While hiking today, a woman my age commented that her 89 year-old father, an “old school” doctor, loved medicine more than anything else, volunteering in medicine after he had retired, 27 years earlier.  I was jealous.  I burned out in medicine, and nobody needs a neurologist as a volunteer abroad, where most major medical issues are handled by surgeons. Come to think of it, not much was needed from neurologists here at home, either, except when it came to people with normal tests, post-surgical disasters, and chronic pain.  Looking back, probably the best thing I did was to know when enough was enough and did the thankless job allowing patients to die without further intervention.

I was the one who heard the comment, “We won’t know the extent of damage until he wakes up,” and replied, “he won’t wake up.”  People didn’t like this truth.  I used the word “die,” one of the strongest words in the English language, not “pass on” or “expire.”  I took issue with miracle full recoveries after years in coma, when these people were either vegetative or severely disabled.  Misquoted anecdotes and reflexive smiling in vegetative states has led to numerous patients being supported in irreversible coma for weeks, months, or in some instances years.  I discontinued tubes, when doctors and nurses both believed once a tube was placed, it had to stay.  No it didn’t.  I took the first responder “saves” and stopped the ventilator a week later, when the patient still showed decerebrate rigidity and would not survive.  I told more than one family I was a “hard marker,” and “he squeezed my hand” did not count, if a patient could not hold up three fingers to command.  I listened to “he never wanted to be like this,” and if the time were right, acted.  These actions in retrospect had a great deal of value, but made me unpopular.  I was told I would deal with my parents’s deaths differently, but I didn’t. I kept my promise to them.

When there were no living wills, my job was more difficult, which is why I was incensed when the concept of paying doctors to discuss death with the elderly was referred to as “Death Panels.”  I hope many of these ignorant people may some day understand.

To me, “old school” doctors remind me of “the good old days,”  during which we had legal segregation, unsafe cars, frequent plane crashes, drunkenness was funny, smoking was cool, and adult women were “girls.”  On the other hand, we didn’t have the singing commercial, “your call is important to us,” and weren’t addressed by our first name by a stranger a third our age. In the “golden years of medicine,” when I trained, doctors were king.  Nobody questioned their actions, when questioning should have occurred.  “See one, do one, teach one,” was a problem to those of us who simply couldn’t do one right.  We didn’t track outcomes, we hid errors, we referred to friends, rather than those who had the best outcomes.

In the “good old days,” patients didn’t expect as much; we couldn’t do as much.  Medicine was simpler, costs were less, charity care was expected, and patients stayed in the hospital a lot longer.  It was a different world.  We had poor ventilators, so pneumonia was called the friend of the elderly, except now a ventilator can tide some over and lead to resumption of normal life.  Cancer was a disease of children, not adults, as it is today.  We did disfiguring radical mastectomies and kept heart attack patients in bed 6 weeks, both procedures harmful and long since abandoned. Mental illness was treated by commitment to awful hospitals, although the present “right” to not take medication and to live on the street is the current price.  I’m not sure where we should go with that one.  No firearms for them would be a start.

Technology changed the world, along with a medical arms race among hospitals from CT, MRI, and helicopters (about 10 deaths a year are caused by medical helicopter crashes, making it one of the most dangerous occupations).  Scans are expensive; CT radiates more than most doctors realize.  Doctor’s labs were found not to be good, privacy wasn’t, leading to HIPAA, which has created issues for non-relative “best friends,” and the profession almost bankrupted the country by charging fees they set and expected to be paid.  Lawsuits occurred, which seldom brought justice to many who deserved it, adversely affected the physician-patient relationship, and a reason I left medicine. 

Medicine in the old days I compare to Phoenix in the old days.  It was nice, a lot smaller, people liked it, and all was fine, but completely unsustainable.  We have known for a long time medicine limits access; good care isn’t affordable for everybody.  We haven’t wanted to address the issue, but it won’t go away.  [Phoenix is unsustainable, for there is no way we can continue growth where rainfall is diminishing, the climate is warming, and water supplies are tenuous.]

Medicine has opportunities and a potentially wonderful future.  The solutions to the problems, however, will not be implemented, because as much as voters say they want politicians to tell the truth, no politician, no matter how charismatic, can tell the truth and be elected.  I don’t have the charisma that the Republican challengers for Arizona’s 8th CD have had, but I am smarter than they are and better educated.  But try to tell voters that we can improve access to and quality of health care only by increasing tax rates, including a net worth tax, an investment tax, and concomitantly decrease military spending to true defense, not wars.  We need a reporting system for medical errors, and in the era of computers our inability to have medical statistics 6 months after the end of a year, rather than 4 years later, is inexcusable, appalling and achievable. There is absolutely no way anybody can get elected saying the above, but I think the above is close to the “truth.”

Old school medicine was easier.  We didn’t worry about cost of hip and knee implants, because we didn’t do joint replacement.  Trauma patients died, “tragically,” because the skills we now have didn’t exist.  Breast cancer presented as an eroding mass, not a minimally invasive lesion that could be excised, radiated, and treated with aromatase inhibitors.  We didn’t have HIV, pulse oximetry, and colonoscopy, which saved my life.  GI bleeds were irrigated with ice water, rather than treated quickly with endoscopy.  People with ulcers had infusions of milk, rather than drugs, occasionally exsanguinated, not cured with endocscopy.  Cholecystectomy was 2 weeks in the hospital, not outpatient.  Prostate cancer presented with fractures due to bone metastasis, not caught early.

Where will we go with medicine?  Every generation of doctors is at the dawn of a new era.  The “giants” in medicine and the “golden years” were neither large nor golden.  They performed in their world.  We must now perform in ours….better.


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