There is peace in autumn, the calm before the storms, before the bleak midwinter.

More songs of home by Aaron Copland:

Our Town

Quiet City

Fanfare for the Common Man

 

Jurassic Doc

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I don’t recall the exact moment I realized I was sliding towards obsolescence, but by that time it didn’t matter because I didn’t care.

I did my residency during the early days of ultrasound; images looked more like a Rorschach inkblot than pelvic organs or babies. We all believed radiologists made shit up when they read ultrasounds. Few things were more irritating that having one emphatically identify a non-existent tubal pregnancy, committing us and the patient to an unnecessary exploration.

We used one of the first TV cameras adapted for a laparoscope, a rather bulky attachment whose picture was as atrocious as it was fascinating. The attending physician watching the monitor while the residents tied a patient’s tubes laparoscopically said, “Maybe I DON’T want to see what you are doing.”

The hospital where I did my internship bought a Computerized Axial Tomography (CAT) scanner, a great advance over simple x-rays and a fortuitous event. One of the radiology interns volunteered for the initial scan and discovered he had a brain tumor. Word got around only after people began questioning the sudden onset of baldness.

Technology’s transition from medical advance to hospital marketing tool started in the 1990s. Physicians touted “minimally invasive surgery,” which some patients interpreted as “painless and risk-free.” Magnetic Resonance Imaging (MRI) replaced CT scans and generated new revenue as outpatients sites opened. (One small town boasted five MRI machines.)

Administrators became enamored with robotic surgery in the early 2000s, buying a toy that cost $2 million and came with a $150,000 annual service contract. Initially acquired by large private and university healthcare systems, robots found their way into small community hospitals looking to attract more customers to augment declining revenues.

I’ve always been cautious; I was never the first to embrace that which was new and heaped with promise. My choices were often met with incredulity. “What? You DON’T treat warts and cervical dysplasia with a laser?” No, but thirty years ago I saw physicians willing to plunk down fifty grand for an office model, even though they had no idea how to use it. Those contraptions are likely catching dust in a closet, having been supplanted by the far simpler wire-loop cautery known as LEEP.

I never cared for doing surgery exclusively with a laparoscope. I could take out a tubal pregnancy through a small incision and be finished in the time it took to set up all the laparoscopy equipment. I didn’t get on the Laparoscopic Assisted Vaginal Hysterectomy (LAVH) bandwagon, having watched my colleagues turn a 45-minute procedure into a seven-hour ordeal. I learned “new” wasn’t necessarily “better” but was always much more expensive.

I preferred delivering babies to gynecologic surgery, and most of my subsequent jobs were for obstetric coverage. I stopped doing major gynecologic surgeries in 2007, relieved. Then earlier this year an office nurse said, “Any woman who has a big scar on her belly from an abdominal hysterectomy should sue her physician for malpractice.” I’d passed the point of no return and was on the way out.

I don’t mind being a dinosaur, partly due to the direction my profession has taken. We spend far more money than twenty years ago for very little tangible benefit. Younger physicians rely too much on lab tests and scans and too little on actually listening to and examining their patients. I don’t want to talk with a patient while typing notes into a laptop—the health care version of texting during dinner. And I don’t want to take ten minutes to generate a prescription from an electronic medical record (EMR) when I could do it with a pen in 30 seconds.

I’m looking forward to retirement and I’m happy to pass the baton onto a younger generation. My only regret is that I probably won’t be around in thirty years to witness the same realization cross their once-eager faces.

Coming of age

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I started medical school in 1975, around the time the image of physician as a kind, wise, helpful, infallible, and exclusively white male—mythologized by James Kildare, Marcus Welby, and the brooding Ben Casey—was becoming tarnished, replaced by a far more realistic but much less comforting version. In subsequent years, disappointment would turn to anger and cynicism, expressed in mutual distrust and an explosion of malpractice litigation.

My attending physicians in medical school and residency reflected that reality, varying widely in age, temperament and clinical competence. Some of them still embodied those traits patients held dear—compassion and genuine concern—but others had become short-tempered, sarcastic and condescending towards their patients, their colleagues, and those of us in training.

Those physicians reserved a special scorn for the latter-day Inquisition known as the Morbidity and Mortality Conference, during which the care of a physician whose patient suffered a bad outcome was scrutinized. The Grand Inquisitor presented the case piecemeal, pausing to offer up tidbits from the chart—lab results, x-rays, nurses notes—while sometimes occasionally professing amazement that the offending physician had missed something intuitively obvious to the most casual observer. Some of this may have been defensive; the fear of being in the hot seat one day. “There but for the grace of God go I.”

New physicians are invariably young, naïve and idealistic and I was no exception. I’d witnessed bad behavior first hand and swore I would be different. I would listen to my patients and wouldn’t rush them. I wouldn’t become an arrogant asshole. I wouldn’t be afraid to admit, “I don’t know.” Above all, I would make fixing all their problems my personal mission, instead of blithely dismissing their complaints as psychosomatic.

This delusion is comparable to your teenager telling you he or she will be a MUCH better parent than you were, with a similar rude awakening. It’s not as simple when your own butt is on the line and you’re the one making difficult decisions.

My most liberating experience was learning what I could NOT do. I couldn’t solve everyone’s problems, because many of them were rooted in psychosocial and economic realities that were beyond anyone’s power to affect, including mine. I could be empathetic and listen; I could offer suggestions. I could lead the horse to water but not force it to drink.

Some of my contemporaries drifted to the dark side, seduced by the golden handcuffs. The price one pays for the illusion of financial security includes exhaustion, substance abuse, divorce, and alienated children. Others later denounced their early altruism as “liberal naiveté,” wondering how they ever could have believed health care was a right and not a privilege. Two of them refuse to speak to me anymore because I thought our current health care system needed an overhaul.

I’m more comfortable treating the middle class and poor folk than with Yuppies, and I prefer small-town hospitals to the large and often predatory health care systems. My loyalties lie with the nurses and staff who make doing my job much easier, not with other physicians.

I lost a few battles but I think I ultimately won the war. I just did my best.

Clip Art: CanStock Photo

 

Life As A Rental

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I work as a locum tenens physician, or, as I call it, a “rent-a-doc.” I work for companies that supply temporary physician help to hospitals and clinics. I don’t have my own office practice or patients. I go where I’m needed and leave when the job is done.

I’ve done this exclusively for the past 16 years because I got tired of the people signing my paychecks lying to me.

Anyone still in traditional practice understands my feelings. For the most part, health care administrators are as inbred as St. Bernard dogs and just as crazy. The only thing that matters to them is the bottom line. Patients, physicians and staff are necessary evils they could just as well do without. I’m no different from the janitor and more than one has made that quite clear.
“You don’t like it, fine. Quit and I’ll hire three more just like you.”

Working this way comes with distinct advantages. The companies help me get and pay for state medical licenses. They provide transportation to the work site, hotel accommodations and, most important, liability insurance, which can run $150,000 a year.

I don’t get involved in hospital politics or pissing contests with other physicians. I do my job, get paid and go home. I earn about a quarter of what I could make in private practice, but I don’t have the stress and the headaches. If a job becomes untenable, I can give 30-days notice and say “adios, muchachos!”

I can work as much as I want depending on available jobs. Occasionally nothing will come up for a few months, but sometimes there are more jobs than I can do. (I’ve had to turn down jobs in Hawaii because of other commitments.) I’ve had the opportunity to visit places on someone else’s nickel, from Alaska to New Hampshire, from Michigan to New Mexico.

Most of my jobs have been covering solo physicians who want to get away, groups looking to replace physicians who have left or retired, or indigent clinics that are chronically overworked and understaffed. I filled in for an Army Reservist who went to Kuwait for three months of solo call. I subbed for a physician who needed surgery. One woman took off six weeks to have a baby. I worked at a clinic in New Mexico with eight midwives and two other physicians doing 140 deliveries a month.

Sometimes the situations are a bit more delicate. A hospital needed help after firing two physicians who’d gotten into a fist fight at a department meeting, sending one of them to the emergency room. The only two OB/GYN physicians in a remote area, each in solo practice, despised each other and wouldn’t cross cover. Another physician drew a one-week suspension for substance abuse. I’ve learned to not ask too many questions.

The only downside is being away from home and living out of a suitcase. Most of the time I stay in a hotel owned by one of many well-known chains. Occasionally, the accommodations are more upscale. And one hospital had the most luxurious call rooms I’ve ever seen: Sleep Number beds; Bose Sound Docks for iPods; desks with computers and All-Steel Acuity mesh-back chairs; mini-refrigerators; a wall-mounted LCD TV and private bathrooms with showers and motion-activated light switches. The work was grueling, but I could retreat to this relative paradise during lulls.

But some clients are cheap and I end up in a dive.

Two different hospitals put me up in mold-infested housing they owned. One client wanted me to stay at her place with her cat and asked me if that was a problem only after I’d arrived (I’m deathly allergic to the little beasts.) I shared a house with another physician, which worked out reasonably well until he decided to broil a steak at 2 am, setting off the smoke alarm.

I stayed in the last vacant room in a newly-built assisted living facility next to a hospital in south central Illinois. Not bad, but very cramped. I sent the residents a big box of old VHS movies for the enormous TV in their lounge, long before plasma and LCD TVs. I still have the thank you card they all signed.

Locum tenens isn’t for everyone. I’ve gotten used to going to work immediately with little or no orientation. Maybe that’s because no matter where I go, things are usually pretty similar. The names and faces change, but the routines, the challenges and the rewards remain the same.

Image: CBS

Good Bye, Old Paint

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He was the medical director of an Ob/Gyn clinic for the indigent in a southwestern town near the Mexican border. In its heyday, eight midwives and three physicians—including a near-deaf Catholic nun whose car sported an “Ordain Women!” bumper sticker—handled thousands of patient visits a year and delivered more than 130 babies each month.

Poor folk are never a priority for the health care system, even less so if they are black, Hispanic or worse a border-jumper. Many of the patients gave the same rural mailbox number for an address, having paid the “coyotes” thousands of dollars to be smuggled into the US. I can’t say I blame them, because I’d had to deal with the consequences of poor obstetrical care some of them had gotten across the border.

I first met him in 2000 when I worked as a locum tenens physician at the clinic for seven months. At that time he was in his late 50’s, a slight man with thick brown hair and glasses whose quiet demeanor sometimes produced a wry joke that both surprised and amused. I thought he was a kind and decent man, even after I found out he was a staunch Republican and had his picture taken with George W. Bush at an inaugural ball. I’m not sure he ever acknowledged the irony of devoting his life’s work to people the Republican Party despised.

But a sadness always surrounded him as if he recognized the futility of the task while refusing to give in. The hospital expected the clinic to be profitable but funding was always a problem. Private physicians in other specialties never wanted to see the patients in consultation. Some of the hospital staff treated them as vermin. He did his best but most of the time, unlike Sisyphus, the stone never got anywhere near the top of the mountain before falling back.

As often happens, he was pushed out in favor of younger (and less expensive) physicians. He retired a little farther north where he lived before taking his own life the day after Christmas, 2012. His ashes were buried on a ranch in the western state where he’d first practiced—a fitting repose for an old hand.

“Why?” will forever remain unanswered. Was it being discarded like an old pair of shoes? Was being a physician his entire identity and, lacking that, his raison d’être had evaporated? Or had he just reached the end of his trail, tired and dispirited?

He may never have realized to how many people’s lives he brought comfort and healing, but those of us who bore witness will never forget.

Photo credit: CanStock Photo