Further Reflections on Internship

Further Reflections on Internship

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On Tuesday I went without any attempt at a nap. I saw a financial advisor for about 2 hours in the afternoon to try to put some of our financial house in order and hung out with Geoff watching the first year of Breaking Bad. Pain remains about the same.

Reflections on Internship


I managed to spend 6 months of my internship working in the emergency room. In 1969 there were very few emergency room "specialists." The American Board of Emergency Medicine was not created until 1976. I don't believe that there were any training programs for Emergency Medicine in 1970. In teaching hospitals, emergency rooms were likely to be well-staffed and the point of triage for urgent illnesses. The emergency room was a large source of the "cases" used in teaching. In hospitals without training programs, the medical staff generally made arrangements to take turns providing staffing. This was much more likely to be hit or miss depending on the particular skills of the doctor assigned to the call.

The patterns of health care delivery were changing rapidly in the United States in the 1960s. People were more mobile than ever before. There was a decline in the number of general practitioners as young physicians increasingly gravitated to careers as specialists. This meant that fewer people had a long term relationship with a family doctor. It was more and more likely that the emergency room would be used for those problems previously handled by general practitioners.

The truth is that a large percentage of medical complaints are self-limited. Take, for example, the way in which influenza might be treated in the emergency room as opposed to treatment from the family doctor. Arrival in the emergency room with the sudden onset of a fever and cough, is very likely to result in a lab study, the complete blood count, and possibly, a chest x-ray. The visit to family doctor is more likely to result in a physical examination, no blood or x-ray evaluations, and the admonition to go home, get rest and drink plenty of fluids.

Why are these situations so different? I think the driving force is the tolerance (or lack of tolerance) for uncertainty . One morning in 1970 I cared for a man who had driven himself to the emergency room after experiencing a shaking chill that lasted for several minutes. Maybe his name was Joe. He was in his thirties, previously healthy and had a temperature of about 103. There were no physical findings except a runny nose. I spent the next few hours getting common blood tests as well as tests for uncommon infectious diseases. I ordered X-rays. I made sure that there was no evidence of an infection in his urine. I drew blood cultures so that we would have more data should he still be ill in a few days, and I also drew a tube of "acute serum" to be frozen for a couple of weeks so that a comparison could be made if a rare germ were suspected.  Several hundred 1969 dollars later I called the chief medical resident and asked him to look at the patient. The resident was Donald Wood, M.D., a remarkable physician who would go on to found a cardiology center in Salisbury, Maryland.  After examining the patient and looking at the lab data, Dr. Wood called me into the little conference room adjacent to the emergency room. In his usual jovial fashion, he said: "Dr. Sohr, your patient will be happy to know that he almost certainly has the flu--after all we are in the middle of a mini-epidemic.  I'm sure that will put his mind at rest. But, I don't think that Joe will be so happy that you have taken a thousand dollars out of his wallet to impart that information to him."

Let's see how an older, wiser Dr. Sohr might have handled that situation in his family practice office in Worden, MT in 1980. Joe arrives after experiencing shaking chills. The older Dr. Sohr has seen this condition, called "rigor" on several occasions. Joe's examination reveals a runny nose but his chest is clear. In formulating the diagnosis and plan, Sohr says: "Joe, I can't be a hundred percent sure of what is going on right now, but I think it is very likely to be the flu. I don't think that a lot of testing will clarify the picture for us but things should come into focus in the next 72 hours. I think you should go home and take it easy for the next few days...." A general discussion of flu symptoms would follow.

For my patients dealing with uncertainty I was pretty concrete. For suspected flu I might have said: "Things can get better, worse, or stay the same.  I expect that you will have the usual flu symptoms--here is a handout for symptoms and their management. If things get worse, such as pain when you breathe, producing heavy sputum, or inability to keep fluids, down, I'll  want you to see you again--that day. The office will make sure that you can get in. If things haven't changed in 72 hours, call me back."

The other means of for dealing with uncertainty in my own practices was to permit walk-ins beginning late in the day until everyone had been seen who wanted to be seen. I was a solo family doctor for most of my work life. Everyone in my practice knew they could be seen on any day. Late afternoon walk-ins reduced my need for coming back to the office later in the evening and reduced late night telephone calls. I believed that access to care was an essential service. Assurance of access makes uncertainty more tolerable.

When the patient knows that he can always reach help, it makes it easier to live with the earliest stages of an illness. This is one of the most important economic advantages of an established doctor-patient relationship. For the relationship to work effectively, there must be a level of trust on both sides. The doctor must be able to depend on the patient to make reasonable decisions, i.e. to call when things are not going well, and the patient must believe that he can be seen in rapid fashion when he requests the physician's help.

This kind of relationship is generally lacking in the emergency room. Neither party has a long history of successful interaction and problem solving. There is more pressure on the physician to "prove that the patient is not seriously physically ill." The price of such proof is additional expense for lab, x-rays, and other services. At least that's my take on it.

No Room At the Inn

                                     A Reminder to Me about Uncertainty and Humility

During my months in the emergency room as an intern, there was generally a shortage of beds. The rule at our hospital was that the last two medical and surgical beds could only be filled by direct orders from the chief residents of those services. Our hospital had both private and public wards. In those days, before the advent of more rigorous utilization review, it might be economically advantageous for a physician to be less efficient to the point that additional hospital days might be required. Generally the doctor made rounds on the patients in the hospital daily and charged a fee for each visit.

When hospital beds were tight, the private physician was less likely to be firm with a patient or patient's family who wanted immediate hospital care. Consequently, the chief residents were given control over the last few beds. As beds tightened up, the pressure on the emergency room doctor increased proportionately. Whereas the previous week a patient might have been admitted for an evaluation and treatment of an early pneumonia, this changed when beds were not available. A more extensive evaluation had to be done in the E.R. and a much greater effort was devoted to finding a way to treat the patient out of hospital. Sometimes this is a good thing and results in an overall reduction in the cost of care.

A factor that we seldom consider is the risk of hospitalization itself. If you want to find a killer germ that does not respond to common antibiotics, look for it in a hospital. The error rate for medication administration is not trivial among hospitalized patients. I have seen estimates of  thousands of deaths a year. The risk involved in the provision of medical care was euphemistically called "Diseases of Medical Progress" in 1970 when I first became interested in them. Their formal moniker is Iatrogenic  Illness (Greek-- meaning coming from a physician).


Mr. R

Mr. R was in his early 80s and he had an enlarged prostate (Benign Prostatic Hypertrophy--BPH) that compressed his urethra to the point that normal urination was affected. He was seeing Dr. U, the urologist, the last visit being the prior day when Dr. U passed a straight catheter, drained the bladder, and sent Mr. R home.

While the drainage the previous day was relieved, Mr. R's kidneys were still working normally and his bladder was filling up and there was no place for the urine to go. As the bladder distended, Mr. R became more and more miserable. He lived with his son, Bob, who had seen his father's struggle for the past few weeks. Rather than go back to Dr. U,  Bob decided that his dad really needed to be admitted to the hospital to have the problem fixed once and for all. Consequently Bob brought Mr. R to the emergency room with his suitcase. (This is known to all emergency room workers as the 'positive suitcase sign'--the patient expects admission to the hospital.)

Mr. R arrived at the emergency room at about 1 PM on one of those days where there were only 1 or 2 beds. It wouldn't matter what Bob, or Mr. R, or Dr U wanted to do--only the surgical resident would be able to honor this plea for admission.

Since Dr. U was on the staff at South Baltimore Hospital, I was required to assess the patient and give him a call. Sometimes doctors preferred to come to the emergency room to see their patients in person. Dr. U was busy in his office at the time and asked that I insert a Foley catheter and send Mr. R home to be followed up in the office the next day.

I did as requested. A Foley catheter has a balloon on the end that is inserted into the bladder through the urethra. Once the catheter is in the bladder, the balloon is inflated with sterile saline or water to about the size of cherry. This makes it more difficult for the catheter to slide out or to be pulled out by the patient.

During this whole process, Mr. R was lucid, could describe his discomfort, and was able to cooperate with the procedures. Perhaps we drained about a pint and a half from his bladder and he was immediately more comfortable. I relayed Dr. U's instructions--to go home and to the office the next day but Bob was having none of it. He said that it wasn't right to treat his father this way and to require that Mr. R be transported to some facility on a daily basis in order to empty his bladder.

I called Dr. U and told him that the family was refusing to budge. Dr. U talked with Bob for a while and then Bob handed the phone back to me. Dr. U told me to call the surgical resident and have Mr. R evaluated and to then call back.

It was a busy day and the surgical resident didn't get to the emergency room until about 4:30. The resident examined Mr. R, noted that the bladder was no longer distended and that urine was flowing from the catheter normally. He reported back to Dr. U. who then called me and told me to assure the family that surgery was being arranged. I was told to discharge the patient with the same instructions.

I talked to Bob. I told him that there was nothing I could do to help at this point. I did not have the power to admit patients to the hospital, that the hospital was full anyway, and that Dr. U was promising definitive treatment within the next weeks. It was now well after 5 PM. Bob asked me to call an ambulance for his father. I told Bob that I could not do that but that he could. He said he would. Mr. R was now sleeping peacefully.

The emergency room was very busy. There were only 7 treatment gurneys and all were filled. Mr. R was taking up one of them and he was not receiving treatment, only waiting for transport. I really needed that stretcher.  I asked Bob about the ambulance. He said they were still working on it, trying to get the volunteer company from their community. It was about 6:30 and I was scheduled to leave at 7:00. Dr. X, my replacement would be there shortly to make rounds and to sign me out.

I turned to Bob and said: "Look...I can carry your Dad out to your car if you like. Then, perhaps you can get a neighbor at the other end to get him into the house." Bob agreed and went to get the car. A few minutes later, he reappeared and said that the auto was next to the ambulance bay.

I was young and strong and the old man weighed perhaps a hundred and thirty pounds. I carried him in my arms with his head and neck lying on my left biceps. He was very light but I noticed that he didn't wake up when I picked him up. As I began walking toward the E.R. door I noticed that his breathing was no longer regular. It was Cheyne-Stokes...Mr. R has probably had a stroke was likely to die in the next few minutes to hours. I was now at the car. Bob was behind the wheel. His wife was holding open the passenger door. They were expecting that I would  Mr. R him in the middle of the front bench seat with Bob and his wife adjacent and wedging him in.

My face and ears felt extremely warm. I'm sure that they were as red as a beet. I swear the devil was actually telling me..."Sohr. He'll be fine wedged in there. They'll get home before they notice something is really wrong. By then, you'll be off the shift and heading home and Dr. X will have to deal with it." I'm sad to admit that I thought about it for a moment.

I said to the family, "Look...something bad has happened here. Why don't you park the car and come back in."

I turned around and carried him back into the emergency room. But when I tried to put him back on the gurney, I saw that it had already been filled. The only vacant spot was an ancient wheelchair sitting in the corner of the E.R., something that FDR might have used. I sat him there and strapped him in so that he wouldn't fall. I told the nurses that he had not really been discharged and remained an active patient.

It was now about 7 PM and Dr. X was awaiting impatiently. We started with the patients on gurneys. I presented them and informed him about where they were in the evaluation process. Dr. X saw Mr. R out of the corner of his eye and pointed to him,  "Sohr, that man gonna die." Dr. X quickly went on the next patient.

I had to talk to Mr. R's family. Of course they were upset.  Bob said: "Perhaps you guys won't be so certain next time."

This was such a sickening experience. When I debriefed it with others, I didn't see anything more that I could have done. I couldn't be sure that lifting him had not been some final insult to an ancient vascular or skeletal system but I didn't blame myself for that.

It brought home the ugly situation in which I was working. I promised myself to try to avoid the practice of medicine where the hospital was not available to help me manage the evaluation of a patient. I wanted, to the greatest extent possible, to avoid a medical career where I was pressed into service to prove that someone was not sick enough for hospitalization.

For the most part I managed to keep that promise to myself.

Internship

Internship

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Late yesterday afternoon I developed a shaking chill that lasted for 15 or 20 minutes. My biggest fear was that I was developing an infection. It is possible for tumor to obstruct airways and to allow mucous and debris to collect in a closed space and to form a breeding ground for pneumonias.

It is also possible that the tumor itself is producing materials that cause fever. Naturally, I'm hoping that is the source.

I slept for about 8 hours and awoke drenched with sweat, hungry, and no change in pain level. I'm assuming this is a good sign.

My boys and brother Dana left for Oakland and the flight back to the East Coast yesterday a little before noon. My brother Geoff will stay for a while. If he is not careful he may get the moniker of "family undertaker." It's great to have him.

I've had hundreds of laughs and sweet moments in the past few days--I continue to feel lucky.

                     Sunday night at the Thai Restaurant. From Left. Geoff, Brian, me, Jasmine, Dana, Keith

                                 Sunday AM. Dana and Eric Roasting Coffee with a Heat Gun.

               Archie is mystified by the stuffed dogs at the Paso Robles Art Show on Saturday.

    Brian grabbing a beer while Keith makes the deep dish pizza we ate on Friday evening.


Tuesday was a good day. Pain was only moderate. I got a scare from my insurer who called me early this A.M. and told me that Stanford was no longer a participating member of my network and that a significant portion of my care would be out of pocket. However, a few phone calls to Stanford convinced me that things will work out.

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Internship. The first post-graduate year.

The trust that the medical training system places upon young physicians is mind-boggling. Throughout medical school you become increasingly aware of the nature and extent of responsibility that will soon fall upon your shoulders. However, even the most mature 25 year-old can't be expected to have more than a passing knowledge of the human condition. Consequently, the way in which the young physician deals with complexity is likely to be rigid enough to keep him in a zone that is comfortable. This reduces the number of variables and emphasizes the medical data over the social situation.

For Example. At age 33 I was doing family practice, including obstetrics, in Glendive, Montana, a very isolated community 200 miles from the nearest obstetrician. A patient came to me who was a Jehovah's Witness. I was already caring for her children. An essential part of her religious belief was the need to avoid blood products. At the age of 25,  my decision-making would have been simplistic. If she hemorrhaged to the point that I thought her life was at risk, I would transfuse her with or without her permission. I would elect the standard of medical care as the sine qua non and deal with the consequences to her religious beliefs later.

However, by age 33, I was able to take a more nuanced approach to the problem. If she had hemorrhaged during delivery, I would have done my best to manage her condition without blood products unless her husband, also a Jehovah's Witness, had specifically asked me to use blood. I would have placed my patient's conscience and her expressed wishes above my own professional beliefs.

I know that there are a number of physicians  whose solution would be to refuse to take such a patient. I've talked to several. But I've come to believe that medical care is a "negotiation," and that there must be give and take on both sides.  By now you know that I'm not a Jehovah's Witness. When members of that faith come to my door to give me the good news, I tell them politely that I do not appreciate the proselytizing and to please cross my name off of their list.

I think that the Jehovah Witness stance on the use of blood has actually been medically beneficial for them over the past few decades. I believe most physicians would agree that blood transfusions have been used too liberally, frequently "routine," and that the patient would have survived without blood products in a very high percentage of cases where blood was administered. Having refused blood protected Witnesses from HIV, Hepatitis B, and Hepatitis C. There is also actual data on blood use for Jehovah's Witnesses for Coronary Artery Bypass Grafts. The mortality and morbidity is less for those procedures done without using blood products.

Work in the emergency room seemed the most daunting challenge as a young physician. Anything could come through that door at any minute. Some cases would demand immediate decision-making without any opportunity to consult a book or a colleague. There were wonderful satisfactions as well, like making a diagnosis of a ruptured tubal pregnancy, or a leaking abdominal aorta. It was a time for learning techniques, such as suturing children in a way that reduces their terror as much as possible.

Although I had been in clinical training for two years before graduating from medical school, the quality of oversight was mediocre. It wasn't until I began to see children in the emergency room that I began to understand what I had missed. The pediatrics department at South Baltimore General Hospital was run by Robert Irwin and Ernie Maher. At least 10 to 20 children were seen in the emergency room on a daily basis. A critique was done on each and every child's visit and this was thoughtful feedback. What a commitment! You could not help but learn a lot of pediatrics from their notes. Based upon their teaching, I was very well prepared in pediatrics by the time I started my own private practice West Virginia a few years later.

My next favorite rotation was the medical ward. There I met the wonderful nurse, Evelyn Wade. She was probably in her early 60's. There is no doubt that she would have been an excellent physician but she came from an era where women were unlikely to be admitted to medical school.

Evelyn worked the night shift. She would come on duty at about 10 PM and begin reading the charts, not just the nursing notes, but the medical notes as well. She never used the title "doctor" but always "mister." For example, Dr. Bernie Carper was an attending pulmonologist and a conscientious teacher at South Baltimore.  Ms. Wade might grab one of his charts and say, "Let's see what Mr. Carper has been doing today."

Interns had no credibility with Evelyn until she had trained us. "Mr. Sohr...never put an old person on q4h (every 4 hour) vital signs. This means you will be waking them up at night. Old people need their sleep, particularly when they are scheduled for surgery. I went ahead and changed that stupid order of yours. Don't do it again."

Evelyn cursed like a sailor and she carried a hand gun in her purse. There is a story that she had taken out her gun and stuck it in the face of a very nasty, unruly patient and demanded that he return to his room. She had a deep, gravely voice but was all sweetness when she was introduced to our girlfriends. She was very disciplined. Despite her severe arthritis, she always selected at least one of the patients for total nursing care, which she would provide "just to keep my hand in, dearie!"

As interns we were given a room for sleeping and studying. It was similar to a motel room. I recall that I had put a hole in one my walls by throwing my shoe at 3 A.M. when told to come pronounce a patient dead. We were almost always sleep deprived. It was one thing to be called because someone was having a medical problem. It seemed unfair to be called after the death. There was an expectation that for any death, the intern had to examine the body, to pronounce the death, and then to notify the family. We came to understand that people on Evelyn's ward only died at about 6 A.M. We were up anyway, could examine the body, and call the family at a decent hour. The other nurses were not so accommodating.

I made a lifelong friend in my internship, Richard Fisher, who still does internal medicine in the Glen Burnie area. I recall a mandatory meeting of all house staff sometime during that year. I was sitting next to Richard. The chief of medicine began talking about the need to avoid any kind of intimate relationship with patients. He spoke about the ethics of these boundary violations for several minutes.

Finally I turned to Richard, "What's the hell's going on?"

Richard looked at me and said "I don't know either, but somebody here does."

I remember Richard becoming very attached to a patient with a viral hepatitis who died a lingering death from liver failure. They often ate lunch together and Richard visited frequently throughout the day. I don't think that I was brave enough at that time in my life to form such an attachment to a dying patient and I recall my admiration of Richard for being the complete physician and remaining with the patient when all hope was gone.

Medicine is all consuming to those in training. If one were to attend a party of interns, almost all of the conversation will be about medical cases--there is nothing more fascinating at that time of life.

I'm going to tell a story that is easy to misinterpret and to leave the reader thinking that the physicians involved were callous and uncaring, yet nothing could be further from the truth.

George with Barium Impaction

George was a man in his early seventies. He had been given a barium enema and had failed to ingest enough fluid afterward such that the barium had essentially formed a gritty plug that was occluding his rectum. Such plugs with feces are not unusual. I've had one in my lifetime and hope to avoid another. The formal name for this condition is "impaction." The treatment is to remove the impaction manually by lubricating a gloved finger, inserting it in the rectum, breaking up the lump of material there, and hooking a little piece of it and pulling it back out through the anus. You can  see that this is an uncomfortable process for all involved. But those are the essential steps.

Because George's impaction was such a severe one, all of the interns were put on notice. "If you are on the fourth floor for any reason, you are expected to do your part. Go to George's room and 'chip away' at his impaction." And we did for the next several days.

Unfortunately, there is a major nerve, the Vagus, which innervates a number of parts of the gut and the heart. It is possible for distention of the rectum to slow and even stop the heart. This occurred late one evening and George had a cardiac arrest.

George was in a semi-private room and his bed was closest to the door. More and more equipment and people piled into the room during a resuscitation attempt that went on for close to an hour. The crew pulled out all the stops because we knew that there was no known heart disease and that the inciting event was our attempts to relieve his impaction.

Throughout all of our attempts to resuscitate George, the roommate's TV remained on at full blast. Just as George was being pronounced dead, the medical crew heard Ed McMahon say "And here's Johnny!" All of us just broke up laughing in relief from the tension of the previous hour. I've always wondered what George's roommate thought about that incident.

Danny's Easter


I mentioned previously that hospitals were particularly interested in obtaining American Medical Graduates to fill the positions of interns and residents in the 1960s. However, there were many more positions than there were American graduates and there was a large influx of foreign medical graduates into the U.S. In my year at South Baltimore General Hospital only 6 of 16 internship positions were filled by American Medical School Graduates. Most of the internal medicine and surgical residents were foreign born as well. I found it interesting to bump up against other cultures in a working environment and I particularly enjoyed the potluck dinners and parties with such a culinary variety.

The hospital was situated next to a predominantly black housing development known as Cherry Hill. The hospital also serviced white ethnic areas of southern Baltimore City as well as the suburb of Glen Burnie, both of which were blue collar areas. Generally our patients were wary of foreign physicians, especially those that had any difficulty with language.

Sometimes problems with language were extreme. In obstetrics we had a Haitian physician who was just fine technically but with a poor mastery of English. I know that this is hard to believe but I observed him doing a delivery and the woman was screaming at him. "Doctor, you hurt me! God damn it you're hurting me. Stop it! Stop it! You hurt me." The doctor turned to me and asked, "Hurt? What does that mean?" At first I thought, it was a dry sense of humor. But it was real ignorance.

On Easter Sunday 1970 I was working the early shift in the emergency room. At about 7:45 A.M. the ambulance brought us an elderly, Caucasian male who had become exceedingly dizzy while driving through the Baltimore Harbor Tunnel. He was a general practitioner from New Jersey who had been visiting his daughter in Washington D.C. He was on his way home and, according to his wife, had patients scheduled the next morning. His wife said the dizziness was followed by problems with speech that appeared to be improved when she saw him again in the emergency room.  She begged me to find a private physician for her husband.

It has been more than 40 years and I don't recall precisely the sequence of clinical events, signs and symptoms, etc. However, the illness appeared to be a basilar artery stroke and the patient appeared to have a variability in symptoms. I contacted the neurosurgeon who was on call and he said to admit the patient to the hospital and that he would follow sometime later, either in the evening or the following morning. That didn't seem right--the patient was a working physician and had an acute, unstable neurological event. How could the surgeon be comfortable in delaying a visit based upon my assessment?

My next step was to call the Chief of Medicine. I desperately wanted a senior physician to look in on the case and provide comfort even if there were no available medical interventions. There was a time in medicine when "professional courtesy" was the common practice. Generally doctors felt an obligation to other physicians and their families. The Chief was adamant--he was at home with his family and wasn't going to budge. He was unwilling to come and wouldn't accede to my request that he ask someone else to come in his stead.

I had no other options. The emergency room evaluation had been completed and I had attempted to find a physician as the wife requested. I had no choice but to call the intern on the medical service to admit the patient.

Danny was the intern on call for medicine. He was a Sikh with a heavy accent. As Danny began the admitting process for the patient, I couldn't help but notice the wife's look of despair.

I looked in on the patient informally over the next day or two, but he died reasonably quickly.

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By the end of my internship, I was tired of missing sleep and could not envision another year of medical training. So I applied for graduate school in computer science at the University of Maryland in College Park and found an emergency room position at the hospital in Cambridge, Maryland.

A Full House Today and Wrapping Up Medical School

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.

Why Medicine as a Career?

Why a Medical Career?

Yesterday, my brother asked me how I made a decision about the practice of medicine as a career. It was not possible to answer that question with certainty.

I've already mentioned that my interest in medicine was stimulated by a visit to the Armed Forces Institute of Pathology in 1958. Although I was looking for an urban legend, the supposedly pickled penis of John Dillinger, allegedly removed at autopsy after he was gunned down by Federal agents in Chicago in July 1934, I was unable to find it and stumbled into other realms of medicine, things I had never thought about before.

The myth itself, the huge penis, is postulated to have originated in a death photo of Mr. Dillinger wherein his left arm, in rigor mortis under a sheet, was mistakenly assumed to have been his erect penis. The following image from a Google search should clarify if my explanation has been insufficient:

                                     John Dillinger Post Mortem Photograph

In high school I applied for Federal summer jobs at the Public Health Service and I was employed by the Division of Public Health Methods and worked under (very far down the ladder) S. David Pomrinse, M.D. and Marcus Goldstein, Ph.D. They were studying the development of group practice in the United States, a relatively rare phenomenon in the 1950s when only a few thousand such groups were known to exist. Now, most physicians practice within such groups.

Of course my contribution was at the lowest level. A survey of practices had been done and the responses came back to our office. My job was to take the completed survey and code each response numerically and enter it onto a master data sheet--what would look like a spreadsheet today. However, the job gave me the opportunity to work around physicians and other professionals. I was always treated respectfully and I shared an office with Dr. Goldstein, an incredibly kind boss whose Wikipedia bio encapsulates an interesting career.

Marcus S. Goldstein (August 22, 1906 – December 1, 1997) was one of the forefathers of dental anthropology and was also a public health analyst. He was an active researcher with a broad interest in the field of anthropology, writing over one hundred scientific publications during his lifetime.

Born in Philadelphia, Pennsylvania, Goldstein received a bachelor's and master's degree in anthropology from George Washington University, and his doctorate from Columbia. His professional career in anthropology began in 1927, when he obtained a position as aide to Ales Hrdlicka in the U.S. National Museum Division of Physical Anthropology. During World War II, he worked for the U.S. Office of Strategic Services, and in 1946, joined the U.S. Public Health Service as an analyst.

His government career included posts at the Division of Public Health Methods, National Institutes of Mental Health Administration on Aging, and the Office of Research and Statistics in the Social Security Administration, from which he retired in 1971.

As an active researcher, Goldstein's publications include a number of key works on dental variation and pathology, growth, development, aging, and skeletal pathology in past populations of Israel.

Following his retirement, Goldstein, and his wife, Lea, immigrated to Israel, where he joined Tel Aviv University and played an important role in developing research in the newly-formed Department ofAnatomy and Anthropology. Goldstein was also responsible for founding the "Israel Association of Anthropology", which now has well over 150 members. He brought together scientists from archaeology, biological, and social anthropology — no easy task in a country where the three disciplines are taught in separate faculties. In 1987, he was honored with that Association's Distinguished Service Award.

Goldstein summed up his career in his monograph, "An Odyssey in Anthropology and Public Health" (1995), in which he gave a warm portrayal of the people who had helped him in his works. He died in Jerusalem, Israel, aged 91. 


The following summer I worked on a Survey of the Health of Individual Americans. Dr. Carl Dauer, an advisor to the Office of Vital Statistics, was the chief consultant on the survey. Once again I did low level work as a clerk but I worked around professionals and was able to see the manner in which they conducted themselves, treated peers and underlings (generally the same), and I was encouraged to ask questions. The survey material included actual patient data and required that I begin to learn medical terms and to find out what they meant.



In college I was not sure of my professional path. Chemistry, Math, and Physics were interesting subjects and were my major area of study.  I also enrolled in the necessary biology prerequisites for medical school, in order to keep that option open. Physics was my strongest college subject but I didn't believe that I was talented enough to be capable of doing interesting, original work in the physical sciences. Eventually I became convinced that medicine offered me the best combination of gratifying work, geographical mobility, a collegial work environment, and fewer worries about finances.

Medical Career, First Mentor, R.A. Cowley M.D.

Medical Career, First Mentor, R.A. Cowley M.D.

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Medical Update  *
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Nothing much to report today. A little more pain and more regular medication for pain control. I'm using Ibuprofen 600 mg 3 or 4 times a day with a Tylenol #3 which probably helps a little with pain but suppresses cough as well. Stanford has given me a list of labs to be done before I come for my first chemotherapy treatment.
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By my second year of medical school, I was working regularly in D.C. on weekends. The company Android had been folded and Jimmie Osborn, the founder, and I were persuaded to accept Federal employment. My employee classification was called WAE, when actually employed, which meant that I was an hourly worker. By this time, Jimmie Osborn had finished the development work on the report generator for the Economic Development Administration (EDA) and he was spending most of his time trying to write programming algorithms for school class scheduling, something of personal interest for him.

There were several different reports cranked out on a weekly basis and a more detailed report done monthly. On light weeks, there might be ten boxes of printer paper output from these programs. On heavy weeks, more like fifteen.

After a summer of introduction to the COBOL language and the actual operation of the Honeywell 200 computer at the National Bureau of Standards, I became the individual who oversaw the system updating and the production of reports each week.

When the medical school year restarted in September 1966, I had no time for work during the business week and so I was assigned the task of actually producing the needed reports on weekends. This allowed Jimmie Osborn to deliver the the hundred pounds of report on Monday morning. There are weighty reports and then there are weighty reports. Mostly our report had a low information density (value of data per pound of paper).

From Monday to Friday I went to all of my medical school classes. Wife, Sally, was still in Nursing School. I would pick her up late Friday afternoon and drive our newly purchased VW from Baltimore to the Washington suburbs and drop her off at her mother's house. Then  I drove across D.C. to the computer center located on Connecticut Avenue and got to work about 7 P.M. Jimmie Osborn would have left information for updating the data. I made the changes using some of the programs in the system and then began the report cycle. Thereafter my job was to stay awake and feed the printer.

The evening Friday was pretty easy. I could read after getting the printer going. The most vivid memory I have is being unable to stop laughing after reading about Yossarian's bombing run in Catch-22. As the night wore on, the lack of sleep became more telling and it was as struggle to keep from dozing off and awakening in a cold sweat because the computer room was quiet, meaning the printer was out of paper.

The normal reports generally required 16-24 hours of straight work, and I would finish up somewhere between noon and 8 PM on Saturday evening, having missed a night of sleep. With the monthly reports, the time requirement was closer to 30 hours of work. Snafus could always increase the workload. On these heavy months, I might be at the computer center until Sunday A.M. having missed two nights of sleep. There was no cafeteria, only vending machines. Because of the security system, it was very difficult to leave the grounds and to return.

My Sundays were spent in trying to catch up on sleep, attempting any semblance of a social life by hooking up with our circle of college friends, and the trip back to Baltimore sometime in the late evening. It was a brutalizing several months. There was never a week-end off; I found myself falling asleep at traffic lights on occasion; I gained weight with infrequent exercise; and I was stressed with the thought of the coming baby and the need to put money aside.

I was also very frustrated with the randomness of the quality of instruction that I was receiving in medical school. Perhaps half of our lectures were well done, reflecting excitement by the teacher for the subject matter and proper attention to the manner in which the information was delivered. But there were so many bad lectures that I found myself wanting to stand up and scream and hurl my desk at those who didn't really seem to care or who were incompetent teachers. I wondered why in the United States with about 100 medical school we students were not being provided with the best possible instructors using film clips and other media. Why did each school decide to go it alone?

My school experiences and general level of exhaustion came crashing down on me in November 1966. My internal emptiness had driven the search for a female partner and marriage the prior year. I was still yoked to religious beliefs in spite of attempts to remove the harness. (I probably carry a gene for rapid and strong pair bonding--how else to explain my lifelong falling in love with practically any woman that I slept with, including Sally, my first lover and marriage partner.) With the marriage came a child and now I was trying to do something that was quite difficult--to manage medical school and a heavy work schedule as well. It seemed impossible to continue and I decided to leave medical school. I went to the dean and told him of my intention to withdraw.

For the next few weeks I searched for computing jobs within the field of medicine. There were many positions available in academic medical centers throughout the United States.  At least three recruiters told me that they thought I was making a mistake--that I should complete medical school in order to enhance my advancement and salary in this field. It wasn't necessary that I do medical practice, but the degree itself would be very valuable in my career.

It was also about this time that I received a phone call from a nurse who worked for R. Adams Cowley, M.D., the chief of Thoracic Surgery at the University of Maryland. He needed a computer programmer and one of my classmates had given him my name. And so I met my first mentor in medicine.

He was a bear of a man, on the short side but very powerfully built. His hairstyle was a brush cut that was no longer in fashion in the mid 1960's and he was almost always dressed in hospital scrubs. He had what I would call a "determined" gait and always appeared to be in slight hurry to get to an important meeting or event. He explained to me that hospitals were not safe for really sick people and that the level of care tended to fluctuate by nursing shift. He said that he had started a two-bed unit on the 4th floor of the hospital near his office because he was concerned about the level of  care for his very ill post-operative heart and lung patients.

He said that in trying to improve the care of his own post-operative patients, he began thinking more about trauma in general and had become interested enough to want to study the changes that occur, for example, when a healthy person has a severe auto accident. His two bed unit had begun to function as a laboratory for other branches of clinical medicine. The hematologists were following the clotting changes that can occur in trauma, microbiologists were examining cultures to determine if and when antibiotics could be helpful, the pathology department was doing special tissue studies on autopsies from the little unit, and various "fellows" from anesthesia, thoracic surgery, and neurosurgery were spending time "helping out" in the unit.

He had created this little laboratory that provided the best medical and nursing care available in the hospital in a climate where the patient's condition could be followed in a scientific fashion. He was able to draw quality people to him who were interested in working on a significant problem in medicine. There were statisticians, mathematicians, experimental designers, administrators, grant specialists. He had formed his own little "operations research" environment where cross fertilization had occurred.

Cowley was definitely the motor. The rumor was that he was a Mormon who was separated from his wife. There was a nurse coordinator who worked with him, Elizabeth Scanlon, a very beautiful woman who seemed to work as many hours as Dr. Cowley. She nurtured him and put up with his occasional abusiveness. A part of me would have expected them to have an intimate relationship, but I think this was medical intimacy, a mutual embracing of vocation. His hard-working secretary was Sandy, who not only did the primary office work, but was also required to manage Dr. Cowley's business investment, The Cowley Trucking Company, a fleet of local dump trucks. Poor Sandy had eczema and it would flair when the good doctor was on a rampage and at a point where everything displeased him.

In our first meaning he said, "Eric, one day we won't die. If you think about it, the whole purpose of medicine is to keep people alive and in reasonable health for longer and longer periods of time. To my mind, it means that we are working toward immortality."

I thought he had a screw loose, but he offered me a job. He had thousands of observations on twenty or thirty different kinds of punched cards. He wanted me to take those cards and to begin to extract data. The only computing machine available to him on the Baltimore campus was an IBM 704, one of the first mass produced computers introduced in 1954. The available higher level language for the computer was Fortran, a symbolic language primarily intended for use by engineers, mathematicians, and other scientists.

Dr. Cowley's problem was a data handling problem and would be much more difficult to solve in Fortran than in COBOL, a language used in business where data movement rather than data calculation was the primary task at hand. I told Dr. Cowley that I was very interested in his problem, but that I needed to scout out the College Park campus of the University to see if a "friendlier" kind of computing machine was available. I was fortunate enough to stumble into the business center in College Park, where the manager was an unusual kind of bureaucrat--he was pleased think that his computer facility could be used after normal business hours to help in medical research. He offered us free use of his computer at off hours.

This was a wonderful opportunity for me. Dr. Cowley was offering me a job that I could work on whenever I pleased. At that time I lived in Laurel, Maryland -- about midway between College Park and the Medical School in Baltimore. I would have no need to work a solid block of time each weekend, but could break my work life into smaller pieces and perform many of them at home as I wrote programming code.

There was a catch. Dr. Cowley said that I had to get back into school. I had missed about six weeks of the 2nd year at that time. Mid-term examinations were coming within a month.  I went back to the dean and begged to be re-instated. They sent me to a psychiatrists where I cried the requisite number of tears in describing the demoralization that I had been experiencing. They let me back in.  I spent the Christmas vacation studying 16 hours a day trying to catch up. However, they did strip my scholarship. Since it only covered tuition and that had been paid for the entire second year, this loss would not affect me until the following September.

And so I became the programmer for the University of Maryland Shock Trauma Unit, founded by R. Adams Cowley--certainly a medical visionary. He bootstrapped his program into a full hospital for the study of shock and trauma. He worked tirelessly on his goal and eventually convinced the state of Maryland that an integrated Emergency Medical System was an essential part of modern medical care. Cowley was able to persuade the State Police to use helicopters for dual purpose, police work and emergency air ambulance work. The members of the State Troopers who did helicopter duty were trained as paramedics and certified in Advanced Cardiac Life Support and Advanced Trauma Support.

He was generally kind to me. I remember being reprimanded when I missed meeting of his advisors (I didn't go because I didn't think that I was needed or would have anything to contribute.) I remember one Sunday morning he took me out to breakfast. He picked me up on St. Paul Street in his Buick Toronado. He wasn't wearing surgical scrubs, but a nice pair of slacks and a tweed jacket. I remember him recounting his difficulty in medical school with a young wife and child. He recalled raking leaves for survival. He then went into surgery and the Army during World War II and had lots of hands-on thoracic work in Europe before returning to the states.

I last spoke with Dr. Cowley about a year after graduation. I was working as a consultant for the Public Health Service and some public information had come to my attention that I thought he should know about. He offered me a job but when I turned him down. I no longer wished to live in Baltimore at that time.  He wished me well and encouraged me to obtain a doctorate in computer science.

I left Maryland in 1974 before the statewide system had been implemented. When I returned to the state in 1983 I was in a little clinic on Smith Island desperately working on a women who had come to my office on Sunday morning from Church and almost immediately sustained a cardiac arrest. We called for help from the State Police Helicopter which arrived within about 20 minutes and landed a couple of blocks away. I looked up to see a trooper walking through the clinic door. He was carrying two medical bags. There was a strange holster that positioned his side-arm over his left chest.

He was incredibly competent and the tools that he brought were a little more modern than what we had been working with in the clinic. We brought the heart beat back several times and managed to get the patient to the waiting helicopter but we were never able to stabilize her to the extent necessary for transport. It was the first death that I encountered on the Island.

My first tough case back in Maryland from Montana. Dr. Cowley had reached out over 14 years and 150 miles to give me a hand.

http://en.wikipedia.org/wiki/R_Adams_Cowley

Early Education 2

Early Education 2

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medical              *
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Not much to report. Checked in with my family doctor yesterday on a scheduled visit and reviewed my progress. Dr. Kolb has hospital privileges in San Luis Obispo. There are a few likely kinds of complications that may require hospitalization going forward... dehydration...reduced immune competence and infection...pain from tumor itself....It is  helpful to know your admitting doctor at a hospital. You generally have a little more leverage based upon the length of relationship.

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In the weeks prior to starting college, my father had a burst of energy. Much to my mother's objection, he turned the tiny dining room in our house into his "workshop." He bought a few hand tools, including rip and cross-cut saws, a keyhole saw, a brace with bits, a couple of planes--no electric saws or drills. And he started making wooden things, such as corner cabinets in our dining room, valences for curtains to come, built-in bookshelves and desks in the bedroom that I shared with my brother, Geoff, and redwood outdoor furniture. These products were not "perfect" or "artisan" grade by any means. They were functional. My mother was one who was much better at seeing imperfection and particularly expert in finding faults in my father, his beliefs, his behaviors, and his aspirations.

She particularly thought him a fool in his understanding of children. She was right being from a family of eight whereas he was an only child.

I recall two examples that clearly indicate an erroneous appreciation of child development.

Example 1:

I am six years old and I am playing with my friend, Johnny Handiboe. We have pencils and paper. I draw a stick-like figure of a man in profile, including the man's penis. A stream is issuing from the penis to the ground. Of course this is 6 year-old "potty" art--pretty typical stuff. My mother sees the picture and swats me and tells me that she will be showing this to my father, which she does when he comes home from work.

After supper he takes me aside and looks at the picture. He asks me why I drew this picture. "I need to know whether this is serious. Is this art?"

I knew that art was serious. I had seen my father drawing and painting on many occasions. He had never done it while laughing and joking with another person next to him.

I tell him that it wasn't serious. It was meant to be funny. But I was thinking at the time that it was so strange for him to think that my picture could be anything else. "I'm only six. How could he think that?",  I remember saying to myself."

Example 2:

I am seven years old and my father pulls me aside for a conversation. He tells me that if I wanted to date someone, that he could make sure that it was arranged. I believe he explained the function of a chaperon who could be used in such cases. I'm shocked. I knew that "teenagers," (those giants that are not quite adults) could date, but I was several years away from that. I am uncomfortable to be discussing this with him.
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On entry into 3rd grade in 1951, my father was in college and likely to be home in the afternoons.  He had begun driving a cab in D.C. generally between 7 PM and 3 AM. He had a good working knowledge of Washington, D.C. and was an accomplished driver. He had driven every type of vehicle in the army, including traillering heavy guns and tanks. He would come home in the early A.M., get some sleep, often take us to school in the morning, go to classes, come home in the early afternoon and, perhaps, nap  for an hour or two prior to our return from school.

He began receiving the Congressional Record in the mail every day. He explained that it was the right of every citizen to know what the government was doing. He would glance through it and sometimes read out parts of the congressional proceedings. He explained the use of political bombast. Even if you were talking about a Senator who was spreading vicious lies about you, you addressed him in terms such as
"my esteemed colleague." The Congressional Record was of significant bulk and began to occupy an increasing amount of available shelf space in our living room.

My father always had art tools around. His most basic tool was a lightweight, but thick 3' by 2' board that he used as shield when cutting paper or other materials with exacto knives or box-cutters. He also used the board to pin up drawing paper when he sketched.  He generally wore a hat and almost always had a pencil behind his ear.

One day I came home and he was busy working on a project on his art board. He asked me about the day and I expounded on the nature of "souls" particularly the difference between human and animal. I was beginning to learn that my father was not a candidate for heaven. He was not a Christian, much less a Catholic. He did not appear to have been baptized and, according to Sister Mary Francis, this excluded him from heaven forever. Somehow the relating of this information to my father seemed not to faze him in the least.

He continued to look down at his work. He said,  "I think of God as the good stuff ...in that bird outside singing, in the way grass smells in the morning, the feeling you get when you are doing things and you begin to sweat...just everything."

He went on..."How about dogs? Do they get into heaven." I was sad to inform him that dogs did not have souls and could not go to heaven. I backed up my argument with a reference to Sister Mary Francis who seemed very sure on this point.

He still never looked up and said, "I don't know about you, but I don't know if I'd like to go to a place that doesn't allow dogs."

I know that we had several discussions about Catechism. I wanted my father to go to heaven (I guess I still hadn't gotten the word from Sister Mary Francis that my preoccupation with my genitalia made heaven a highly unlikely personal destination.) He managed to turn my arguments aside without rancor and didn't appear to be interested in trying to change my beliefs.

At the age of 8 he began to teach me about history, geography, and politics. Generally I would ask a question and a little lecture or teaching would follow. Occasionally we would play checkers and by nine or ten I was winning most of the time. He never complained when defeated in checkers or chess. Generally he didn't gripe as I got older and was able to beat him in badminton. However, one time I did laugh at him during a game and he threw a racket at me...and one time at the dinner table during a mild dispute, he became so angry that he threw a fork (at least it wasn't a knife).

Seeing my father go to school impressed upon me the importance of education, particularly when I saw the rearrangement and disruptions that had been imposed upon our family by his decision to seek that education at a later age.

My father liked books. He built himself a desk that he could use while sitting up in bed. Occasionally when he had a cold or was exhausted from his work and school schedule, he would lie in bed all day and read. Having been so affected by the war, he was fascinated by its history. Early on we had Churchill's Six Volume Set and he read every word. He was only marginally interested in great literature or thoughtfully constructed movies. I remember seeing "Wild Strawberries" with him in 1958. I loved it and the movie seemed "true" to me--my own definition of a "true" movie might be one that ends exactly where it should. He didn't care for it.

The greatest gift from my father was his refusal to censor anything that I wanted to read. Although I've just made fun of a father who thought my "dirty" picture might be a work of art, this same willingness to concede the possibility of an artistic intent may be from the same source as his allowance of literary freedom.

The second great gift from my father was his refusal to buy into any organized religion, seeing all of them as essentially perverted by the control of the few at the top of the food chain. I think this mitigated the damage from unadulterated rote religious teaching.

Early Education


Thursday October 20/Friday October 21

After returning from Dr. Palchak's yesterday. I was exhausted and took a two hour nap. Then Jasmine fed me some  spicy shrimp and a cabbage dish made with eggs and we watched Will Meet A Dark Stranger, the kind of movie that Woody Allen seems able to crank out on demand.

I awoke refreshed this morning at 3AM. When I stepped outside the temperature was about 60 degrees and I could hear the surf. (I wonder why the sound is so much louder early in the early morning?) Orion is high and to the South. The Pleiades are almost directly overhead. Realizing that I hadn't thought about my medical condition since awakening, I began to compare my current mental state with the way I felt as my daughter was dying.

With Kristin's sickness the dread was always there. With my own illness, I seldom think about the future. I'm aware that full realization probably awaits the rocks on the path ahead.  But generally,  I am focused and very busy cleaning things up and not dwelling on a foreshortened future. When those thoughts do come, I can feel the impending loss of the sweetness of life, but even that thought leaves me thinking about the opportunity for joy in life. When I speak of these things with Jasmine, she describes the more overwhelming sense of foreboding--the one that I recall from my daughter's illness.

Yesterday Dr. Palchak told us that Stanford was offering us an excellent treatment but expressed concern about the time spent traveling back and forth. I was able to tell him that those trips would not be wasted. Although Jasmine and I might prefer to be in our own home, we both liked driving and loved one another's company. There will be many good moments in the commute as tiring as it may be.

Although I eventually want to review my career, I've been thinking quite a lot about my early childhood from about 6 to 14. These were truly formative years. Though school was important, my father probably had an even greater influence on my education until I was 13 or 14.

Early Education Years

In 1950 my parents were looking for a house.  I was 7 years old. We were all still living in the cramped one-bedroom apartment on 7th St in NE Washington, D.C. and we children were getting bigger. My siblings, Sue and Geoff,  were now the occupiers of the single bedroom. I slept on the screened-in porch, an unheated room that made it more difficult to get out of my sleeping bag to use the bathroom inside the house. I remember having some fears about criminals and unsavory characters coming to kidnap me, having but to slit the screen to gain entry. Sometimes my Dad slept out on the porch as well, and, despite my wariness of him, I felt safer at those times.

My parents were unable to afford an older, more graceful home in an established neighborhood. They finally put a deposit on a yet-to-be built model in a cookie-cutter development about a mile north of the D.C. line. The development was named Parklawn and it was analogous to the Levittowns springing up in various places throughout the country. The baby boom was in full swing and there were increased needs for housing. The same type of mass production that had been applied to building airplanes and ships during World War II was now being applied to housing.

Parklawn was a community of about 150 homes, all of which were 2 story, 3 bedroom, 1 bath, 1200 square foot boxes placed on lots of about 110x50 feet. There were three varieties of living room window. The bottom floor was of brick, the second floor exterior was asbestos shingle.  One had a choice of green, grey or white shingles. Mom chose the double window with green shingles.

My parents were careful in their choice of a lot and selected the last lot on a dead-end street with woods on two sides. We moved in sometime in early January of 1951. It was a sea of mud for two months. Sod was finally put down on my birthday in March. I was fascinated by the process of unrolling the grass. The workmen let me help.

I went to a new school, Our Lady of Sorrows in Takoma Park, about a ten minute walk. It was a relatively new, one story cinder block building. The class size was about 60, seated in 6 columns of 10 desks each. The desks were put on runners. The construction was such that each desk unit contained the built-in seat for the pupil in front. You could always reach forward and poke the person in front of you.

The teaching methods at the new school were "softer" with greater use of games and contests for learning. Art and music were also incorporated into the curriculum.

I was very glad to be leaving the old neighborhood where I was frequently tormented by the Smith boys who lived across the street. Their parents were really serious Catholics and the family was living in a 1 bedroom apartment with at least 8 children, three of whom were boys about my age, each meaner and tougher than the next. They hadn't developed their protection racket to the point where they were extorting my lunch money, but it was coming. In our annual flower show at school, the Smith boys had told me that I better cast my vote for their brother's arrangement. I did. In order to avoid the Smith's I tried to make sure that I was out of the apartment and down the alley before they set out for school.

At least with the Smith's I was not dreaming about them. The Chens terrified me. They ran a cleaning shop on 12th street and had a family that included several boys. An industrious family, the boys each had a wagon and spent Saturdays at the shopping district waiting to be hired to carry home bags of groceries. This was still a neighborhood where most families did not have an automobile. The term "thrifty" would do an injustice to my mother's grasp upon her pocketbook. There was no way the Chens were getting any of her money. She had a portable, wheeled basket that she used to cart her own groceries.

Harry Chen, one of the brothers, was my age and attended Brookland Elementary School with me. He was selectively mute. He would not talk to the teachers or say a word to anyone during class time. He could talk up a storm with his family after school. Henry had been "adopted" by one of the little caretaker girls in our class who spent recess hovering over this intentionally speechless child. I was never unkind, but it seemed that every day after school, one of his older brothers would grab me by the front of my shirt and demand to know if I had hurt Harry. It was scary.  Soon I was having nightmares of being chased by a Chinese man holding knife. I recall working with this nightmare and trying to teach myself to wake up or to remind myself within the dream that it was not reality. My recollection is that I sometimes succeeded. However, memory is a funny thing. I would give this particular memory of dream intervention only even money for validity.

Escape from the old neighborhood's early childhood "gang" structure was wonderfully liberating. I liked my new school partly because it put Sr. Marie and her henchwomen far behind me. Best of all I had two new pals, Buzzy Carragher  and Johnny Robson, who lived within a stone's throw of my front door. Johnny would be in my class at school for the next six years. We also attended the same high school and often commuted to the University of Maryland together.

Shortly after  my parents had made this big move taking us to the 'burbs',  my Dad came home in July or August with a major announcement that shocked my mother. We three children were too young to understand the implications and the manner in which it would change our lives. My father had quit his job and decided to go to college. One of the benefits of military service during World War II was the so-called GI bill that guaranteed help with housing (my parents had already purchased a no down payment house) and with further education. There was an expiration date for using these benefits. My father had to take the benefit or lose it.

More About Army Bill

Army Bill was how I thought of my Dad while I was a toddler to distinguish him from my uncle Bill who was in the Navy. Both men were married to red headed women who lived at 912 Quincy Street. After he returned home from the war, Army Bill became thought of as "Dad."

My father's life was difficult. Both parents were from disturbed families.

His dad's father (my great grandfather) had committed suicide. The story is one of a German immigrant, a brewer, who immigrates to New York and opens a bar. However, rather than drinking at his own establishment, he parties elsewhere and goes broke both financially and health wise, and at some point was wheelchair bound and dependent upon his wife's ironing to survive. One day he asks his wife for a nail file and uses it to gouge out his throat.  As he is bleeding, the ambulance is summoned. My grandfather is about 9 and playing nearby. He follows the ambulance to his own home and sees his father, bleeding from the throat and fighting with ambulance attendants in order to continue to hemorrhage and complete the suicide. And he succeeded in exsanguinating shortly thereafter. My grandfather then quit school and helped to support the family. He volunteered for WWI and was a stretcher bearer and worked on a sanitation train...analogous to the modern hospital ship.

During the depression my grandfather moved the family 13 times in order to obtain jobs as a maintenance man for apartment buildings. During WWII he became a steelworker and finally moving to Erie PA to continue to work his union job.

My father's mother, Florence Kiel, had been dropped off at the orphanage on two occasions during her father's hobo days. She quit school in fourth grade to work in a hat shop. She was a binge alcoholic who would disappear for a few days at a time apparently in the company of men. My grandfather always took her back. By the time I knew her, the drinking days were over. She was a great baker and I think of her whenever I see blueberry muffins.

Her mind was very sharp. My mother claims that Florence could add up the grocery charges faster than the machine. Her favorite past time was keeping up with the "stars." When she saw that I had received a "Warfield" scholarship to medical school, she pointed out that this was Wallace Simpson's family. I really didn't know my grandmother until she had put aside her wild side. I loved her sense of humor. To describe a difficult situation, she would say. "And that would put you up the well-known creek." I didn't understand the allusion until I was fourteen or fifteen and  heard "up shit's creek without a paddle."

At the age of 17 my father migrated to Washington D.C. from Yonkers and stayed with his mother's first cousin and her family. He was an incredibly efficient typist and obtained a job with the Federal Government as a clerk. He joined the D.C. National Guard and he once described the wonderful feeling of coming back from Guard Duty with a hundred dollars in his pocket and getting on the early evening train to New York to visit his friends. He remembers having a drink or two and feeling incredibly high.

                                       My dad with an unknown girl friend at age 18 or 19.

In 1940, the D.C. National Guard was called to active duty and Dad advanced rapidly to Sergeant. He became bored with the peacetime army and wanted to join the Canadians who were already at War with Germany. He wrote a letter to his commanding officer asking to be allowed to enlist with he Canadian rangers and to rejoin the American army at a later date. My Dad's stated reason was "for the good of the Army." Dad says his commanding officer replied with the question "Whose Army?"

Dad never talked about his wartime experiences except when he was drinking or drunk. I'm sure that he was significantly traumatized. When I was three I was given a motorized toy army tank that was battery operated. It had rubber treads and could climb up over cushions and it made a chattering sound as it moved along. It was the most wonderful toy ever, even better than my Native American Doll who had the papoose doll on her back. I remember staying up very late playing with it. The following morning I was up early, eager to play with the tank. I couldn't find it. When I asked my mother where it was, she feigned ignorance and claimed the events of the previous night had never happened--that it must have been a dream. My father backed her up. It never happened! I didn't find out until many years later, that the sounds of the toy tank was too disturbing for my father. He had been under attack from tanks.

As children we went through the top drawer of his dresser fairly frequently (probably not as frequently as my mother who would have been looking on a weekly basis for evidence of his philandering). We found his bronze star, service medals, and two purple hearts.

We eventually got some of the story from him. He was in Patton's army. They had crossed over from France to Germany. One evening he was part of a four jeep convoy that made the mistake of attempting to return by the outgoing route. The were caught in an ambush. The first jeep had been damaged and the second had taken fire. Those in the third and fourth jeeps abandoned them and sought cover in the woods on the side of the road. Dad says that he could hear two buddies calling for help, so he crawled toward the first jeep, but it was completely destroyed with a mortar. He crawled under the second jeep and reached up to grab the hand hanging over the side. When he pulled, the entire arm came loose. He crawled to the edge of the woods where a soldier was lying on his back sobbing and complaining about arm pain. Dad grabbed and began dragging him toward the remaining Americans. From time to time the soldier would scream about his arm and Dad would tell him to "Shut up!" there were Germans all around.

The wounded man died at about the time that they reached the medic. When the soldier was turned over, he had a large penetrating wound of the back in the lung area.  The sobbing and screaming about the arm was really referred pain from the chest and lungs.

When my father returned to school, he apparently wrote a short story based on his experiences. One of the fellows in his outfit was called "Baby Doll," who had a liking for German and Swiss watches which he sometimes expropriated from the dead. In my dad's story he writes of a firefight where "Baby Doll" is removing and throwing away seven or eight watches because he had heard that the Germans would immediately execute Americans who were found with war trophies.

When my father quit his government job, he took his retirement money and enrolled at the University of Maryland, about a 3 mile drive from our home. My grandfather, Walter, was selling cars at the time and found a used, 1948 hunter green Studebaker sedan. My mother's lot in life was to have to leave her homemaking and go to work full-time. Except no women really leaves the homemaking--it just gets done evenings and week-ends.

In the fall of 1951 my father began classes in Political Science and I started the 3rd Grade. He was home most afternoons.