A Full House and Medical School Wrap
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Pain is becoming more of a problem. I am unable to take a full breath without some sharp pain in my left back. On Saturday I didn't pay enough attention to it and it got out in front of me to the point that I was irritable with my brother Geoff when he arrived from Mexico for a visit. He has been the medical caretaker in our family. After a career of hard work and careful investment, he was able to retire in his fifties. He was the driving force in persuading our oxygen-dependent mother to leave her 5 level home and enter an assisted living program. He got her house ready for sale and handled the transaction. He was also there every step of the way during her terminal illness. Being so good to Mom meant he was being wonderful to us four siblings.
I'm paying more attention to my clues about pain control. This tumor causes pain referred to my left jaw, upper teeth, and left throat. Chest pain tends to follow behind. I have started to time use of analgesics based upon my facial pain. When I notice it, I medicate before things become more intense. I have no reason to expect the overall pain to diminish until chemotherapy is started. If I am fortunate, it will decrease the size of the tumor and reduce pain from an attack at the source.
I'm using three separate analgesics, Ibuprofen (motrin), Acetaminophen (tylenol) , and Oxycodone (an opiate). Because of my age (68) I've set daily limits for myself about 25% lower than generally listed adult maximum doses. I don't intend to use more than 2400mg for Ibuprofen and 3000mg for Acetaminophen in a 24 hour period. Ibuprofen appears to be much more effective.
If I reach a point where I can't control pain using Ibuprofen and Acetaminophen, I'll be forced to increase the opiates.
My two sons, Brian and Keith and two of my brothers are here for a visit. Jasmine is surrounded by five large guys. The amount of trash that we are generating is impressive. Our recycling bin is beginning to overflow with beer and wine bottles.
On Saturday we drove about an hour to the site where James Dean died in 1955. It is at the junction of CA 41 and 46. There is a little diner nearby called the "Jack Ranch Cafe," which has a number of photographs and memorabilia. In the parking lot of the cafe is a memorial
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As I approached my final year in medical school, the situation in Dr. Cowley's unit was changing. Their funding had improved greatly with NIH and US Army grants. A new four-story unit complete with heliport was being built and would replace the two bed unit that had been put together on a shoestring. Although I was the only person doing the computer work, it was time for that to change. It is too risky for any larger organization to become dependent upon a single person for the provision of a critical product, such as control of the data. The computing center at the University of Maryland Baltimore Campus had purchased an IBM 360 and wanted to obtain Dr. Cowley's business. They were very busy wooing him and provided him with a very sharp college student who was studying computer science. So change was definitely coming.
By the end of my 3rd year of medical school, I had decided that I would not pursue clinical medicine. I would take the advice of employment recruiters who had recommended that I get the M.D. degree before focusing full-time on Computer Science. This would give me some instant credibility and better earning opportunities.
That summer in 1968 I received permission from Dr. Cowley to reduce the time I worked for him in order to take a temporary position at the NIH in the National Cancer Institute (NCI) which was gearing up to conduct the 3rd National Cancer Survey. Prior to actually doing such a survey, there were thousands of individual decisions to be made. The single most important task was the formulation of an explicit, non-ambiguous questionnaire that could be answered reasonably quickly (to not turn off the volunteer who has agreed to provide the information) and provide the data that the survey was meant to collect.
I worked for a man named Ted Weiss at NCI. He had come from the District of Columbia Government where he had managed the payroll system with an IBM 1401 computer with 4K--that's right, 4000--characters of memory, 1/250th of a single megabyte. This was done by using a single punched card for each of the tens of thousands of employees who were being paid under than 30 different contracts, each of which had a variation in calculations of pay and leave. The card for each employee for a particular pay period that included hours worked, time off, etc. had to be matched against a "master card" for that employee that provided information about rate of pay, deductions, contract, prior leave, etc. As I get older, Ted's work seems even more mind-boggling because it was so dependent upon mechanical processes, like feeding punched cards into machines without destroying them. I think of Ted with every paper jam I encounter.
During these few months I was exposed to what was called "Systems Analysis," the process by which one defines the necessary output from a computer system and works backward to identify the tasks that will be required to provide that output. All programming requires such working backward. However, the 3rd National Cancer Survey was going to cost millions--$5,000,000 alone for data collection in 1968. It would involve thousands of people. The project was too big to be handled within National Cancer Institute and required the use of outside contractors. This was Systems Analysis on a much grander scale--not only computer processing but all system aspects including the manner in which questionnaires would be stored after completion, sent to the home office, whether processed manually or by various machinery, etc.
To totally define the operation of the 3rd National Cancer Survey would require thousands of individual steps. Snafus could occur at many places in the processing chain. Obsessive attention to detail was required and Ted was a perfect fit. I shared his office and I was sometimes annoyed that he absent-mindedly rearranged my desk whenever he spoke on the telephone for any extended period of time. However, I learned a lot about the discipline necessary to manage very large projects. He was hell on contracting companies that were doing the computer work. His obsessive-compulsive make-up and his fear that contractors were likely to do sloppy work (good enough for Government work was a prevalent motto) meant that he had to understand everything down to the dirty level of the algorithm from which the programming code would be composed.
I learned an awful lot in 3 months and was energized upon returning to school. My marriage was disintegrating. Sally had completed nursing school the previous year. She was very smart but also "quick." She was pretty, seductive and had endowments that would have allowed her to make an excellent living even if her IQ had been halved. She was also hanging out with older resident physicians and attending doctors. I was still a lowly medical student who was considered a nerd by most of her crowd.
My last year of medical school was the most enjoyable. My medicine rotation at the University of Maryland was with the resident, Gary Wilner, M.D. who eventually became a cardiologist. Wilner was a wonderfully practical physician and he excelled in managing hospitalizations. He taught me that discharge planning had to begin at the time of admission. Generally a patient will require the marshalling of a number of resources to leave the hospital. If possible, each resource should be considered at the outset and arrangements made for their coordination. Wilner's voice has lived in a part of my brain for more than 40 years and over the course of my career, his influence saved my patients millions of dollars in hospital costs. He had his idiosyncracies, though. I remember him banishing a junior student for a day for using the f*** word. This was 1969 and I was flabbergasted to see the poor student driven from the ward for saying a word in common use in the lyrics of the times.
My career plans changed radically in February 1969 when I was offered a job 3 evenings a week in the emergency room at South Baltimore General Hospital. It was a 6 hours shift from 6PM until Midnight and paid about $50. This was a time when the minimum wage was about $1 per hour.
The money was an attempt by the hospital to attract students to fill the next internship group. Hospitals had requirements for lowly paid interns and residents who did much of the day-to-day work in the hospital in return for educational and training opportunities.
Programs such as Johns Hopkins or Massachusetts General Hospital could pay poorly and require more work hours because these programs were seen as being prestigious and a good launching pad for fast-track academic careers. A hospital such as South Baltimore General was second tier, unlikely to be known to the larger outside world. Perhaps Hopkins takes 5-10% of students who apply for internships in internal medicine. South Baltimore General Hospital would be unlikely to turn down any graduate of an American medical school not wearing a parole ankle bracelet. In 1969, South Baltimore had 16 internship slots and filled only 6 with American graduates. The remainder were filled with Foreign Medical Graduates.
I found emergency room work the most stimulating that I had every encountered. I loved computer programming because it was like getting paid to work on puzzles. Emergency room work was satisfying because of the immediate reality, the excitement, the drama. I was constantly learning and quickly became comfortable with lacerations, minor orthopedics, high fevers in children, and abdominal pain.
The shift passed very quickly most nights. When it was quiet after 11 PM, we were often dismissed and adjourned to Burke's Bar for beer, food, and conversation. It was such an exciting time of life.
Within a few months I put my computer science plans on hold and decided to do an internship at South Baltimore General Hospital. I was going to take the plunge and find out more about medical practice.
When I look back on my life, I see that I failed to recognize racism as the most important ethical issue of my time on the planet and that I came late to the realization that the Viet Nam War was immoral (and partially fueled by racist decisions as well). I will need to spend more time (but at a later date) on racism because it is so entwined with my upbringing and is a generational thing as well.
I believed almost everything that my government told me until about 1967. The about-face came in November. I was talking with a law student who mentioned that our losses in Viet Nam "are just cannon fodder anyway." I thought about my wife's young cousin who had been killed there, about friends of Geoff who were dead, and the use of education to avoid the draft and felt revulsion. Prior to that time, I believed that the Viet Nam War was a necessary part of resistance to communism, like the Berlin airlift and Korea. But now I was forced to think about it and to read more about what was known.
In 1968 there were three basic options for medical students planning their future around military service.
1. Do nothing except what you are told. When told to report for your draft physical, do so. Wait to hear from the Selective Service Board.
2. Volunteer.
3. Make a deal. Get at least a year deferment, maybe even more. The deal was called the "Berry Plan." You agreed to enter the service but you requested that you be deferred until you had completed training, after which you would enter the service and practice your field of specialty.
When you applied for the Berry Plan, the military could accept--that's what you wanted. However, even if they turned you down, they would permit you to obtain another year of training in your chosen discipline before pulling you in.
I was told that all males medical school graduates of 1968 who failed to volunteer or make a deal were drafted.
By the end of my last year of medical school, I had decided to not permit myself to be inducted into the military. I wasn't worried about personal danger--that's generally not an issue for physician even in combat zones. I would have been an officer, receiving quite an increase in salary and benefits compared to my compensation in a residency program. The military offered me an opportunity for further training and hands-on experience in a chosen specialty. However, I believed that anything that I did as a military physician was a tacit endorsement of military policy.
I decided to take my chances and forgo making any deal with the government. Based upon the history of the previous graduating class, I expected to be drafted sometime during my internship. Given my beliefs, I would have to refuse to serve and risk jail. I didn't like the thought of that. So, instead of attending my medical school graduation, I took two weeks and went to Canada to see what it would be like to continue a career there. It would be hard to be away from my family and friends and not be able to visit them legally, but I was very comfortable among Canadians. I could make that move.
Midway through my internship, I received my notice from Selective Service to report to Fort Holabird for a physical examination. It was a very complete evaluation and I left feeling apprehensive. When would I hear from them? When would I be inducted?
I waited and waited. They never called. Within a year or so, a lottery system had been introduced and my birth date made it less likely that I would be drafted.
Gradually the cloud over my head evaporated. An appropriate quote from Calvin Coolidge now comes to mind. "If you see ten troubles coming down the road, you can be sure that nine will run into the ditch before they reach you." My induction worries were among the nine.
Sometime in June 1969 I passed the licensing examination as a physician in the State of Maryland. On July 1, 1969 I began my internship, starting out in the Emergency Room at South Baltimore General Hospital. And so my active medical career began.
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