Category Archives: narrative

County [Updated]

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Those of you that like to see behind the veil of medical care in the U.S. will enjoy the new book by Dr. David Ansell: County: Life, Death, and Politics at Chicago’s Public Hospital.

Ansell began internship at Cook County Hospital in 1978. He stayed there seventeen years.

Along the way, he got involved in politics, fighting the good fight for the poor and disenfranchised of Chicago. He co-authored the landmark 1986 New England Journal of Medicine article understatedly titled “Transfers to a Public Hospital,” that led to the passage of EMTALA that same year.

[EMTALA is the law that was enacted to prevent "patient dumping," the practice of transferring patients from one emergency room to another (such as Cook County) because of a patient's lack of insurance.]

Dr. Ansell was responsible for another success: he helped establish a breast cancer screening program for women at Cook County. Prior to his work, it was believed by many that only specialized breast surgeons could implement such a screening program. Ansell fought medically and politically to achieve better access for poor and uninsured women, in addition to showing that disease screening could adequately be handled by frontline health personnel and not just specialists.

Part of what made the book so interesting for me was the recent history of Chicago and the stories of Ansell’s colleagues at County–many of whom I’ve been lucky to meet and learn from over the years:

There’s Quentin Young, social activist and physician who doctored to MLK and Jesse Jackson, among others. There’s husband and wife team Gordy Schiff and Mardge Cohen, who have inspired generations of Chicago medical students to put their progressive values out front when thinking about their profession. There’s also Renslow Sherer, a pioneer in developing AIDS treatment both at home and abroad, and someone I’ve been blessed to call a colleague for the last few years.

County is an excellent exploration of one doctor’s professional development over a lengthy career. Ansell, in an NPR radio interview, was asked about the poor conditions at the hospital. He likened it to working in the developing world. He and his colleagues were “Doctors within Borders,” as contrasted with the esteemed NGO that works globally in humanitarian disasters.

One thing Ansell didn’t touch on: He now is Chief Medical Officer at Rush, a major academic teaching hospital in Chicago. He made the leap from anti-establishment to major power player in the Chicago health stratosphere. I would have appreciated learning more of his mindset as he made this transition to leadership. I wonder, too, about reconciling values from his longhair days of picketing and demanding change to the more cloistered world of institutional change in the executive suite.

Maybe I’ll ask those questions diplomatically when I interview him.

[UPDATE: Abigail Zuger reviewed County in the NY Times. Link here.]

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Striving

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Here’s the kind of story I love:

Albert Liebman, class of 2011

Meet Dr. Albert Liebman of Milwaukee. A member of the Greatest Generation, he enrolled as a freshman at the University of Chicago in 1939. He answered the nation’s call to war by enlisting in the Navy in 1942. He’d only completed three years of college. Fortunately for him, he’d already received an acceptance to medical school. [A bachelor's degree was not a requirement in those days.]

After the military, he completed a residency in internal medicine. But he later added subspecialty qualifications in psychiatry and geriatrics. “I was always pursuing something that would expand my usefulness in medicine,” he said. To me, that shows resourcefulness and resilience.

He taught at medical schools throughout his career, and only stopped as a volunteer teacher at age 86.

He self-published six books, and is currently at work on his second book of poetry. [You can read an example, called "A Meandering Path," here. This is a poem I can relate to.]

You gotta love a guy who gives his all to his country, his family, his profession, and his passions.

But what about that bachelors degree?

Better late than never, he concluded. So he checked with the university, which still had his records. Combined with some course work that he completed at the University of Wisconsin, he had enough credits to earn his degree.

So there he was at convocation, the oldest member (by several decades) of the class of 2011.

Serving as an inspiration to all of us; exemplifying the life of the mind.

And always striving.

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The Magic Curtain

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It’s graduation time again…..so I’m reposting this essay about transitions:

Hail, graduates!

After the first day of medical school, my mother called to ask me how it went. Then she threw in a kicker:

“I have a small rash I want you to look at.”

What the heck did she think I learned in one day?

I now know is that she was giving me an early lesson in boundaries:

I had crossed some magical line into MD-land, where I’d be expected to answer any question and have an opinion on all parts of the body and all medications, herbal supplements, chemicals, diets, beauty products, and the latest studies written about in newspaper articles (people read actual newspapers back then).

No matter that I’d had one day of the Krebs cycle, and nothing to show for it. I was now an almost-doctor!

Persnickety guy that I am, I really got frustrated when my Mom sent her friends in my direction, too. “I’m not a doctor, I just play one on TV,” became my go-to line to deflect their unwanted medical questions.

Things changed even more dramatically when I started internship.

My first day on the wards, I took over the care of Mrs. Manganelli, an unfortunate woman in her midfifties afflicted with severe multiple sclerosis (MS). This is a disease that wreaks havoc with the connections between nerves, and nerves to muscles, making things we take for granted like swallowing, walking and breathing very difficult. It also affects “toileting.”

Mrs. Manganelli (not her real name) had been admitted for severe constipation. Her MS had made her intestines barely able to move food and the resultant waste products along their course. An x-ray confirmed that her colon was “FOS” (full of stool, or a less nice word we somtimes use).

My supervising resident and the patient’s nurse gave me a strange look, with big eyes and a smile I mistrusted, telling me that “disimpacting” was the intern’s job.

I was scared to admit that I didn’t know what disimpacting was, but their looks told me it wasn’t pleasant.

To hide my ignorance, I asked what “tools” I’d need for the job. The resident pointed his finger at me, and the nurse handed me a chux, those ubiquitous blue pads that are all over hospitals to place under patients and clean up messes.

Then I understood: I was going to be making and cleaning up a mess from poor Mrs. Manganelli.

“I don’t want to be a doctor,” I thought to myself, in response to this form of hazing. “This is going to be a long and awful year.”

Mrs. Manganelli, apparently used to being disimpacted because of her illness, rolled onto her side (with help) and assumed the position.

Using a gloved finger and lubricant, I found what we would technically call “copious amounts of soft brown stool in her rectal vault.”

Her disease meant she had nearly no sphincter tone, so once I was able to initiate the flow of poop out of her bottom, it started coming out on its own. Lots of it.

A heaping pile.

And as gross as this story is, there are a couple of interesting facts and lessons I took from it.

Mrs. Manganelli felt about a million times better after being disimpacted. It was really remarkable both to see how dramatic her improvement was, and that I’d had a direct hand (so to speak) in making her feel that way.

When my family wanted to hear about my first day of internship, I proudly related some of the details of what I’d been through, thinking they’d find it amusing, or at least fodder for some storytelling.

Their reactions told me that I’d crossed over. Never again would I be able to share unfiltered details from my world. They couldn’t handle the truth.

So now, for better and worse, I live behind a magic curtain of people’s expectations and perceptions.

Like Mr. Gorbachev, I hope to tear down this wall.

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Doctoring Down Generations

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William was an old-fashioned GP. In his practice he delivered babies, set broken bones, sutured cuts, and ministered to the dying. He made house calls. His profession was his calling. He was the doctor for his community. His wife handled phone calls, record keeping, and to the extent that it was necessary, billing.

The times, they are a changin'.

Their son Bill became a doctor. Bill wanted to be like his Dad. He started out doing house calls but eventually found that it made more sense to see patients in an office since the practice of medicine was changing. To earn income, Bill had to have an organized system to bill insurance companies, which had become the main way that doctors were paid. Eventually he took on a partner, and moved into an office building.

The practice kept growing, adding more doctors in order to attract more patients. Income grew, but everything about managing such a large practice had a more business-like aspect. There was more red tape. Eventually, Bill’s large practice needed thirty-five people to handle billing, collections, and record-keeping.

Bill’s daughter Kate wanted to be a doctor, too. She loved the intellectual challenge of solving puzzles and the biological knowledge that a medical education would provide her. But she’d seen her father miss too many family meals because he was “on call” when she was growing up. She was determined that she would be a different kind of doctor.

She is.

Kate is part of a generation that views doctoring more as a job and less as a vocation. She’s chosen to go into Emergency Medicine, since it affords her a more manageable lifestyle. Kate, like most ER docs, is a shift-worker. At the end of her shifts, she goes home. She’s never “on call.” When she’s home, she’s home. She may spend time reviewing a case in her mind, but she sheds responsibility for it when she leaves the ER.

Kate is an employee. She makes a good salary, but she doesn’t own her practice, or assume the risks and liabilities of running a business on top of being a doctor. At least for now, she likes it that way.

This story of three generations of the Dewar family from Pennsylvania was featured in the NYTimes.

It generated a lot of comments, both from current doctors who resent the notion that relationships with patients were better in the old days, to older professionals who feel that something essential from medicine has been lost.

My own view is that medicine has matured; it’s gone from being a profession to a major industry, and that has entailed myriad changes in its workforce. The doctor-patient relationship, still the crux of the medical exchange (dare it be called the ‘medical transaction?’), has lost some of its inherent value as it’s become wholly commodified. It’s like a dollar. Still important as a unit of measure and trade, but not as valuable as it once was. The technological and regulatory aspects of medical care have rendered the smaller scale medical practice obsolete.

I value time away from medicine (though this blog does keep me thinking about it even on “off” time). I’m glad that there’s been a new emphasis in the profession on centeredness and family; we doctors should role model healthy, non-workaholic behavior for patients. But I do worry that the new regulations limiting work hours for doctor trainees are altogether changing the mentality of what it means to be a doctor. It’s one thing not to want to work all the time, but it’s another altogether to lose one’s sense of calling and responsibility for a patient’s care.

Though I’m on board with the team approach to medical care, with whom will the buck stop?

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Touchy Feely

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Medicine sits at the vertex of art and science.

The tremendous success of molecular biology over the last three decades has fueled astonishing growth in Medicine’s scientific elements; often (though not always) this detracts from its more artistic renderings.

For some of us (doctors and patients) this is no doubt a good thing. We want our medicine based in science-it offers an exactness that we covet and a feeling that our actions, based on the best available evidence, are right.

For others, the increasing dominance of science has come at the expense of Medicine’s art. Not from direct competition per se, but more from benign neglect. With so much science and technology to learn about (dare I say master?), it’s not a big surprise that doctors struggle to learn the more artistic aspects of Medicine: compassion, empathy, communication, healing touch, and of course, uncertainty.

'Nuff said.

These aspects relate to emotion, never a strength in a data-driven culture.

A recent story in the New York Times explored how the field of psychiatry has almost completely shifted away from Freud and talk therapy toward psychopharmacology and efficiency. Upon reading it, I felt a sense of loss over the changes. Progress is never easy; people, places and ideas are inevitably left behind.

The story symbolizes for me that in our workaday world of medicine, there just isn’t much time or space for emotion. We want answers to our medical questions, without expressions of doubt, or at least as few as possible.

Yet emotion and medicine are laden with doubts:

  • Will I be OK?
  • What disease/condition do I have?
  • Can you help me understand and treat this pain?

The term “touchy-feely” is used pejoratively in most of Medicine. I often hear students and residents lament that certain classes or even whole specialties are “too touchy-feely.” This usually occurs with “messy” situations like birth, death, divorce, emotional trauma, substance abuse, mental illness, and chronic pain.

Problems like these don’t confine themselves to pat diagnoses or straightforward therapies. Nor do they get “solved,” if at all, in single episodes. Clinicians in broad fields like Family Medicine, Psychiatry, and both general Pediatrics and Internal Medicine contend with these types of issues on a daily basis.

It’s not a surprise that in a world valuing technology and clear answers over emotion, students choose fields that offer the promise of discrete and solvable problems.

“Touchy feely” may not be valued by those in medical training, but good doctoring requires it.

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