medical *
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2nd round of chemotherapy was done Friday. Had no problems but we made the mistake of trying to eat supper on the way home. We left the clinic at 5:30 PM and ran into San Jose traffic. We stopped for dinner but it was Friday evening. We had a terrible meal at Outback and wandered around Salinas trying to get back onto Route 101. We lost about 90 minutes in doing so. It didn't seem significant then, but was.
Jim is great company. He is a remarkably wiry, fit man in his mid-fifties. His major hobby is cleaning a stretch of beach in Santa Barbara where he went to college. He drags objects out of the sand and surf and moves them to a pick-up point for trash and junk. Some of the objects are large...like shipping containers that he cuts down before moving.
I love driving and did both ways using Jim as backup. I started having some intestinal griping about 15 miles before home. I thought that I had made it safely, but as I exited the car in my driveway, what I had supposed was gas turned out to be something more substantial and made the next hour more interesting than it should have been. I'll come directly home next time.
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My ex-wife Molly and husband Jerry came to Morro Bay for a two day visit. It was an amazing time. There were some tears, a lot of laughter, good wine, good food, and very good company. They are very tight, both high powered CPA ass-kicking auditors who had interesting careers with the General Accounting Office, an arm of Congress. Both have now retired and spend a lot of their time traveling the world.
Here is photo of Molly and me battling to see who can keep the resentments left from our physical union of more than 14 years. This occurred at Sebastian's General Store in San Simeon...the best french dip ever in my opinion. Notice the sign that the kind people at Sebastian's have posted for parents who might decide to leave a child unattended. "All kids left alone will be given Espresso & a Kitty." The result of the contest was we both lost and therefore won.
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| Molly and Eric battling for supreme control of all resentments from 14 years of marriage. |
In December 1976 I notified my patients and the hospital that I would be closing the practice and moving on. I then attempted to exchange more than $50,000 in accounts receivables incurred in emergency room work for my debt of $15,000 that had been borrowed from the hospital. The hospital declined the offer and asked when I intended to repay the $15,000. I told them as soon as I was able.
The Poison Cup and Accounts Receivables
By fronting me $15,000 at little or no interest, the hospital lost the use of that money until such time as I would repay it, but it was a sweetheart deal for the hospital.
In return:
In return:
- the hospital was able to reduce its cost for providing week-end outside medical coverage of its emergency room--this put immediate money in the hospital pocket by expense reduction.
- the hospital had yet another physician in the community who would feed the hospital a constant stream of laboratory and x-ray diagnostic work.
- a new physician offered the community another possibility for care that might eat into the traffic of the locals to out of town medical services.
A significant problem for Stan and me had been a kind of competition with the hospital. When a patient went to the emergency room for a problem, there would be two bills. The hospital would bill for the use of space and supplies, and the physician would bill for the doctor services. If you were a patient and had to choose which of those two bills to pay, chances are you would pay the hospital first. The hospital had a variety of collection resources including lawyers' threats that could be directed at patients in arrears.
When Stan left town in 1975 Molly and I were still physically present to manage collections. Stan's account were pretty much collected over the next 12 months. After Molly and I left, less than a few hundred dollars in accounts receivables were ever collected.
Winter 1976 through 1977
This was the coldest winter weather in Maryland and West Virginia since the founding of the republic. Readings of zero and below began in early January and continued for about 6 weeks. Nearby Shepherdstown lost its municipal pipe system that had been put in the ground 150 years before. These were wooden water mains where the expansion of freezing water split the pipes longitudinally.
The following clip is from: http://www.erh.noaa.gov/lwx/Historic_Events/md-winter.html
The plumbing in the house at Harpers' Ferry was much less protected and remained frozen for several weeks. Bruce Waxman and his sons helped us with designing a work around using a large, clean trash can as a water reservoir to give us enough to cook, drink, and flush the toilet occasionally. The office water system was unaffected and we used that as necessary for showering.
In the meanwhile, we were packing up both the office and the house while our relationship was in limbo. I knew that I needed a job and that I was going to Montana to start on February 1, 1977. Molly had not decided whether she wanted to go West with me.
On the morning of January 17, 1977 I set-off for Glendive, MT by way of my brother Geoff's place in Denver. I packed our International Scout II with initial clothing and personal items I would need for a couple of months and set out with our dog, Shiva.
Shiva
What a dog! I ran across her while I was doing insurance physicals after returning from an extended camping vacation in 1972. We were living with Charles Eby while I was being processed for a Federal job with the National Center for Health Services Research.
One day in December I had to visit a client in Upper Marlborough. It was a large, newly constructed home in an affluent neighborhood. It was a cold day and there was a puppy tied to a tree in the front yard. She was shivering and whimpering. The family was inside watching T.V. The examination was for the male head of household. While sitting at the kitchen table completing the insurance form and waiting for the patient to provide me with a urine sample, some of the family were standing around the kitchen exercising a fairly normal curiosity about having a doctor in the home.
I asked about the dog in the front yard. Well, the dog wasn't working out very well. When the children petted the dog she would nip them. They were planning on taking her back to the shelter where they would probably euthanize her. I asked if they would let me have the dog and they were very happy to be done with her.
Overtaxed in my knowledge of Hindu mythology, I named the dog Shiva as I untied her and put her into my car. Shiva was actually the god of destruction, not the goddess as I thought. Charles and Molly were very kind to never point this out to me.
Once back at Charles' house, it was easy enough to identify the dog's problem. She was hypersensitive to prolonged touching and patting and would grab your hand in her teeth after a stroke or two. However, by taking an old undershirt and tying a couple of knots, she would let you pat her while she gnawed away on the cloth--no problem at all. After a few weeks, she didn't need a mechanical teething cloth of any kind and never had further issues.
Shiva was a vegetable thief and she raided gardens in the area. She could dig up potatoes and bring them home for us, although she wasn't interested in them for her own food. She stole tomatoes, some of which she ate, others of which she put on the front steps. She loved salads but would never eat onions or mushrooms. She especially liked corn on the cob and had her own method for managing to eat this delicacy without the use of hands and doing a reasonably good job of cleaning the cob.
She was very smart, was housebroken immediately, and fit in well with the family.
There was a very embarrassing moment with her in the Spring of 1973. I maintained my VW beetle on a regular basis and was changing oil one Saturday morning when I heard a car crash a hundred yards up the road on Ednor Avenue. It was a semi-wooded area and I couldn't see much, so I trotted through the trees up to the road way. It was a two car collision, with two passengers in each car. It was a rear-ending at a stop sign. The struck car had been pushed into the intersection in the arc of a left turn. The passenger from that car was lying on the ground, complaining of neck pain. The passenger of the striking car had struck the windshield and sustained cuts on the face and left arm. He was leaning out of the opened door and there was minimal bleeding from the wounds.
I turned my attention to the neck pain fellow who was fully conscious. He was lying flat on his back, nose front and center, holding onto his head with both hands. This seemed like the best possible position at the time. He was able to speak. He denied a head injury or pain in his chest abdomen or elsewhere. I told him that he was doing exactly the right thing to maintain his neck in that position. I then brought the driver over and positioned him behind the injured man and explained he could assist the victim in maintaining this position by merely placing a hand on each side of the head from the rear. I explained to them that there should be no twisting of the back or attempt to roll over or get up and that the EMTs would take the necessary steps to immobilize him completely in a few minutes.
Then I went back to the second vehicle as several other motorists and neighbors began to arrive on the scene. The injured passenger was spun around in his seat about 45 degrees with the door open. Immediately below him in the street was a small pool of blood. Positioned next to the pool of blood was a small black dog doing her best to lick that blood off the street. Embarrassed, I shooed her away and was beginning to assess the bleeding man when the ambulance came. The bleeder also had some likelihood of neck injury, and I asked the ambulance crew to consider moving that patient to a spinal safe position before attending to the man on the ground who was already in a safe position.
Then I went back to the house with my cannibal dog who had begun to taste the good life.
Shiva was also an accomplished dermatologist. As we began making a move to our new home in Harper's Ferry, Shiva broke out in a rash that looked like eczema. She was itching fiercely and was scratching herself raw. I got prescriptions for Thorazine for itch and Prednisone to decrease inflammation and gave her a dose of each. Molly and I went out to the movies and when we returned we found that Shiva had gotten into the medications, opened the bottles, took no Thorazine but all of the prednisone. The rash was gone in 48 hours and never recurred.
Shiva and I headed West. She was having trouble with her anal glands. She ended up marking the front of my warm blue sweater and I smelled terrible for the next two days. I had brought some rubber gloves and lubricant to try to express the glands if necessary. Several people beeped their horns when they saw me off to the side of the road with my index finger up Shiva's butt trying to milk her anal glands.
The only scary part of the trip was an ice-storm that stayed with me across Missouri during the night. Four wheel drive was absolutely useless and I was too scared to pull over because of the lack of visibility and my fear of being blasted from behind. The storm didn't seem to affect the speed of the eighteen wheelers that kept screaming past me for several hours. It was just turning first light when I reached Kansas City and had my first look at Arrowhead Stadium.
We had travelled more than 1000 miles. I was no longer tired and we just rolled the next 600 miles across Kansas and into Colorado. Maybe we napped for an hour and then on to Denver--the miracle of the Interstate Highway System where having an auto is the ticket for use.
When I arrived at Geoff's house, the only thing that I noticed was some problems with my balance, the sensation that I was still moving. I had driven pretty much straight through in 36 hours.
I hadn't spent much time with Geoff since the camping trip in 1972 when Molly and I visited him at Ft Polk, Louisiana where he was doing his military service as a dentist. Following that he had settled in Denver and started his own practice in the suburb of Littleton. He had become very busy and was expanding his practice. In his free time, he was renovating parts of his home, including the construction of a massive masonry fireplace and chimney. We spent some time together drinking and playing a new game for us, "Mastermind." It was a relaxing few days. I did some shopping in Denver for some better winter gear, both clothing and essentials for the Scout, including a basic survival kit and a plug-in block heater that would give me a chance of starting the car at 40 below in the mornings.
On Sunday night I took off for Montana. At about 4 A.M. I pulled off the empty interstate at Douglas, Wyoming and got out of the truck to take a leak and I was standing there, with one hand holding my spiritual steering wheel (at the time) and the other hand pulling aside my coat so that I wouldn't spray it. I looked up and fell into the sky. I had never seen stars like this, so bright and magnificent. I was awestruck, one of the truly mind-bending moments in my life. This was exciting!
It was early light as we wound through the Caspar oilfields and soon after I could see the Bighorn mountains in the distance for the next couple of hours. I got to Hardin MT sometime around late morning and turned northeast to hit I 94 and then east the final 160 miles to Glendive, Montana and the home of Stan and Joan where I would be staying temporarily until my situation was clarified.
I still was not 100% certain that Molly would decide to come west. The office had been packed up and was being shipped to Glendive and was to arrive in the next two days. I would spend the week sorting things out and setting up my own space adjacent to Stan's and Brendan O'Keeffe. Brendan was a year or two behind Stan, but had opted out of further training after an internship at South Baltimore General.
Glendive had a long history of successful recruitment of Irish Nationals to provide medical services to the community. The Irish doctors had been trained under the British system, they spoke good English, and there was a large contingent of American Irish in Glendive. It had worked out well. So, Brendan had always intended to go to Glendive. It was a relatively prosperous town and partially booming as the local energy economy revived in response to the Arab oil embargo and the soaring prices of energy. By working hard, and he certainly did, he expected to be able to buy his parents a house in Ireland with his earnings the first year.
Although younger than us, there was no doubt that Brendan was the senior partner. He worked night and day and partied hard. He had been there a few years and was accumulating properties. He owned the house that Stan and Joan were renting. Brendan had recently purchased a five or six unit hotel adjacent to the hospital. It was fondly called Brendan's whorehouse by some in the community.
Brendan was quite the character. He was short and a little thick in the body but very strong. He had dark hair, heavy brows, a twinkling eye, and a charming brogue. He was quick on his feet and witty and on our first meeting he told me that "when my mother carried me, she went into false labor on Fool's day." We both loved medicine. We were both relatively high energy, but he more so than me.
Glendive Community Hospital
The technological miracle of the 19th century for the United States was the development of the transcontinental railroads. The western portions of the major U.S. East West highways are all located alongside the rail lines built before 1900. For example, in Northern Montana, Rt 2 is the major roadway, called the high line. It parallels the rail bed of the original Great Northern Railway. Interstate 90/94 is the Southern Montana East West route and tracks the original rail bed of the Northern Pacific Railroad.
The history of Western railroads includes the need to scale the Rockies and the Sierra Nevada using a variety of techniques including switchbacks and tunnels. In winter, temperatures of -40F are not so unusual. It is estimated that the winter outdoor gear worn by the men working on these steel monsters weighed an average of 80 lbs. in 1890. There was no thinsulate at the time.
Most of the larger towns in Montana developed from railroad stations and depots. Even Custer's actual mission at the time of the Battle of Little Bighorn was to find a suitable path across parts of Montana for the Northern Pacific Railroad.
In 1882 a house was built for the first railway superintendent in Glendive, Montana. A roundhouse and significant rail storage and repair facilities were established here. When the railroad created a benevolent society in the late 19th century, one of the four hospitals was established at Glendive. It was intended primarily for the treatment of railroad employees in an organization that was a forerunner of an employer established HMO.
In 1965 the railroad decided to get out of the business of providing medical care and sold the hospital to the City of Glendive. The old hospital became a nursing home after a new medical facility was built adjacent.
Most of the doctors in Glendive had been "railroad doctors" with the Northern Pacific Railroad and established private, fee-for-service practices upon the departure of the railroad from the hospital.
The Rural Health Initiative
Eastern Montana is a big place and doctors were scarce and were generally to be found as near as possible to modern types of facilities that could support them in the practice of medicine--that is they were most likely to be found in offices near hospitals. In Montana it is not unusual to drive more than 100 miles each way to see a physician, some part of that mileage over dirt roads winding in and out of large ranches and farms.
Sometime in the 1970s, grant funds were provided for the improvement of access to health care for Eastern Montana citizens. It was called a Rural Health Initiative (RHI) . Office space for the agency had been rented in Glendive. An administrator for the program had come to town. He was in his late 30's or early 40's, appeared to be well-paid, was living in a big house, was driving a large Chevrolet Suburban, and he became very visible by speaking to various citizens groups about health care. At the time that I arrived in town, the RHI had hired an excellent dietitian and had gotten behind the WIC program for the provision of food for pregnant mothers and infant children.
However, one of the missions of the RHI was to provide primary care services to particularly remote areas. The only physician that they had provided was an orthopedic surgeon, not a good fit for primary care. The orthopedic surgeon had believed that the older ex-Northern Pacific physicians were hostile and he left as soon as he found a better position.
The same evening that I arrived in town, I went to a special meeting of the medical staff where I was introduced as a new physician practicing with O'Keeffe and Huber. I remember that most of the meeting was a discussion of this "communist" entity, the Rural Health Initiative.
Sorting Out the Office
My medical office from West Virginia arrived on Wednesday. The moving van had jackknifed at Bozeman and there was some miscellaneous damage to various items. The remainder of the week was spent setting up exam rooms, making a bookcase for my medical library in the consultation office, and getting a temporary Montana license. There was a local physician, Dr. M, who was quite proud of being one of the members of the medical board. He was able to examine my credentials and sign off on the license application, thereby saving me a plane ride to the state capital, Helena.
After meeting with Dr. M, Stan pulled me aside and told me one of the most bizarre stories that I'll do my best to relate here.
The Unfortunate Dr. Collins
If this story is to be believed, Dr. Collins, an Irish National, is renting space from Dr. M., who is very careful with his money. There is an ongoing and slowly escalating discussion over some weeks about the exact allocation of utilities, particularly the "fair share" of the electric bill.
Both Dr. Collins and Dr. M are fond of an occasional snort that leads to several more snorts. On this evening after many snorts, the two begin to feud. Dr. M tells Dr. Collins that as a member of the State Board of Medical Examiners, he can have Collins locked out of the hospital. Collins leaves the drinking establishment and heads to the hospital on foot to see if it is true.
In his state of inebriation, Collins goes to the high school instead of the hospital and determines very quickly that he has indeed been locked out. Using his cowboy boot he smashes out a window to gain rightful access to his place in the hospital. Once inside he discovers his mistake and leaves.
The Glendive Police notice the chronically overworked and apparently inebriated Dr. Collins staggering down the sidewalk and kindly take him into their cruiser and drive him home.
Sometime before daybreak, the police find that a window has been shattered at the school and the door is unlocked and opened. When they investigate they discover a cowboy boot. They look at each other and remember that Dr. Collins was wearing only one boot when they picked him up and took him home a few hours before.
Dr. Collins, breaking and entering.
Nuts and Bolts of the Operation
The medical office space was in the third building of the complex. The nursing home was immediately adjacent and a long corridor was used as a natural pathway to the hospital, the first building. This pathway made it possible to go from hospital to office without concern about the weather.
Stan had found nurses for my practice. They were sisters, Connie and Bev, who wanted to share the job and child care. They were both incredibly efficient, knowledgeable, hard-working, resourceful and dependable. Connie was particularly interested in community health practices and internal medicine. They were natives, knew the people of the Glendive and were important sources of information about living conditions, social situations, health of relatives, etc. They were a good team and a great hire.
There were thousands of existing medical records. My pet medical record system would have to go by the wayside to a large extent. I would begin to organize a problem list and stack it in front of the existing medical records as I used them.
I also started the EBook with a list of illnesses and diseases with particular attention to chronic illnesses.
There was a common waiting room and a single front office that handled all of the billing for the practice of our three individual offices. There were two full-time people employed answering phones, making appointments, posting charges, taking messages, and sending out bills.
The time frame for practice was restricted to posted office hours, generally 9-12 and 2-5. There were no weekend or evening hours posted. Anything done after hours was done in the hospital emergency room. Patients seemed glad enough to be able to get in for appointments and made the time to do so despite long distances of travels to the outlying farms and ranches.
Physician dress was actually more formal in the wild west than in West Virginia where I frequently wore casual pants and flannel shirts to work. O'Keeffe was the senior physician and he wore three piece suits with expensive shirts and ties. He wore shoes with heels that increased his height a bit. Stan and I wore three piece suits.
In my first week in Glendive I had a couple of meetings with O'Keeffe including a time that he cooked some steak and cabbage for me while we drank too many beers. He was a very sharp guy--street smart, and money smart. He was charismatic and a showman. For example, one day we were walking back from lunch at the hospital cafeteria and engaged in some low-key topic. As soon as the door opened to the medical offices, his demeanor changed immediately--body up straight, serious expression, and a determined, rapid-paced walk through the waiting room into his office suite.
He had a natural way with people and gained their confidence easily. He had a very good command of occupational worries and stresses, like some of the nuttiness seen in farmers when rains delay spring planting. He understood life's timing and the timing of life's problems. Early pregnancy occurs in young girls. That anxiety that you see in the suddenly anxious 15 year-old girl may be reflecting some fear of that. The 50 year old male who may be concerned about declining interest in sex or worries about maintaining erections.
He had a respectful earthiness. He might ask about the diminution of urinary stream that occurs with a growing prostate with "Can you still piss over a fence?"
In cowboy movies, it was common to see a coiled rope hanging from the saddle. Brendan drove a cream colored Volvo with a coiled extension cord wrapped around the driver side mirror. The electrical cord let him more easily utilize electrical outlets for plugging in his block heater.
On the Sunday before I was to begin practice, Brendan, Stan and I sat down for a meeting. We went over their agreement with me about the guaranteed salary for a limited period of time. They both stated that they intended to send me overflow patients to get my workload up to an acceptable level quickly. In this way, the contract would expire as soon as possible and we would all be on equal footing. Well, not quite equal footing. They were in the process of complicating their practice in a fatal manner.
The Lab and X-Ray Acquisition
Brendan and Stan had made a decision to add a clinical laboratory and an x-ray capability to their medical practice. This would require a significant investment in capital equipment, supplies, and labor costs to pay for technicians. They hired the best in town.
Brendan was working all the time. He seldom handled any problem over the phone, but insisted that the patient come to him in the Emergency Room. This is not my style, but there is a certain logic to this method. The physician always sees the patient before making a decision. The hospital has lab and x-ray services available if necessary. There is a fee for providing an emergency service due to the physician. So Brendan has made the decision that "I will be available. I will do the work. I expect to paid for it."
Brendan slept in until about 8 A.M. on Sundays and then did nursing home work for most of the day. The man had energy. He told me that he really only relaxed when he traveled. He took a couple of weeks off a year and got out of the country and did heavy duty R&R in places like Tokyo or the Caribbean. He believed Glendive living was so restrictive that he might as well be working as much as possible.
Brendan and Stan told me that I was expected to use the new office lab and x-ray services and that they would be the responsible physicians for billing of those particular services. Lab and x-ray income and expenses would accrue to their practices.
The single radiologist in Eastern Montana commuted by air to 4 other hospitals and might only be available 1 day a week to do film readings. By the time he looked at the film, the case would usually have resolved in some fashion. The attending doctor suspecting pneumonia would have taken the x-ray and made some immediate decision without the benefit of the radiologist's thinking.
One of the most egregious examples was pelvimetry done on women with a delay in labor. Supposedly a set of measurements of the pelvis could be compared with baby head size and an assessment of the advisability of C-section could be estimated. If the lady was in labor on Monday afternoon, she was likely to have gone on to have the baby and to have been discharged before the radiologist ever saw the film. The radiology charge for the reading of the pelvimetry after the fact is a joke since there is no value in it. Any value expired sometime before the birth of the child.
I didn't see a problem with Stan and Brendan charging fees for real-time services. If I ordered an x-ray, one of them would take a look at it and write a report and give me a call. It was a better immediate service than I would get from the hospital radiologist.
No one had promised me that I would be given an opportunity to be a full partner. They had given me a chance to start a practice with a very generous offer. If they saw an opportunity to increase their revenue by further investments in their practices, that was up to them. I needed a job. I needed to do medicine. I was ready to get going.
The Handling of the Emergency Room
Like Charles Town, there was no full-time emergency room physician for the Glendive Community Hospital. There was an alphabetical list of the doctors in town on the board in the emergency room. As each case came to the ER, the next name on the list was called. If that doctor was unavailable, then the next one was called. The only rule was that at least one doctor had to be in town. Other than that, there was no rule that said you couldn't leave town whenever you wanted. If you didn't answer your phone, the next doctor would get the call.
The Medical Politics
At that time, despite their youth, Brendan and Stan had the best medical reputations in town. Stan had more surgical training than any other of the local physicians. The nurses had evaluated his work and let the community know that he was very good. Brendan was the sharpest at diagnosis in the town. They were both becoming ever more busy.
Brendan was wrapping up most of the obstetrics and doing a great deal of the general practice. He was always available and if he showed up to see your sick child at 11 P.M. in the emergency room when you were 200 miles from a pediatrician, you wouldn't quibble about the fact that he was coming from some night spot down town. The point was that he was coming in the middle of the night. And he would be charming.
The established doctors, all previously employed by the Railroad, were now in competition with younger, energetic and recently trained physicians in an era of more rapidly increasing medical knowledge. They were not happy to see me joining a thriving practice. Their own patients would feel increasing pressure to utilize the newer physicians. The local physicians were also unhappy about the RHI association with the hospital. A commitment to providing more primary care physicians threatened the established physicians with more unwanted competition.
The hospital was certainly upset to see O'Keeffe and Huber getting into the lab and x-ray business and costing the hospital this part of expected business. Nevertheless their volume of patients was responsible for many admissions to the hospital. The willingness to see patients after hours in the hospital emergency room brought significant additional revenues to the hospital.
And this is where things stood on the day that I started practice in Glendive, Montana on Feb 1 1977.
When Stan left town in 1975 Molly and I were still physically present to manage collections. Stan's account were pretty much collected over the next 12 months. After Molly and I left, less than a few hundred dollars in accounts receivables were ever collected.
Winter 1976 through 1977
This was the coldest winter weather in Maryland and West Virginia since the founding of the republic. Readings of zero and below began in early January and continued for about 6 weeks. Nearby Shepherdstown lost its municipal pipe system that had been put in the ground 150 years before. These were wooden water mains where the expansion of freezing water split the pipes longitudinally.
The following clip is from: http://www.erh.noaa.gov/lwx/Historic_Events/md-winter.html
January 1977: The Bicentennial Winter was the coldest seen on the East Coast since before the founding of the republic. In Maryland, the snow began on January 4, just as the Carter Administration was moving into town. New storms dropped a few more inches every few days to put a fresh coating on the streets that were just clearing from the previous storm and give a clean look to the piles of dirty snow that were accumulating along roadways and in parking lots. The Tidal Potomac (salt water) froze solid enough that people could skate across it near the Memorial Bridge. The average temperature for the month of January was 25.4� F which was the coldest since 1856 when the temperature averaged 21.4� F in Washington. The normal January average temperature for Washington is 34.6� F. Baltimore averaged only 22.9� F , again almost 10 degrees colder than normal. The prolonged cold wave caused oil and natural gas shortages. President Carter asked people to turn thermostats down to conserve energy. Maryland did not see heavy snow like the Great Lake region did that winter. The cold winds blowing across the warm lakes brought 68 inches of snow to Buffalo, NY. Washington recorded 10 inches of snow in January and Baltimore had 8.5 inches, but none fell the rest of the winter ending it 9 inches below normal in Baltimore. The cold wave penetrated into the South. On January 19, snowflakes fell in Miami, Florida!
In the meanwhile, we were packing up both the office and the house while our relationship was in limbo. I knew that I needed a job and that I was going to Montana to start on February 1, 1977. Molly had not decided whether she wanted to go West with me.
On the morning of January 17, 1977 I set-off for Glendive, MT by way of my brother Geoff's place in Denver. I packed our International Scout II with initial clothing and personal items I would need for a couple of months and set out with our dog, Shiva.
Shiva
What a dog! I ran across her while I was doing insurance physicals after returning from an extended camping vacation in 1972. We were living with Charles Eby while I was being processed for a Federal job with the National Center for Health Services Research.
One day in December I had to visit a client in Upper Marlborough. It was a large, newly constructed home in an affluent neighborhood. It was a cold day and there was a puppy tied to a tree in the front yard. She was shivering and whimpering. The family was inside watching T.V. The examination was for the male head of household. While sitting at the kitchen table completing the insurance form and waiting for the patient to provide me with a urine sample, some of the family were standing around the kitchen exercising a fairly normal curiosity about having a doctor in the home.
I asked about the dog in the front yard. Well, the dog wasn't working out very well. When the children petted the dog she would nip them. They were planning on taking her back to the shelter where they would probably euthanize her. I asked if they would let me have the dog and they were very happy to be done with her.
Overtaxed in my knowledge of Hindu mythology, I named the dog Shiva as I untied her and put her into my car. Shiva was actually the god of destruction, not the goddess as I thought. Charles and Molly were very kind to never point this out to me.
Once back at Charles' house, it was easy enough to identify the dog's problem. She was hypersensitive to prolonged touching and patting and would grab your hand in her teeth after a stroke or two. However, by taking an old undershirt and tying a couple of knots, she would let you pat her while she gnawed away on the cloth--no problem at all. After a few weeks, she didn't need a mechanical teething cloth of any kind and never had further issues.
Shiva was a vegetable thief and she raided gardens in the area. She could dig up potatoes and bring them home for us, although she wasn't interested in them for her own food. She stole tomatoes, some of which she ate, others of which she put on the front steps. She loved salads but would never eat onions or mushrooms. She especially liked corn on the cob and had her own method for managing to eat this delicacy without the use of hands and doing a reasonably good job of cleaning the cob.
She was very smart, was housebroken immediately, and fit in well with the family.
There was a very embarrassing moment with her in the Spring of 1973. I maintained my VW beetle on a regular basis and was changing oil one Saturday morning when I heard a car crash a hundred yards up the road on Ednor Avenue. It was a semi-wooded area and I couldn't see much, so I trotted through the trees up to the road way. It was a two car collision, with two passengers in each car. It was a rear-ending at a stop sign. The struck car had been pushed into the intersection in the arc of a left turn. The passenger from that car was lying on the ground, complaining of neck pain. The passenger of the striking car had struck the windshield and sustained cuts on the face and left arm. He was leaning out of the opened door and there was minimal bleeding from the wounds.
I turned my attention to the neck pain fellow who was fully conscious. He was lying flat on his back, nose front and center, holding onto his head with both hands. This seemed like the best possible position at the time. He was able to speak. He denied a head injury or pain in his chest abdomen or elsewhere. I told him that he was doing exactly the right thing to maintain his neck in that position. I then brought the driver over and positioned him behind the injured man and explained he could assist the victim in maintaining this position by merely placing a hand on each side of the head from the rear. I explained to them that there should be no twisting of the back or attempt to roll over or get up and that the EMTs would take the necessary steps to immobilize him completely in a few minutes.
Then I went back to the second vehicle as several other motorists and neighbors began to arrive on the scene. The injured passenger was spun around in his seat about 45 degrees with the door open. Immediately below him in the street was a small pool of blood. Positioned next to the pool of blood was a small black dog doing her best to lick that blood off the street. Embarrassed, I shooed her away and was beginning to assess the bleeding man when the ambulance came. The bleeder also had some likelihood of neck injury, and I asked the ambulance crew to consider moving that patient to a spinal safe position before attending to the man on the ground who was already in a safe position.
Then I went back to the house with my cannibal dog who had begun to taste the good life.
Shiva was also an accomplished dermatologist. As we began making a move to our new home in Harper's Ferry, Shiva broke out in a rash that looked like eczema. She was itching fiercely and was scratching herself raw. I got prescriptions for Thorazine for itch and Prednisone to decrease inflammation and gave her a dose of each. Molly and I went out to the movies and when we returned we found that Shiva had gotten into the medications, opened the bottles, took no Thorazine but all of the prednisone. The rash was gone in 48 hours and never recurred.
Shiva and I headed West. She was having trouble with her anal glands. She ended up marking the front of my warm blue sweater and I smelled terrible for the next two days. I had brought some rubber gloves and lubricant to try to express the glands if necessary. Several people beeped their horns when they saw me off to the side of the road with my index finger up Shiva's butt trying to milk her anal glands.
The only scary part of the trip was an ice-storm that stayed with me across Missouri during the night. Four wheel drive was absolutely useless and I was too scared to pull over because of the lack of visibility and my fear of being blasted from behind. The storm didn't seem to affect the speed of the eighteen wheelers that kept screaming past me for several hours. It was just turning first light when I reached Kansas City and had my first look at Arrowhead Stadium.
We had travelled more than 1000 miles. I was no longer tired and we just rolled the next 600 miles across Kansas and into Colorado. Maybe we napped for an hour and then on to Denver--the miracle of the Interstate Highway System where having an auto is the ticket for use.
When I arrived at Geoff's house, the only thing that I noticed was some problems with my balance, the sensation that I was still moving. I had driven pretty much straight through in 36 hours.
I hadn't spent much time with Geoff since the camping trip in 1972 when Molly and I visited him at Ft Polk, Louisiana where he was doing his military service as a dentist. Following that he had settled in Denver and started his own practice in the suburb of Littleton. He had become very busy and was expanding his practice. In his free time, he was renovating parts of his home, including the construction of a massive masonry fireplace and chimney. We spent some time together drinking and playing a new game for us, "Mastermind." It was a relaxing few days. I did some shopping in Denver for some better winter gear, both clothing and essentials for the Scout, including a basic survival kit and a plug-in block heater that would give me a chance of starting the car at 40 below in the mornings.
On Sunday night I took off for Montana. At about 4 A.M. I pulled off the empty interstate at Douglas, Wyoming and got out of the truck to take a leak and I was standing there, with one hand holding my spiritual steering wheel (at the time) and the other hand pulling aside my coat so that I wouldn't spray it. I looked up and fell into the sky. I had never seen stars like this, so bright and magnificent. I was awestruck, one of the truly mind-bending moments in my life. This was exciting!
It was early light as we wound through the Caspar oilfields and soon after I could see the Bighorn mountains in the distance for the next couple of hours. I got to Hardin MT sometime around late morning and turned northeast to hit I 94 and then east the final 160 miles to Glendive, Montana and the home of Stan and Joan where I would be staying temporarily until my situation was clarified.
I still was not 100% certain that Molly would decide to come west. The office had been packed up and was being shipped to Glendive and was to arrive in the next two days. I would spend the week sorting things out and setting up my own space adjacent to Stan's and Brendan O'Keeffe. Brendan was a year or two behind Stan, but had opted out of further training after an internship at South Baltimore General.
Glendive had a long history of successful recruitment of Irish Nationals to provide medical services to the community. The Irish doctors had been trained under the British system, they spoke good English, and there was a large contingent of American Irish in Glendive. It had worked out well. So, Brendan had always intended to go to Glendive. It was a relatively prosperous town and partially booming as the local energy economy revived in response to the Arab oil embargo and the soaring prices of energy. By working hard, and he certainly did, he expected to be able to buy his parents a house in Ireland with his earnings the first year.
Although younger than us, there was no doubt that Brendan was the senior partner. He worked night and day and partied hard. He had been there a few years and was accumulating properties. He owned the house that Stan and Joan were renting. Brendan had recently purchased a five or six unit hotel adjacent to the hospital. It was fondly called Brendan's whorehouse by some in the community.
Brendan was quite the character. He was short and a little thick in the body but very strong. He had dark hair, heavy brows, a twinkling eye, and a charming brogue. He was quick on his feet and witty and on our first meeting he told me that "when my mother carried me, she went into false labor on Fool's day." We both loved medicine. We were both relatively high energy, but he more so than me.
Glendive Community Hospital
The technological miracle of the 19th century for the United States was the development of the transcontinental railroads. The western portions of the major U.S. East West highways are all located alongside the rail lines built before 1900. For example, in Northern Montana, Rt 2 is the major roadway, called the high line. It parallels the rail bed of the original Great Northern Railway. Interstate 90/94 is the Southern Montana East West route and tracks the original rail bed of the Northern Pacific Railroad.
The history of Western railroads includes the need to scale the Rockies and the Sierra Nevada using a variety of techniques including switchbacks and tunnels. In winter, temperatures of -40F are not so unusual. It is estimated that the winter outdoor gear worn by the men working on these steel monsters weighed an average of 80 lbs. in 1890. There was no thinsulate at the time.
Most of the larger towns in Montana developed from railroad stations and depots. Even Custer's actual mission at the time of the Battle of Little Bighorn was to find a suitable path across parts of Montana for the Northern Pacific Railroad.
In 1882 a house was built for the first railway superintendent in Glendive, Montana. A roundhouse and significant rail storage and repair facilities were established here. When the railroad created a benevolent society in the late 19th century, one of the four hospitals was established at Glendive. It was intended primarily for the treatment of railroad employees in an organization that was a forerunner of an employer established HMO.
In 1965 the railroad decided to get out of the business of providing medical care and sold the hospital to the City of Glendive. The old hospital became a nursing home after a new medical facility was built adjacent.
Most of the doctors in Glendive had been "railroad doctors" with the Northern Pacific Railroad and established private, fee-for-service practices upon the departure of the railroad from the hospital.
The Rural Health Initiative
Eastern Montana is a big place and doctors were scarce and were generally to be found as near as possible to modern types of facilities that could support them in the practice of medicine--that is they were most likely to be found in offices near hospitals. In Montana it is not unusual to drive more than 100 miles each way to see a physician, some part of that mileage over dirt roads winding in and out of large ranches and farms.
Sometime in the 1970s, grant funds were provided for the improvement of access to health care for Eastern Montana citizens. It was called a Rural Health Initiative (RHI) . Office space for the agency had been rented in Glendive. An administrator for the program had come to town. He was in his late 30's or early 40's, appeared to be well-paid, was living in a big house, was driving a large Chevrolet Suburban, and he became very visible by speaking to various citizens groups about health care. At the time that I arrived in town, the RHI had hired an excellent dietitian and had gotten behind the WIC program for the provision of food for pregnant mothers and infant children.
However, one of the missions of the RHI was to provide primary care services to particularly remote areas. The only physician that they had provided was an orthopedic surgeon, not a good fit for primary care. The orthopedic surgeon had believed that the older ex-Northern Pacific physicians were hostile and he left as soon as he found a better position.
The same evening that I arrived in town, I went to a special meeting of the medical staff where I was introduced as a new physician practicing with O'Keeffe and Huber. I remember that most of the meeting was a discussion of this "communist" entity, the Rural Health Initiative.
Sorting Out the Office
My medical office from West Virginia arrived on Wednesday. The moving van had jackknifed at Bozeman and there was some miscellaneous damage to various items. The remainder of the week was spent setting up exam rooms, making a bookcase for my medical library in the consultation office, and getting a temporary Montana license. There was a local physician, Dr. M, who was quite proud of being one of the members of the medical board. He was able to examine my credentials and sign off on the license application, thereby saving me a plane ride to the state capital, Helena.
After meeting with Dr. M, Stan pulled me aside and told me one of the most bizarre stories that I'll do my best to relate here.
The Unfortunate Dr. Collins
If this story is to be believed, Dr. Collins, an Irish National, is renting space from Dr. M., who is very careful with his money. There is an ongoing and slowly escalating discussion over some weeks about the exact allocation of utilities, particularly the "fair share" of the electric bill.
Both Dr. Collins and Dr. M are fond of an occasional snort that leads to several more snorts. On this evening after many snorts, the two begin to feud. Dr. M tells Dr. Collins that as a member of the State Board of Medical Examiners, he can have Collins locked out of the hospital. Collins leaves the drinking establishment and heads to the hospital on foot to see if it is true.
In his state of inebriation, Collins goes to the high school instead of the hospital and determines very quickly that he has indeed been locked out. Using his cowboy boot he smashes out a window to gain rightful access to his place in the hospital. Once inside he discovers his mistake and leaves.
The Glendive Police notice the chronically overworked and apparently inebriated Dr. Collins staggering down the sidewalk and kindly take him into their cruiser and drive him home.
Sometime before daybreak, the police find that a window has been shattered at the school and the door is unlocked and opened. When they investigate they discover a cowboy boot. They look at each other and remember that Dr. Collins was wearing only one boot when they picked him up and took him home a few hours before.
Dr. Collins, breaking and entering.
Nuts and Bolts of the Operation
The medical office space was in the third building of the complex. The nursing home was immediately adjacent and a long corridor was used as a natural pathway to the hospital, the first building. This pathway made it possible to go from hospital to office without concern about the weather.
Stan had found nurses for my practice. They were sisters, Connie and Bev, who wanted to share the job and child care. They were both incredibly efficient, knowledgeable, hard-working, resourceful and dependable. Connie was particularly interested in community health practices and internal medicine. They were natives, knew the people of the Glendive and were important sources of information about living conditions, social situations, health of relatives, etc. They were a good team and a great hire.
There were thousands of existing medical records. My pet medical record system would have to go by the wayside to a large extent. I would begin to organize a problem list and stack it in front of the existing medical records as I used them.
I also started the EBook with a list of illnesses and diseases with particular attention to chronic illnesses.
There was a common waiting room and a single front office that handled all of the billing for the practice of our three individual offices. There were two full-time people employed answering phones, making appointments, posting charges, taking messages, and sending out bills.
The time frame for practice was restricted to posted office hours, generally 9-12 and 2-5. There were no weekend or evening hours posted. Anything done after hours was done in the hospital emergency room. Patients seemed glad enough to be able to get in for appointments and made the time to do so despite long distances of travels to the outlying farms and ranches.
Physician dress was actually more formal in the wild west than in West Virginia where I frequently wore casual pants and flannel shirts to work. O'Keeffe was the senior physician and he wore three piece suits with expensive shirts and ties. He wore shoes with heels that increased his height a bit. Stan and I wore three piece suits.
In my first week in Glendive I had a couple of meetings with O'Keeffe including a time that he cooked some steak and cabbage for me while we drank too many beers. He was a very sharp guy--street smart, and money smart. He was charismatic and a showman. For example, one day we were walking back from lunch at the hospital cafeteria and engaged in some low-key topic. As soon as the door opened to the medical offices, his demeanor changed immediately--body up straight, serious expression, and a determined, rapid-paced walk through the waiting room into his office suite.
He had a natural way with people and gained their confidence easily. He had a very good command of occupational worries and stresses, like some of the nuttiness seen in farmers when rains delay spring planting. He understood life's timing and the timing of life's problems. Early pregnancy occurs in young girls. That anxiety that you see in the suddenly anxious 15 year-old girl may be reflecting some fear of that. The 50 year old male who may be concerned about declining interest in sex or worries about maintaining erections.
He had a respectful earthiness. He might ask about the diminution of urinary stream that occurs with a growing prostate with "Can you still piss over a fence?"
In cowboy movies, it was common to see a coiled rope hanging from the saddle. Brendan drove a cream colored Volvo with a coiled extension cord wrapped around the driver side mirror. The electrical cord let him more easily utilize electrical outlets for plugging in his block heater.
On the Sunday before I was to begin practice, Brendan, Stan and I sat down for a meeting. We went over their agreement with me about the guaranteed salary for a limited period of time. They both stated that they intended to send me overflow patients to get my workload up to an acceptable level quickly. In this way, the contract would expire as soon as possible and we would all be on equal footing. Well, not quite equal footing. They were in the process of complicating their practice in a fatal manner.
The Lab and X-Ray Acquisition
Brendan and Stan had made a decision to add a clinical laboratory and an x-ray capability to their medical practice. This would require a significant investment in capital equipment, supplies, and labor costs to pay for technicians. They hired the best in town.
Brendan was working all the time. He seldom handled any problem over the phone, but insisted that the patient come to him in the Emergency Room. This is not my style, but there is a certain logic to this method. The physician always sees the patient before making a decision. The hospital has lab and x-ray services available if necessary. There is a fee for providing an emergency service due to the physician. So Brendan has made the decision that "I will be available. I will do the work. I expect to paid for it."
Brendan slept in until about 8 A.M. on Sundays and then did nursing home work for most of the day. The man had energy. He told me that he really only relaxed when he traveled. He took a couple of weeks off a year and got out of the country and did heavy duty R&R in places like Tokyo or the Caribbean. He believed Glendive living was so restrictive that he might as well be working as much as possible.
Brendan and Stan told me that I was expected to use the new office lab and x-ray services and that they would be the responsible physicians for billing of those particular services. Lab and x-ray income and expenses would accrue to their practices.
The single radiologist in Eastern Montana commuted by air to 4 other hospitals and might only be available 1 day a week to do film readings. By the time he looked at the film, the case would usually have resolved in some fashion. The attending doctor suspecting pneumonia would have taken the x-ray and made some immediate decision without the benefit of the radiologist's thinking.
One of the most egregious examples was pelvimetry done on women with a delay in labor. Supposedly a set of measurements of the pelvis could be compared with baby head size and an assessment of the advisability of C-section could be estimated. If the lady was in labor on Monday afternoon, she was likely to have gone on to have the baby and to have been discharged before the radiologist ever saw the film. The radiology charge for the reading of the pelvimetry after the fact is a joke since there is no value in it. Any value expired sometime before the birth of the child.
I didn't see a problem with Stan and Brendan charging fees for real-time services. If I ordered an x-ray, one of them would take a look at it and write a report and give me a call. It was a better immediate service than I would get from the hospital radiologist.
No one had promised me that I would be given an opportunity to be a full partner. They had given me a chance to start a practice with a very generous offer. If they saw an opportunity to increase their revenue by further investments in their practices, that was up to them. I needed a job. I needed to do medicine. I was ready to get going.
The Handling of the Emergency Room
Like Charles Town, there was no full-time emergency room physician for the Glendive Community Hospital. There was an alphabetical list of the doctors in town on the board in the emergency room. As each case came to the ER, the next name on the list was called. If that doctor was unavailable, then the next one was called. The only rule was that at least one doctor had to be in town. Other than that, there was no rule that said you couldn't leave town whenever you wanted. If you didn't answer your phone, the next doctor would get the call.
The Medical Politics
At that time, despite their youth, Brendan and Stan had the best medical reputations in town. Stan had more surgical training than any other of the local physicians. The nurses had evaluated his work and let the community know that he was very good. Brendan was the sharpest at diagnosis in the town. They were both becoming ever more busy.
Brendan was wrapping up most of the obstetrics and doing a great deal of the general practice. He was always available and if he showed up to see your sick child at 11 P.M. in the emergency room when you were 200 miles from a pediatrician, you wouldn't quibble about the fact that he was coming from some night spot down town. The point was that he was coming in the middle of the night. And he would be charming.
The established doctors, all previously employed by the Railroad, were now in competition with younger, energetic and recently trained physicians in an era of more rapidly increasing medical knowledge. They were not happy to see me joining a thriving practice. Their own patients would feel increasing pressure to utilize the newer physicians. The local physicians were also unhappy about the RHI association with the hospital. A commitment to providing more primary care physicians threatened the established physicians with more unwanted competition.
The hospital was certainly upset to see O'Keeffe and Huber getting into the lab and x-ray business and costing the hospital this part of expected business. Nevertheless their volume of patients was responsible for many admissions to the hospital. The willingness to see patients after hours in the hospital emergency room brought significant additional revenues to the hospital.
And this is where things stood on the day that I started practice in Glendive, Montana on Feb 1 1977.
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