| | | |

THE GOOD DOCTOR:  vignettes of Johnny, physician-diplomat

As from prison, I reach through what cannot be described, remember the joyful coincidence of truth and beauty which still forms and confirms my world.  It is not remembering my past as if it had been lost, but it is to make more vivid what is even now my light, my air, my atmosphere.  I use my imagination to reify experience, to actualize dreams.  I explore the complexities of one real man, human, unique and nominally anonymous, hero whom I have continued to rely on the past thirty-five years (never complete unto myself).

e.e. cummings and Aleksander Solzhenitzyn (in The Enormous Room and Archipelag Gulag) teach us the ordinariness of stark human reality in political imprisonment, through which they bring to our reading consciousnesses pain and confusion, powerlessness, cold, hunger and overwhelming stench.  They transcend their prisons, lead us to the light of human freedom within which we no longer can be innocent nor inanely happy, but where we can live and love and work.

***

I met Johnny at seven o’clock in the morning of a bright day in the dirt-brown prairie town.  Warm air was there, but it did not convince me budding green would come, left me wondering between the desert and the mountains whether I would find a home.  I had truly become a doctor during the years which led me there, but would the Deputy Manager for Medical Affairs of the Department of Health and Hospitals smile on me, find me worthy, a physician for the People?

Johnny always smiles.  He is slick and confident, smooth and glib.  He may be the only man in contemporary culture who seems powerful in a brown suit.  Like his energetic effectiveness is, he is neither self-effacing nor threatening, but all of him is as composed and smooth and comfortable as is his straight neat hair (a community of several hairs in harmony, no malcontent or rebel among them).  His glasses, likewise, neither advertise his blindness nor make him seem to peer myopically––they merely confirm his visual acuity.

By clues I could not hide from him he knew me.  He was friendly––which is not at all to say he loved me.  He has no compulsion to love or to hate anyone, but he does not fail to judge their worth.  I had no need to speak for me, nor he to ask questions (although he must have inquired something, and I must have spoken in response).

“Malpractice suits?  We welcome them!  If a patient has been poorly treated we cannot repair the damage, but we want to be straightforward in making amends without delay.  If the suit is frivolous (which is usually the case) we want it out of our way as soon as possible so we can pursue our work of taking care of other patients undistracted.”

Straight bullshit, but in my own idiom.  He can speak to anyone in that person’s own language.  I was hooked, packaged, bought and sold––a doctor for the People.

***

The Neighborhood Health Center had barred windows and armed guards, but repellent though the grey converted bakery was I was not repelled.  My bleak bureaucratic orientation was flagrantly highlighted by the only other truly powerful figure I was to encounter as a public doctor, whom I will also carry with me always as my colleague and my friend.

Looming large and black she took me firmly by the lapels, held me up against the wall a foot above the floor so that my little compulsive doctor feet flailed the air ineffectuous.  “White Jew male doctor, I have good advice for you:  Remember who is in charge here.  I will tell you when you are off probation.”

That reminded me the Clinic had been established not to provide health care primarily, but to employ the disadvantaged as part of the War Against Poverty.  She had been just another welfare mother, but suddenly some years before had become the muscular effective founder and director of the clerical staff, protector and provider for the welfare of the People.

Gladly I became servant to the ghetto community of Five Points, still rich with the residuals of a Renaissance of the period about the First World War and of the Jazz Age, like Harlem and like the Greenwood section of my home town Tulsa.  Bathing the feet and tending the ails of daughters and granddaughters of slaves (crotchety old women to most) I was a real person in relation to my patients.  Never was I robbed or beaten leaving the ghetto clinic late at night, nor was my car broken into or stolen, even the week before Christmas.  After two years she told me I was okay, off probation.

***

I called Johnny when I smelled problems, omitting several bureaucratic layers.  I took seriously the contract, never articulated or signed, we had confirmed that previous May morning, a sort of spiritual Hippocratic Oath which wed clinician to administrator, that we would collaborate for the health and welfare of the people.  The Department’s mandate was clearly documented, and thereby his:  to provide effective emergency treatment to all, and needed health care to the needy of the county.  Mine was clear to me, as Hippocrates was said to have said, “...to help the sick according to my ability and judgement...” (for following which I have often enough been called lawless).

There is a difference between a clinician and an epidemiologist.  To be a clinician means to be at the bedside of the individual patient; to be an epidemiologist means to attend to what comes upon a community of persons.  The seeming dilemma about confidentiality and AIDS testing reflects the difference between the needs of the individual and the needs of the community.  There need be no conflict.

A garrulous woman who weighed more than three hundred pounds lived on the third floor of an old apartment house whose stairs were narrow and rickety.  She could not stand or walk.  She had not been to the clinic in years (nor out of her apartment).  She called to ask that someone come to see her (but house calls were against clinic policy).  When I came to her apartment to interview and examine her (to meet her, chat, and by listening, looking and feeling ask what was what) I realized we could accomplish more for her sake with laboratory and x-ray studies down the street at the clinic.  The Transportation Department declined to carry her lest one of their employees strain his back, the City be sued.  I, provocative and defiant despite my righteous benignity, called an ambulance to take her.

Several days later as I walked down the hallway past his office door John called me in, smiling through his fury.

“What the hell...?”

“She’s sick,” I told him.

“Don’t do that again––it costs too much.  Other patients suffer too, and we must care for them.  That ambulance ride cost us seven clinic visits.”

“I understand.  I do not disagree.  From now on I’ll make my house calls after hours.  John, thanks for helping me.”

“Okay.”

“Okay, and thanks again, John, for the People.”

***

I had a plan.  If I could work in the Neighborhood Health Center half time I could finish my training in psychiatry in a year.  I always eschewed credentials, but to be both Family Practitioner and Psychiatrist might assuage my current mother-in-law and allow me to do my work more freely.  Johnny told me the Director of Psychiatric Services could help me, that I should call him.  I made an appointment, came on time, sat to wait politely for two hours while he sat in his office yelling at the telephone, then without meeting him I left to see patients who had been waiting for me at the clinic.

My psychoanalyst, Chairman of the Psychoanalytic Institute, advised me to see the Acting Chairman of the Residency Program in Psychiatry at the University Health Sciences Center.  Several letters, a phone call from John and six months later he allowed me an audience.

“We don’t accept residents at the third year level.  In fact, we don’t like to take first year residents who haven’t graduated from our Medical Center.”

“I have come only to ask your advice about completing my residency, but I have received powerful clinical lessons from you in the process.  If I treated my patients the way you have treated me they would all be dead.”

I stood, turned, walked out the door, heard the hollow thump of his chin on his chest.  Perhaps no one ever before had spoken to that poor man honestly.

***

My supervisor’s supervisor was directly accountable to John.  He was the occasion of many of my calls and letters to John.  John always answered cheerily, took my problems neutrally (for they were my problems, not his until he appropriated them to himself, which he calmly eschewed to do).  He always gave me generous responses full of encouragement,  but noncommittal, always in closing wishing me good luck in solving my problem.  He is not evasive, but accepts problems selectively, imaginatively, politically.

Ralph, my supervisor’s supervisor, seemed a lot like me.  He studied public health, made his career of seeming expert on the problems and welfare of the people.  In public he talked like a saint; in private he screamed incoherently or was obdurately silent (a lot like me).

But Ralph was allergic to patients.  Perhaps that is why he didn’t like me, that our personality disorders were too similar, or that he thought his better than mine.  I saw the whole Department as based on the primary clinician, the one who responded directly to the person who had been elected the patient.  Ralph saw the integrity of the health care structure based on the pyramid of increasingly intense specialization.  He seemed to believe the easy stuff was on ground level, the complex stuff should be kicked “upstairs” to the specialists, and some saintly genius like himself should run the show from the penthouse, far away from the ground level where the patients were.  No matter how similar or different we may have been, Ralph and I didn’t get along.

Ralph offered me my own one-doctor peripheral health station in the housing projects, “where a family practitioner ought to be.”  I had several thousand patients at the Health Center whom I was reluctant to leave.  I thought Family Practitioners should become more active in the heart of our system, at the General Hospital where the several specialists then held sway.  I believed those who specialized in generalism might offer leadership in clinical care without overpowering the bureaucrats, indeed cooperating with them.

Where the heart cannot find resonance let the mind seek entry first.  I wrote an essay on the dichotomy between the clinical relationship (patient-clinician) and the power relationship (bureaucratic or political)––just for Ralph.  Earlier I had given him my essays on the changing parent-child relationship (“An End to Parenting, an End to Being a Child”) and on madness (“How to Stand on Your Head”).  I had always reached out to him, but now I was mad, and the essay on clinical bureaucracy was meant to be a pithy moral message (containing my least prolix sentence, “Bureaucracy is ubiquitous.”)

At a committee meeting of the Medical Society John sat next to me.  As we ate lunch and tried to solve the problems of medical indigency he read my essay on bureaucracy.  He didn’t get angry.  He took exception with no statement.  He didn’t agree.  He didn’t disagree.  He simply said, “You know, Nathan, you’re not a bad writer.”  John is not a bureaucrat; he’s a diplomat.

***

I have made many political errors, but having no political understanding, I cannot identify them for you or me.  I resuscitated the Department of Family Practice, which the specialists on the Staff and the Board of the hospital were too embarrassed not to approve, but when I was elected by the other people-doctors to chair the new department and I asked for a salary of one dollar per year as a token for the extra work, it was denied by the Hospital Board for budgetary reasons.  For complex and chronic cases I proposed a conference of all interested parties to be chaired by the patient himself or herself.  That died even when the patients wouldn’t.

I was so concerned for Ralph’s person (after six more months of screaming silence) that I confidentially begged John as Ralph’s supervisor (and as a physician) to help him get some help.  Discreetly John received my communications with no comment, no response.

I pushed further knowingly, naïvely, by transcribing a case conference I had moderated for the clinic staff.  When I gave copies of the transcript to the participants to emend, my supervisor collected and shredded them.  I was threatened by the attorney-spouse of one of the physicians with some sort of legal punishment (hand-delivered by registered mail).  John’s comment was simple, that it had been a good conference, that their response to it was stupid, and that I should ignore it.  I did.

***

John had a policy.  Each physician on the staff was to attend patients directly, at least some small part of the time.  That was easy for John, a good doctor, an expert in tuberculosis who enjoyed people and the clinical challenge.  That was anathema for Ralph, whom John compelled to see patients.  A black woman physician had led a family planning clinic four afternoons a week at a neighborhood health station.  She took a federal bureaucratic job, leaving the clinic without a doctor.  Mondays and Wednesdays Ralph attended.  Tuesdays and Thursdays I came by to repair the damage.  (Pregnant teenagers are delicate.)

Ralph tolerated me poorly, perhaps especially because my heart went out to him, or more likely because I appeared as truculent and insubordinate as I sometimes felt.  He left me unassigned.  I was to be paid, but I was scheduled for no clinics.  This sinecure was communicated to me by silence, mere omission from the schedule.

***

Johnny called me.

“Nathan, I have just the job for you.”

“What is it, John, the addicts, the alcoholics or the schizophrenics?”

“The addicts of course, but...”

“You know they’re all good patients, real patients as far as I’m concerned.  When and where?”

I had to submit to interviews with the entire addiction treatment staff in each of the drug treatment clinics; I was deeply impressed again by John’s administrative skill.  The staff expected me to hate “junkies” because I was trained as a physician.  At first they were confused and jealous as the patients and I began to accept each other.

During these years I came to the Mayor’s office three times, ignoring several more layers of bureaucracy.  I came as a citizen (a voter) and as a concerned public servant, so the Mayor received me.  The first time I came to beg him to stop promoting a charter amendment proposal which would allow him to appoint a Manager of Health and Hospitals who was not a physician--or at least that he specify some sort of clinician, someone who had had to face a sick patient or had had to face a family when someone had died or had been killed.  I feared a bureaucratic Manager more than I feared the managerial incompetence of physicians.

The second time I came to the Mayor’s office was after that charter amendment had passed against my advice and vote.  The Mayor was considering four candidates (all physicians, all insiders) to replace the clumsy old gentleman who took such a job in a much larger city.  Ralph was one candidate.  I went to beg the Mayor to choose one of the others, all of whom I had known well for some years.  The newspapers heard he had chosen Sam, but when they crowded Sam’s front yard to film and interview him he thought of his wife and daughters, his peace of mind, and withdrew his name.

I heard it on the radio on my way home that afternoon.  The Mayor had appointed Ralph.  I spent the late night hours writing my resignation letter, for Ralph’s sake.  The job would be difficult enough for him without me.

Next morning Johnny was in highest form, laid back in his chair, feet on desk, grinning on the phone.

“Don’t worry.  Everything will be okay.  Just do what I tell you.”  He motioned for me to come in from the doorway where I politely stood, but I hesitated.  “Yes, of course the flood of resignations consists of Pollack only...”  Again he motioned with his hand for me to come into his office.  I took a step.  “His letter is articulate, as usual...”  Furiously he beckoned.  Under his breath he bade me, “The letter!  Give me the letter.”  He read cold from the middle of it, more smoothly and skillfully than any radio announcer.  He closed delighted, “...and don’t worry, Ralph.  Just do what I tell you and you’ll be okay.”

He didn’t tell me that public docs aren’t equipped for private practice.  He let me resign, left me to reinvent the wheel, again.

***

I left the security of my Career Service position, but I didn’t leave the patients or the staff of the methadone program.  I stayed as a Contract Physician only until they could find a replacement––two more years.  I found an office, paid rent, paid a secretary, paid suppliers and consultants, waited for patients and wrote a book about the clinical relationship.  Lonely lessons.

The Mayor’s Commission sat under tight security for weeks scrutinizing the necessity of massive budget cuts in the Department of Health and Hospitals.  I came to the Mayor for the third time to ask him to let me gradually shut down the drug clinics.  If we had some time to phase the program out we could finish treatment for some, transfer others, take no new patients for this lengthy treatment, avoid some day soon slamming the doors in the faces of addicts dependent on the City for a supply of methadone.  I considered it near certain that the Commission would find a cost-intensive service for a few hundred addicts a prime target when other cuts would affect thousands, tens of thousands.  The Mayor played dumb, said he had no idea what the Commission would come to recommend.  Even John denied any plan to eliminate drug treatment.  He told me he didn’t know.  When I showed him copies patients had brought me of letters to the landlords of the two clinics stating the City would pay no rent as of the first of the next month, his response was simple, “Those idiots!” (meaning bureaucrats who had allowed their letters to leak).

When the addicts filed a class action suit to force continuation of services (as had the schizophrenics, being heard at the same time in a courtroom down the hall) the Administration scowled at me as if I had put the patients up to it.  Ralph was livid.  The Director of Psychiatric Services called me a traitor through his clenched teeth.  John was calm.  In the hallway of the courthouse his was the only warm hello.

I was never called to testify.  A clinical crisis was converted to a legal haggling over whether the City was defaulting in its contract with the State.  The patients who had dared expose themselves publicly were exploited so that bureaucrats could wrangle and ignore them.  The Assistant City Attorney was so callous, coarse and abrasive I wondered how this could be called “a civil suit.”

Fast approaching five o’clock on Friday afternoon Judge Foreman ordered both clinics to stay open until he could hear further arguments two weeks later.  I raised my hand in the back of the courtroom, said calmly as I could, “Your Honor...”  He was horrified, hesitated not at all to offer me a contempt citation, and finished his decree as the clock struck five.

Saturday morning reading the newspaper headlining the Judge’s decision I decided to call him.

“Bob?  Nathan.  I tried to tell you yesterday, but you wouldn’t listen.  One of those clinics was cleaned out two days ago.  There is no furniture, no telephone, no safe and no methadone.  If the patients follow your order and go there it will be a mess.  The clinics open at nine on Saturdays and it’s after eight already.”

“Oh God!  What will you do?”

“I don’t know that I can do anything.  What will you do?”

“What do you recommend?”

“Call John.”

Johnny had the Transportation Department run a shuttle to the clinic which had not yet been dismantled.

***

I continued to call John with some regularity, even when I was no longer a City doctor of any sort.  Patients had trouble in the emergency room, were refused treatment at private hospitals when they had no money, needed drug treatment they couldn’t afford, got bit by an angry dog...  I still worked for the People, and so did John.

Everyone who had worked with him knew he was skillful.  Many disliked or feared him, but mostly they mistrusted him.  They thought him a snake, an exploiter, a politician.  I trust him because of all these things.  He does and is all of them, but he does not hide them.  Not for himself (his egotism is not for the sake of his own image) but for the sake of the task at hand he does what is needful.  If I disagree with him it is not a disagreement about the basic question, but merely about the ephemeral answer.  His integrity is like Barry Goldwater’s, not always in the same direction as my own but as simply elegant as I wish my own to be.

***

One January First the management of the Mental Health Centers transferred from the City to private contractors.  Nurses, now ex-employees of the City, asked me to attend as physician an outpatient clinic for schizophrenics.

An elderly confused woman suffered diabetes.  After I examined her I requested a blood sugar level be measured so I could review it with her the next week, adjust her insulin dose.  When I returned to the clinic a week later the nurse told me there was no blood sugar measurement because the patient had been turned away from the General Hospital laboratory.  Of course I called John.

“What took you so long to call?  I’m late for an important meeting.”

“I’m sorry, John.  There’s a foot of snow on the ground and traffic made me forty-five minutes late.  Anyhow, why was an innocent sick person refused service at the laboratory?”

“Why should the City pay for services the private contractors are promising?”

“I don’t disagree with you, John, but why should this patient be used like this, and...Hey!  How did you know I would call you about this matter this morning?”

“Who else would take care of the schizophrenics when the City stopped?”

“...and you knew when I would be back at this clinic!”

“If you want to complain to someone I’ll give you the number of the Director of the State Mental Health Department, direct line.”

“You’re using me again to do your dirty work for you.”

“I’m late for a meeting.  Tell the Director hello for me.  Goodbye.”

He had known for months all this would happen.  I still worked for the People, and John was still in charge.

***

One day I called Johnny just to say hello.

“Hi, Nathan.  What’s the problem?”

“Oh, no problem, John.  It’s just that I haven’t heard a good lie lately.”

He melted on the other end.  “No one appreciates a good lie any more.  They don’t understand that it’s an art form.  You have to knead it and nurture it and adjust it...”

He did understand that I understood––the good lie for the sake of the sick and poor, the true service of the public servant, the bureaucrat’s burden, the administrator’s dissimulation, the manager’s mendacity––truly a work of art.

***

The new Mayor selected a new Manager, neither male nor medical.  Ralph was moved sideways to a well-paid new position created for him personally, Director of Research.  He didn’t get along with Her, so soon after that (despite my letter against it) he was appointed Director of the Medical Staff of the hospital I most frequently had used for my patients.  Ralph was not the reason I left that hospital, but rather (during that crisis of “DRG’s”) it was my own self-righteous principles which rejected a hospital so eager to accept Reagan Administration bureaucracy (and dollars).

I think John butted heads with Her too.  He resigned immediately after the Mayor decided to refuse care to non-resident indigents.  I don’t know that John himself knew that was the reason, but I could sure smell it.  For nearly a quarter-century, through seven Managers he had been the good doctor-bureaucrat who kept intact what was needed for the poor patient.  He always declined offers to become Manager (a political appointment); he wanted to be just another of the City’s working docs (and not have to change jobs every time the City changed Mayors).  He connived, manipulated, negotiated, exploited, tolerated, budgeted, assuaged, arbitrated, expounded, diagnosed, treated and smiled.

John took a job as Medical Chief of Staff of a seven hospital system.  When I went to visit him I was not surprised to wait through animated rapid-fire meetings with staff and administrators, John always on one or two phone calls at the same time.  I enjoyed watching the late-afternoon Johnny show.

A hospital administrator from across town:  “Hello, my friend.  How can I help you?  You know I will do anything for you––we always help each other...”  (The two hospitals hotly compete, cut-throat.)

A surgeon who was instructed to get John’s permission for surgery to be done at another hospital:  “Sure, you can do it there––but do it well, my friend.  She’s the daughter of one of our oldest employees.  I will approve payment at that hospital only if we don’t have the equipment or the staff to do the procedure here, you understand.  Of course, I’d rather you do it here.  Come over, visit, tell us what we need to get for you to be able to operate here regularly.  No, no one has a monopoly here.  You’re welcome as long as you meet our standards.”

Between calls we talked some politics and business.  Seeing in my eyes my usual response to politics and business he kindly asked, “Are you on antidepressants yet?”

Again the phone:  “No, I didn’t tell you he would do a good job.  I told you he could do a good job if someone could rein in his personality disorder.  Well, I’m sorry to hear that.”

I didn’t have to ask whose sinecure had just hit the fan.  I didn’t even have to ask God why that call came just when I was sitting in that chair.  Poor Ralph.  At least I could treat patients, even if it was for a plucked chicken or a peck of tomatoes.

***

Recent years have brought me all the troubles a free-thinker deserves.  Our society and culture (and our health care, certainly) take place in and between institutions (public, private, formal, informal, large, small).  Individuals are free to pursue their private lives, their thoughts and feelings; but not in public, not in the marketplace, not in the school, the hospital, the courts, the polling place.

John is back in a public institution, teaching medical students and residents how to get along in institutions, how to fulfill the requirements of the bureaucracy and make a living, stay sane and take care of patients.

Not so long ago I had a series of meetings with him aimed at mollifying the Federal and State authorities who, although they could find nothing with which to charge me, knew I had been “different” and must be done away with somehow.

“Thanks for meeting me, John.  I’ll buy the coffee.”

“No, we’ll each pay for our own.  I won’t be accused of taking bribes.  Nathan, if you can get out of this state, if you can get a license and a job some place else, just don’t treat addicts and you’ll be okay.”

“But, John, if I remember correctly you are the one who said it was just the job for me.”

“Sorry.  I was wrong.”

“Thanks for the advice, John.  I’ll try to follow it,” and I thought to myself I’d do it again in a heartbeat if I could help someone.

“John, why are you willing to help me now, when so many times before when I asked you, you declined.”

“You did not ask me for help.  You offered me some hare-brained deal or another, favors you would do for me, when we both knew it was you who needed favors, not the other way around.  So I’ll help you if I can, but I’ll buy my own coffee.”

“Okay, you be cautious and I’ll continue to be a sloppy profligate.  I think I know the problem.  I think I finally found the diagnosis the psychiatrists couldn’t give me all these decades.  I’m a political psychotic.  By ‘psychosis,’ of course, I mean I am divorced from reality.  I may be able to relate to persons pretty well sometimes, but I am utterly unrealistic when it comes to relating to institutions, business or bureaucracy.  Yes, I think that’s it––I’m a political psychotic.”

“You’re right.  And the sad part is, in Russia they would recognize your illness and treat you, but here we have no treatment for you.  You’ll have to wander the streets.”

Free at last.

| | | |