system of life, but for the first time they were doing so self-consciously; they were looking at their lives from the outside, scrutinizing them, judg-ing them, thinking them hard and a bit unfair, and for this reason the
whole system was rotting and waiting for the jolt that would bring it all crashing down.
Both the medical profession and the Dworkin family household faced
analogous threats.
The following year, in mid-September, a hot, dry, boisterous Santa
Ana wind blew down from the mountains. The thirsty earth steamed. My
hometown was like a furnace, and one spark in the dry scrub would have
set the whole city aflame. Dogs and cats moped across the bare and
unhappy asphalt. A puddle of rust-colored water on the sidewalk seemed
to them like an oasis. Outside the professional building that housed my
father’s new office, a flag flapped violently on its pole, sounding to
A T A L E O F T W O O F F I C E S
1 1 5
passersby like a great chained bird beating its wings with all its strength, desperate to get away.
My father and I were on the sixth floor surveying an examination
room in his new office. The machines were beautiful to look at. The EKG
monitor, the diathermy machine, the blood pressure monitor, the scanner,
the microscope, the incubator, and the X-ray machine—all were nickel-
plated and streamlined; some sat on special polished platforms. The con-
trol panels had only a few buttons to press. Machines simply decorated,
but on closer inspection therein lay their distinctiveness. Here were ma-
chines for the rest of your life, machines for the average man, machines
for princes. Never will these machines be out of fashion, I thought. Never will they grow old, just as diamonds and emeralds never grow old.
My father walked over to his new waiting room and smiled proudly at
the furnishings. A dignified lamp sat atop a cherry wood stand, the legs of which meandered gracefully toward a Persian carpet on the floor. Fine
red leather sofas and chairs dotted the rugscape. Enormous ficus plants
sat in white marble pots with gold handles. On the wallpaper hung several elegant paintings with ocean themes, along with a few cozy works
painted by my sister when she was nine. My father saw real handiwork in
his decorating; some doctors might even want to study with him, he said.
He almost seemed to regret that his work, which really ought to be placed on public view somewhere, was instead going to be seen only by a small
group of people with leukemia and cancer.
My father was smiling for another reason. Although his home life was
as bad as ever, something had changed. He couldn’t quite put his finger
on it, but he had noticed that doctors’ wives had less control in directing their husbands’ referrals. Something about the new insurance system,
something called “managed care,” where bureaucrats now decided where
patients went. Doctors’ wives had lost power in other ways. He had heard
about a recent hospital board meeting where a businessman had discussed
ways to improve the hospital’s finances. When a doctor’s wife suggested
improving the food in the cafeteria (which had always worked before),
the businessman laughed with derision and dropped fancy abbreviations
that no one had ever heard of, such as PPO, HMO, and ERISA. Then he
mocked the poor woman, announcing to the room that the quality of the
chicken in the cafeteria no longer drove health care.
In the past, for financial reasons, my father had been too afraid to
leave my mother. But now, standing in his waiting room thinking about
1 1 6
C H A P T E R 6
how much he loved medicine, but also how he had used medicine to
divert his mind from his hatred of my mother, how he had thrown himself
into the task of building a beautiful office, how he had moved the furni-
ture about personally, and yet every evening, as soon as the bustle of the work day had subsided and the time came to go home, the mere thought
that there, in the bedroom, like a vulture on a grave mound, sat my
mother, frowning and terrible, causing him to feel weak in the pit of his stomach and all his energy to go out of his movements . . . yes, while
thinking all this he was smiling. He knew he had the courage to leave.
My father and I returned home an hour later for another party. The
doctors and their wives began to arrive. My sister was already treading
water in the pool. The sun stared stubbornly in the sky.
I overheard snippets of conversation.
“Did you hear what happened to [some doctor’s wife] last week?” the
first woman asked a small crowd.
“No, what happened?”
“She was home alone when a burglar came through the side door. She
fled upstairs to the bedroom and got out her husband’s gun. The burglar
followed her upstairs, and she shot him in the leg! Can you believe it?
There was blood all over the marble floor, the police raced over . . .”
“What? They have marble on the second floor?” a second woman
exclaimed.
The first woman telling the story looked stunned by the response, but
others followed the second woman’s lead.
“I’m surprised,” a third woman said, turning up her nose. “I didn’t
think her husband was that successful.”
“I’m sure a rich relative helped them,” added one of the doctors.
“Helped them how? Paid for the marble floor?” interrupted the second
woman.
“Most likely.”
“I don’t know,” a fourth woman said. “They’re adding on, I hear. I
don’t know if a relative would pay for an addition, too.”
Life tensed thirty minutes later when a divorced woman walked
through the door. She had been the wife of a very successful doctor, his
practice a well-stocked hatchery from which to refer patients at will. My mother often imagined herself a queen, but this doctor’s wife, she had
once told me, was the “queen of the queens.” That was all over now.
A T A L E O F T W O O F F I C E S
1 1 7
Although there was no longer any business reason to invite this woman,
my mother had done so out of pity.
Some of the other guests were less welcoming. Before her marriage,
the divorced woman had been a nurse. As a doctor’s wife she had vaulted
to greater status. After the divorce she had gone back to being a nurse—
and in those days inviting a nurse to a doctors’ party constituted a major social breach. Although doctors and unmarried nurses stood firmly with
one another on the wards, their social lives never mingled, and neither the doctors nor their wives thought unmarried nurses were entitled to such
equality. Indeed, at all the parties my parents threw or that my parents
took me to, I never saw an unmarried nurse at any of them except this one time. A nurse had to be married to a doctor to attain the necessary social rank.
Many of the guests were rude to this woman. The doctors shunned her.
Some of the wives feared her, for she reminded them of what might
happen to them some day. They treated her the way pack animals aban-
don a wounded comrade in the forest. Other wives gloated, their body
language saying, “Ah, girl, you failed in life.” Already the party atmos-
phere was muted. In southern California, a Santa Ana w
ind drives people
to water, but it also drives them apart; it makes life unmerciful, and
people start to care only about themselves and how to get cooler. The
presence of the divorced doctor’s wife made the party atmosphere that
much more sullen.
That night my parents had another fight. It was so loud that one of the
teenagers next door yelled, “Shut up!” from over the fence dividing their house from ours. The party had been a failure, but I don’t think either of my parents cared about that anymore. “I’m sick of these people!” I heard
my mother shout. The next day my father moved out for good.
Finished, the comforting thought passed through my mind.
Two years later, my father’s medical practice was in deep trouble. He
didn’t have enough patients to pay for his overhead. The office lease
alone was killing him. The insurance industry’s new dominance, in the
form of managed care, was the problem. It affected not only how much
doctors were paid but also whether they had any patients at all. And
managed care had powerful allies, especially in government. Federal leg-
1 1 8
C H A P T E R 6
islation had earmarked millions of dollars for the development of man-
aged care. Later, in 1982, California state government would make en-
rollment in a managed care program mandatory for all Medicaid patients.
Meanwhile, the federal government had removed all barriers from man-
aged care’s involvement in Medicare. The very mechanism that had al-
lowed my father to leave my mother spelled doom for his career. He had
gained his freedom, but at the price of a world.
Other doctors were in the same boat. And not just doctors were af-
fected. The Catholic sisters also felt their power ebbing away. Once in
charge of their hospital, they increasingly ceded control to professional businesspeople (often men). When Catholic sisters brought up their long-standing commitment to the community, businesspeople were usually
milder in their criticism compared to their treatment of the doctors’
wives. They said the sisters, at least, remained a “useful marketing tool”
for the hospital. Yet the old business model—build a professional office
building, entice doctors to come, pamper them, worship them, give them
their own room in the cafeteria to dine in, and they’ll bring the patients—
was dead. It didn’t matter if the sisters put a doctor’s office in the middle of the chapel; patients weren’t going there unless the insurance companies let them.
My father was despondent, but on this particular day his troubles
struck him like a piano falling from an open window and crushing him to
the ground. Once a year, his father (my grandfather) came out to Califor-
nia for a visit. The man had emigrated from Russia to Canada in 1912. To
make a living he had owned a small candy shop. He had never finished
high school, while his wife, already dead, had been illiterate. This man
was incredibly proud of his son. During his visits to California, he would put on his best suit and go sit in the waiting room of my father’s office, all day, and gaze at the beautiful furnishings, feeling himself to be somehow connected to them. Whenever patients came in and sat down, he would
find a way to strike up a conversation with them and talk to them about
their problems, and then tell them that his son was their doctor and would help them. There was something magnificent and touching in the pride of
this old man, worn out by hard work and life in general, yet ready at any moment to tell someone that his offspring was more than just a speck of
dust in the universe but, on the contrary, a son who had made good. My
father knew how his father felt about him, and the actual truth of his
situation tore at his heart.
A T A L E O F T W O O F F I C E S
1 1 9
That evening my father took me to a meeting of the local medical
society. He was already in a bad mood. The topic of discussion was
“managed care.”
We got off the freeway and drove west along the street toward the
hotel where the meeting was being held. Upon arriving, I noticed anxiety
on the doctors’ faces. Managed care threatened them all alike. In their
daydreams some of them gave managed care a face, picturing it in their
minds as a one-eyed giant marching across town, grabbing doctors, chok-
ing them, squeezing them to death with its cold, unfeeling fingers.
I heard snatches of conversation going on around me.
“Managed care is taking over everywhere,” one doctor moaned.
“Where did you hear that?” another doctor asked through a mouthful
of donut.
“I read it in a magazine,” the first doctor replied. Then he added, “And
they say nurses are going to be running everything. No more doctors.”
“So what do we do?” asked the second doctor, still chewing.
“I don’t know. But we have to fight.”
The guest speaker was an insurance company executive trying to get
the doctors on board with the new order. Tall and immaculately dressed
in a gray suit, with fearless blue eyes, he looked like a colonel, and before uttering a word he posed in a picture-postcard attitude, his arms crossed, his face expressing great confidence, as if preparing to give orders with the expectation of being obeyed. His whole presentation was an indication of the insurance companies’ might.
He outlined the present situation, touching briefly on rising medical
costs, the inability of employers to pay their insurance premiums, and the problem of the uninsured. Playing to the crowd, he criticized and mocked
the very idea of socialized medicine. Then he outlined what he called “the third way”—managed care—that would preempt government intervention, although it would alter how doctors organized their practices and got paid. This part of the speech was quite technical, filled with such terms as
“preferred provider,” “capitation,” and “point of entry,” and it confused the doctors, almost as if on purpose. Many of the doctors in the room
grew suspicious. Although only a few of them could grasp the details of
what the speaker was saying, they sensed the main thing, which was a
threat to the old ways of doing things. Almost immediately there was a
shout:
“Explain to us about ‘capitation’!”
1 2 0
C H A P T E R 6
Hardly had the speaker finished his complicated explanation when
another shout arose:
“We don’t understand what you’re talking about. We’re not econo-
mists here. Use simpler words.”
A howl of scorn arose from the assembly. The speaker’s head turned
this way and that, studying the doctors attentively and waiting until they were quiet. His first feeling of certainty that the doctors would welcome managed care to escape the threat of socialized medicine had passed, and, realizing the doctors’ mood, he knew that a serious fight loomed.
A doctor in the audience attacked him in a personal way, telling him
that he knew nothing about taking care of patients, that empty words were coming out of his mouth like soap bubbles, and that all he really cared
about was making money. The insurance executive shot back vauntingly,
and with a scornful look, that doctors wanted to make money, too. The
doctors in the room fell silent; some of their faces clouded over. For the first time in their lives they had seen an insurance man who dared
to
insult a doctor in public. Used to deference from businesspeople, they
stared back in astonishment.
The speaker left the podium. As he passed by, the doctors glared at
him, while he, in turn, hid his disdain for them behind a smile. Afterward, the doctors herded together into clusters to share their contempt and
apprehension with one another.
They could be broken down into three groups according to their shade
of panic.
The first group consisted of foreign doctors who were born in authori-
tarian countries, had fled to America as adults, and were afraid of politics.
Habitually passive in the face of conflict, their instinct was not to fight but to pray. Many of them wore gold chains around their necks, not to
show off their wealth, but because in their home countries troublemakers
were often jailed or shot; a person might have to flee at a minute’s notice, and gold chains were a proven way of bribing a border guard. These men
came to America to live in peaceful obscurity, to make as much money as
possible, until the moment the authorities told them they couldn’t make
any more, at which point they would steal away with whatever loot they
had and thank the authorities for sparing their lives. They were easy to
spot in the large room, not because of their accents, but because they
looked like mice, the way their eyes darted and glanced, and their whisk-
A T A L E O F T W O O F F I C E S
1 2 1
ers twitched, suspiciously sniffing the air and looking around the room
carefully, as if to check for the presence of a cat.
The second group consisted mostly of American-born doctors. Unlike
the doctors in the first group, these doctors wanted to fight managed care.
But how to fight? By what means? These doctors had long felt superior to
businessmen, and yet now, when faced with a real threat from business-
men, they were flummoxed. Although each of them had more than a
decade of advanced education and considered themselves privileged
members of the American elite, they were incapable of intrigue, having
Medical Catastrophe Page 17
