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THE BIRTH AND DEATH OF A CLINIC1

As I write today I am happy but exhausted.  I have a clinical assignment which seems suited to me, so I have an optimistic attitude.  Now I have the privilege to serve as physician for a women’s prison of about a thousand inmates.  I knew before meeting any of them personally that without exception each of them has suffered deprivation, exploitation, dependence—intense forms of common human suffering, but in these individuals suffering chronic and severe.  Almost without exception they each suffer as cultural minorities, abused by men from before birth, impoverished, undereducated, addicted (in the shadow of men).  Because of these deprivations their children and families have suffered, so any amelioration we can promote for any of them will benefit a large network of real persons.  Even though each of my patients has made painful and destructive errors in judgement and behavior, her punishment is not my concern but the judge’s who has already sentenced her; I am here to attend to her essential health needs rather than to judge or punish my patient.

Today I am exhausted because the learning curve is sheer vertical with regard to technical medical realities, with regard to a complex legal and bureaucratic state agency which can never be satisfied in the face of its own impossible mission (simultaneously to care for but not to trust) and internal contradictions common to all state agencies.   Especially I am strained because this one is yet another imperfect clinical team with a heavy recent history of dysfunction and distress.  Each clinical team with which I have spent my career has been quite imperfect (despite their variety of clarity or cloudiness in direction, more crystalline or more muddy structure, icy sterile or warmer human texture); and my sincere efforts to improve each have been at best only slightly constructive, sometimes (despite my intended sincerity) counterproductive.

My improved attitude is not from any great accomplishment of my own, just the gentle maturation which shifts from the “Aha!” new discovery phase to the “Oh, yeah (I knew that)” re-discovery phase of learning.  I mean in this essay to summarize some of the highlights of my own experience in various clinical teams over four decades as a clinician, the painful slow learning I have tediously accomplished which sorts itself into two rough lumps of difficulties—those inherent in all human aggregate behavior and communication on the one hand (which I wish to study with you), and the too frequent obdurateness of my own disordered personality.  (For decades I have looked for energetic bright young normal persons to do my professional tasks, but repeatedly I have discovered I must do my own work despite my all-too-human limitations.)

I came to residency training in Family Practice and Psychiatry, became a generalist physician because of my distrust of the post-World War II materialistic specialization of my father and his mercenary physician colleagues (whom I soon came to understand and forgive, these survivors of the Great Depression and the Second World War).  I had intended to serve with honest work, to be a teacher:  I started as tutor then therapist to emotionally disturbed and dyslexic children, but soon I saw in order to serve my patients I needed to learn and be credentialed either as a psychologist or as a psychiatrist.  Of course once I started training as a psychiatrist I found my patients in the state mental hospital needed a “real doctor” and a psychiatrist rolled into one, for the person of the patient cannot well be split into parts (body separate from soul), so I had to become what I had been reluctant to become, a doctor like (and unlike) my father.

When I first had come to Denver I found an ideal prospect for a fellow of my age and temperament, to work as physician in the historic ghetto of the city in a neighborhood health program designed on the principles of the Kennedy-Johnson era War on Poverty, a primary care clinic staffed by specialty-certified professionals humble enough and savvy enough to seek health and welfare for their patients at ground level, in the very neighborhood in which those patients lived (rather than in a distant Ivory Tower Medical Center).  A few years later I resigned impulsively when the Mayor appointed a Manager with whom I could not communicate comfortably.  It was a merely histrionic gesture on my part, my own grandiose professional self-sacrifice meant to illuminate the failings of the other.  (I didn’t hurt him at all; he was quite able to do that himself, as he did do later.)

I spent a dozen years as a consciously willful dinosaur, a solo private practitioner general physician in the age of developing “managed care,” intending to treat the sickest and poorest patients more effectively than any of the governmental institutions could.  Of course that effort ended with me physically and fiscally bankrupt but with a defiant grin on my face for having tried the impossible.

Part time for almost two decades I worked for the Federal Employee Occupational Health Division of the Public Health Service, to leave only when I became convinced of short-sighted self-serving duplicities of the managers locally and in Washington.  I hoped by moving into the private sector to treat these same patients and their employer federal agencies I might be more effective and economical than that bureaucratic quagmire would allow.

The next nine years I worked as an occupational health physician for the largest health care corporation in the universe in several different clinics; the last three of these settings seemed important to me because I thought I was in a position to influence their harmony, their productivity of good clinical results for the patients and the patients’ employers, stability and security for the clinic staff.  In its own ways The Corporation was quite more self-defeating even than the State Department of Corrections or the Public Health Service with regard to the business of making a profit, and more counter-productive with regard to delivering health care to the patients in the community.  These are large complex organizations characterized by the power-oriented information-withholding style I have discussed in previous chapters, rather than the information-sharing patient-oriented style characteristic of the classic clinical relationship.

I don’t know exactly what I thought I could deliver to my patients, but I knew my work was for their sakes rather than for my own, hoping I would fare well enough if I worked for patients rather than for myself.  I quickly learned I could not know what they needed out of my own imagination only, that I would have to pay attention to what they said they wanted (or could not so clearly say) and I would have to study to learn what they truly needed as living beings.  I learned early that I felt most myself when I paid attention to others for their own sakes, certainly not the “normal” attitude all of us were taught in this culture (“Look Out for Number One”=LONO).  I have come to believe most clinicians are every bit as altruistically motivated as I have been though they risk being as isolated as I.

In this essay, as to the clinical teams and the contexts within which they were set, I shall try to share with you enough candid (though unavoidably biased) highlights to allow you to consider with me the realities, and I shall try to avoid utterly any tedious compulsive analytic post-mortems of them.  It is my purpose here to suggest why we as a culture and economy have not yet been able to deliver health care effectively nor economically even though we have paid many times over to get that done.  If I come up with any bright ideas it will not solve these problems (unfortunately), for it is not what I think but what we do which will matter.

***
The outpatient child psychiatric clinic where I first worked as a lay-therapist at first awed me.  Everyone else seemed to know what they were doing when I did not.  Interrelationships were intricate and complex.  There were separate medical, nursing, psychometric and social work divisions.  Everyone’s activity and responsibility seemed well-intentioned, sophisticated, highly professional--yet somehow faulty, for more energy directed toward the institution than toward the patients.

They told me to read Slavson’s text on group activity therapy, to propose a treatment project, then execute it.  I knew no better, so I scheduled three or four one-and-a-half hour group therapies each day with six or eight disturbed children, fifteen minutes between sessions to dictate my detailed therapy notes and eat my lunch.  I made appointments with the parents one day a week, changed from tee shirt and baggy pants to dress shirt and tie.  The administrators of the clinic allowed me do this Augean task, impossible though it may have been to sustain.

I learned an immense amount from the children and their parents, and quite a bit from the professionals who casually shared insights and feelings with me about my patients who were their patients.  I was not invited to case conferences or other in-service training even though I was the one most in need of training and experience, nor was I even told of those regularly scheduled staff training activities.  I logged more patient hours than the rest of the department combined (all the psychologists and all the social workers) billed by the department as if accomplished by a certified professional.  I guess what I learned from my supervisors (the head social worker and the psychoanalyst medical director) was that they were quite willing to exploit me at two dollars per hour for their own short-term fiscal profit.

***

I decided for the sake of my patients I needed to study and to learn, so I applied to the nearest medical school and after taking additional courses to meet their entrance requirements I began as a medical student to study and work in many different departments with many different sorts of supervisors and teachers.  I didn’t always get along with them and I didn’t always make their lives easy, but I did get through the hoops and examinations even though (as you easily read between the lines of these few paragraphs) I tended toward stubborn idiosyncrasy rather than obediently memorizing twentieth-century high tech dogma (a poignant example:  my presentation to a seminar of anatomy graduate students a historical review of theories of the anatomic seat of the soul--not gently received).

Some of my teachers manifested an outmoded medical authoritarianism the patients could no longer tolerate gracefully; yet the casual attitude in vogue at the time (for doctors to wear jeans and tee shirts and to call patients by their familiar first names) seemed in its own way demeaning of the patients, especially in the ghettoes where we studied.  A need for a safe measure of formality brought me to shave my beard before working on the wards at the Veterans’ Administration Hospital, to address patients as “Mister Jones” and “Ms Smith,” and to allow them to call me “Doctor Pollack” even before I had merited my formal degree.

I found I could get closer to my patients by coming to where they lived or worked than if I stayed only in the sterile institutional clinics.  Yet I found they were more comfortable, and I was too, if I used formality in a respectful but not a distancing fashion.  On the wards I squatted down at the bedside so I did not loom over the supine patient.  When I made house calls I stuck to the business at hand for the patient’s sake, politely declining offers of refreshments, steering clear of personal chit-chat.

During medical training I probably paid too little attention to supervising authorities, knowing my manners and habits too often met with upraised eyebrows or even complaints.  (“Doctor Pollack, you’re acting like a social worker!” exclaimed one charge nurse who wanted me to behave like the rest of the medical students, loyal to the professor rather than to the patient.)  With a bit more experience, and under the kind tutelage of some supervisors who cared for me and for the patients I became a bit more flexible and tried again to follow unwritten rules I really did not intuitively understand.

***

My first job after medical training was with that Neighborhood Health Program.  The man who hired me and supervised my supervisors is a man I depend on and admire today, more than thirty years later (as reflected in the chapter “Johnny:  Physician/Diplomat”).  I understood he was my partner in caring for each patient, the administrator who cared for all patients.  He had to keep the system going in a way which understood what each patient needed.

Our staff in that clinic as a whole was not perfectly harmonious, but hung together with a lot of energy, a lot of common goals and methods.  We were all physicians who were specially trained (specialists in infectious disease, pulmonary disease, gastroenterology, psychiatry, hematology, family medicine) each of whom practiced general medicine there; and a new special discipline, nurse practitioners who had learned not only the special skills of nursing but also the disciplines of physical diagnosis and treatment.

The clerical staff and practical nursing staff had been hired and trained from the neighborhood, women who had been on welfare themselves, for this program had sprung from the federal Office of Economic Opportunity (the War on Poverty).  Now these folks were no longer themselves dependent, but increasingly expert at helping the neighborhood as a whole to become more independently healthy.

I could not at all get along with my supervisor’s supervisor (the fellow who soon was to be chosen by the Mayor to be the Manager).  For a time I was employed but unassigned until Johnny said, “Nathan, I have just the job for you…”  “Which do you mean, John, the addicts, the alcoholics or the schizophrenics?”  “The addicts, of course.”  “Well, you know they’re all good patients to me.”

I stayed on as the medical director of the methadone clinics on contract for over two years after my rash resignation from city employment, for the sake of the staff as well as of the patients.  I opened my own office to single-handed practice general medicine (meaning to care for the sick and poor better than the governments could do it).

As in any human organization, the political interrelationships, the seemingly arbitrary misunderstandings, competition between subgroups of the whole (especially the specialists in the central hospital versus the generalists in the outpatient clinics), attachment to “the way we’ve always done it” all together too easily limited our communal capacity flexibly to solve new problems.  When I encountered what seemed “political” losses, I tended to react inflexibly and reluctant to compromise.  As I consider the majority who stayed in that municipal health system, that they had indeed made sacrifices and compromises but stayed in the organization productive to the present day I applaud them each.  I don’t blame me for going my own way, nor others who left to go to “the private sector” but I wonder if I might not have done much better for myself and for my principles by staying.

***

It took me thirty years to begin writing “The Clinical Team.”  I have worked in and for this series of teams, but I don’t understand them well.  My experiences have convinced me that it is easy to damage or disrupt them, having watched many sorts of negative factors:  imbalances in loyalty (as alluded to in the chapter “Medical Ethics:  there are no dilemmas”); indolent personalities (smiling persons who do no work, or empty the till); toxic personalities (usually self-centered control-freaks, sometimes physicians); external circumstances of politics and economics; and many other permutations and perversions.

Recently I was impressed at the demolition of a trio of services of which I was one of the main doctors.  Although my perspective is just one, it seemed clear to me that the destructive changes for that clinical team, its neighborhood and the patients, were the direct result of the notoriously imperious personality of the CEO of what we may call The Hospital.  She was not going to tolerate anyone having influence on her institution, its physical and commercial growth or tight control of its employees.  The Regional CEO obviously agreed with her, or at least declined to disagree.  I assure you that I am candid for the sake of honesty, honoring the truth, which may lead us to improvements in our expectations and behaviors in clinical endeavors.  We have already lost inestimable values and resources with regard to health, economy, education and public integrity; certainly we need to acknowledge the sorts of mistakes we have been making if we are to avoid repeating them or to begin to correct them.

I tried in a note to the then-CEO of the Clinic Division to summarize politely the ways in which The Corporation shot itself in the foot on my watch.  If a technical audit needed to be made, certainly The Corporation could do that itself.  I have learned to say, “Don’t bother me with what you consider to be the facts; I care only about the truth” and the truth is that corporations (large, small, formal, informal, public, private) are run on primitive principles of short-term individual power, conflict and ego, no way considering principles of longer-lasting community growth, conservation, health, service or human good (and, as I have long ago discovered, human aggregate function is usually based in withholding and confusing information for the sake of individual power rather than sharing information for the common good.) 

Dear Ralph [not his real name],

It was good to see you briefly last night at the holiday party.  You are looking hale indeed.

You asked me with sincerity in your voice why anyone would wish to refer outside The Corporation.  I owe you an answer to your question, and a response to your letter of a month ago.

It is not that there are not or cannot be good services or skillful consultants in the The Corporation system.  It comprises a huge proportion of the market, it contains a majority of the facilities and professionals in the community (owning over half a dozen hospitals in this town, several ambulatory surgery facilities, and all the rest, which you can certainly enumerate better than I).  Therefore it is likely to contain much of the technical and clinical quality available to any patient or client.

What you seem not to understand clearly is that clinical values (the real goods which can come to a patient through a clinician) are not in the same dimension as market values.  Do not think I am doubting your understanding; most of our economy and culture have been unclear on this distinction over the past three decades and more.  The bottom line is that a good clinician makes judgements on the basis of the needs of the patient immediately present before her or him, not on the basis of the economic aspirations of the corporation which constitutes the clinical workplace.  These are not conflicting but utterly unrelated considerations, one fiduciary (based in personal trust), the other fiscal (based in corporate contracts).

It may calm your concern to know that I have found “in-house” referrals to be preferable on the average to “outside” referrals because both convenience for the patient on the one hand, and on the other hand facility of communication for the clinician will thereby be enhanced.  These are not superfluous luxuries, for simplifying the patient’s experience and clarifying the clinician’s perspective are essential to achieving health and economy in the clinical enterprise. 

Robert Veatch, a most prominent bioethical pundit, has disagreed with me on this distinction for ever so long, but we are both glad to have the freedom to disagree on such important issues.  Rather than to burden you with a tedious lecture I shall attach a couple of relatively brief essays from my collection, lessons I have learned from my patients and my work over the past four decades (“In Defense of The Oath” and “Dehumanized Health Care”).

So you see it is not a question of a clinician wishing to refer outside The Corporation, but “according to my ability and judgement” doing what is best for the patient.  I trust it is as you implied in our brief exchange last night, that if The Corporation does its best to provide techniques, services and expertise it will succeed in the marketplace.

As to your brief letter of last month advising me that my contract will not be renewed, I am quite sympathetic with you (but perhaps more sympathetic with Alan B. as medical director and my immediate supervisor).  The disjunction succinctly encapsulated in your question last evening is more than merely germane to the strain you have been confronted by from the moment you met me.

When you took the reins from Mark P. I had been struggling unsuccessfully to pull together a clinical team at the Hospital Healthpark Southwest Urgent Care and Occupational Health Center.  The surrounding residential and commercial community had trusted and relied on that clinic for fifteen years, and there was no competition for The Corporation in the vast and rapidly growing Southwest neighborhood.  Without any apparent coordination among The Corporation, The Hospital Medical Center and The Clinic Division (and certainly with no communication to the staff or clinicians of Southwest Clinic) The Hospital planned, developed and built a new emergency department at The Hospital Southwest Healthpark, not only refusing to cooperate or coordinate but insisting on the elimination of the established clinics (Urgent Care, Occupational Health and Sports Medicine Rehabilitation).

You know the details of the process which was in progress as you took the job of CEO of the Clinic Division:  the productive urgent care, occupational medicine and rehabilitation facilities were abruptly closed in mid-June and their staff members terminated; urgent care facilities were to be moved twenty miles away to the Northwest Clinic (but when one pivotal physician was understandably dissatisfied and quit, the whole project was abandoned and eventually “out-sourced” or “sub-let” to an enterprise unrelated to The Corporation; and now several Corporation competitors are busy occupying the vacuum left by the closing of those clinics).  My occupational medicine practice was moved to another Occupational Health Center very near The Hospital.

Transitions are difficult for everyone.  We had a lot of instability and dysfunction in the team at that new clinic (which may now be easing ever so slightly).  One of the unanticipated burdens was about fifty calls a day asking for urgent care clinic services, so many that it was more than merely difficult for the staff to care for the occupational medicine patients.  (That disgruntled physician soon opened a competing non-Corporation urgent care clinic in the Southwest neighborhood, or the flood of calls from an unmet fifteen year-old community expectation and demand might have been even more onerous.)  The new emergency department was opened with great fanfare in October; I hope it will meet some of the community demands (although emergency facilities are not an economic way to meet non-emergency clinical needs).  Perhaps the new emergency facility will be profitable for The Corporation.

The Hospital Medical Center employees were to be seen for on-the-job injuries at the new Occupational Health Center.  Initially it seemed there was no problem, but soon the anxiety and intrusion of the nurse case managers from The Hospital became apparent, and finally the clinic and I were emphatically notified I was not to see The Hospital employees.  No reasons were given and no specific complaints were documented.  The other physicians on the staff independent of my own opinions disagreed with and faintly and futilely opposed such a policy, especially as there are times when I am the only provider at the facility and there are times when a large number of new Hospital staff on-the-job injuries require my participation in order for the clinic to function sanely and for good patient care.  I oppose the policy because it is patently assaultive to my ability to do my work, as well as to my reputation (even though I have been a medical staff member in good standing at The Hospital first about 1980, and at the present time).

When Alan gave me your letter and discussed it with me he made it clear that your “business decision” not to renew my contract was not at all because of deficiencies in my professional performance or because of deficiency in productivity, but because of “customer dissatisfaction” which clearly emanates from the administration of The Hospital.  To me that means they are controlling the Clinic Division over which you are the CEO.  Ah well, there is a great difference between clinical relations (for the welfare of the patient, characterized by thorough sharing of information) and political relations (to serve the interests of those who wish to control, characterized by withholding of information).

You have informed me my contract will not be renewed.  I apologize for having withheld from you the information that I would not renew my contract.  When I trusted Alan to straighten things out with the administration at The Hospital in early September, I felt relief from the strain of conflict as I realized I was free to stay with The Corporation.  Freedom cuts both ways:  freedom to stay is freedom to go.  Thereupon I began considering and applying for other professional occupation.  You had asked me more than once to go full time with The Corporation, which I had declined as for several decades I have had other engagements in clinical services, consulting, writing and teaching.  I was willing to stay for the sake of the patients and the staff, but for my own sake I am certainly willing to go.

I assure you I will not calumniate The Corporation.  As you can see from what I have said to you today, I have warm regard for all the persons who have worked to give me a reliable setting within which to attend to my patients, especially the administration of Clinic Services (for previously I did not succeed in the marketplace when I was the administrator of my own one-person corporation).  The disappointments and discrepancies we suffer belong to all of us and are mostly triggered by what you and I have discussed last night in shorthand through your question “Why would anyone wish to refer outside The Corporation?”  Our unrealistic expectations of health care and our difficulties in communication and understanding come from the double-vision caused by trying to see patient care and fiscal profit in a reverse order of priority:  the task of the clinical enterprise is simply to pay attention to the patient; all other goods to all other parties fall into its wake.

Or, as Hippocrates has taught us in his First Aphorism (my own translation):  "Life is short, the art intricate, experiment slippery, decision hard to come by.  The physician must be ready not only herself (or himself) to do what must be done for the sake of the patient, but also to engage the patient or any outsider--even third parties (which includes The Corporation)."

Good luck.

Sincerely,

Nathan

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1Michel Foucault’s The Birth of the Clinic is about the pathoanatomic approach to diagnosis and treatment developed by the eighteenth century, “clinic” meaning teaching and charity hospitals and appended clinics.  This title refers not so much to the epistomologic development of clinical perception and action but to the human and corporate relationships which determine health care.

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