A Life in Medicine

by Robert Coles

  No, I won’t.

  I’ll see you in a couple of days, I said to them all.

  Doctor! the old woman was still after me. You come back. I pay you. But all a time short. Always tomorrow come milk man. Must pay rent, must pay coal. And no got money. Too much work. Too much wash. Too much cook. Nobody help. I don’t know what’s a matter. This door, doctor, this door. This house make sick. Make sick.

  Do the best I can, I said as I was leaving.

  The girl followed on the stairs. How much is this going to cost, she asked shrewdly holding the prescription.

  Not much, I said, and then started to think. Tell them you only got half a dollar. Tell them I said that’s all it’s worth.

  Is that right, she said.

  Absolutely. Don’t pay a cent more for it.

  Say, you’re all right, she looked at me appreciatively.

  Have you got half a dollar?

  Sure. Why not.

  What’s it all about, my wife asked me in the evening. She had heard about the case. Gee! I sure met a wonderful girl, I told her.

  What! another?

  Some tough baby. I’m crazy about her. Talk about straight stuff . . . And I recounted to her the sort of case it was and what I had done. The mother’s an odd one too. I don’t quite make her out.

  Did they pay you?

  No. I don’t suppose they have any cash.

  Going back?

  Sure. Have to.

  Well, I don’t see why you have to do all this charity work. Now that’s a case you should report to the Emergency Relief. You’ll get at least two dollars a call from them.

  But the father has a job, I understand. That counts me out.

  What sort of a job?

  I dunno. Forgot to ask.

  What’s the baby’s name so I can put it in the book?

  Damn it. I never thought to ask them that either. I think they must have told me but I can’t remember it. Some kind of a Russian name—

  You’re the limit. Dumbbell, she laughed. Honestly—Who are they anyhow?

  You know, I think it must be that family Kate was telling us about. Don’t you remember. The time the little kid was playing there one afternoon after school, fell down the front steps and knocked herself senseless.

  I don’t recall.

  Sure you do. That’s the family. I get it now. Kate took the brat down there in a taxi and went up with her to see that everything was all right. Yop, that’s it. The old woman took the older kid by the hair, because she hadn’t watched her sister. And what a beating she gave her. Don’t you remember Kate telling us afterward. She thought the old woman was going to murder the child she screamed and threw her around so. Some old gal. You can see they’re all afraid of her. What a world. I suppose the damned brat drives her cuckoo. But boy, how she clings to that baby.

  The last hope, I suppose, said my wife.

  Yeah, and the worst bet in the lot. There’s a break for you.

  She’ll love it just the same.

  More, usually.

  Three days later I called at the flat again. Come in. This time a resonant male voice. I entered, keenly interested.

  By the same kitchen table stood a short, thickset man in baggy working pants and a heavy cotton undershirt. He seemed to have the stability of a cube placed on one of its facets, a smooth, highly colored Slavic face, long black moustaches and widely separated, perfectly candid blue eyes. His black hair, glossy and profuse, stood out carelessly all over his large round head. By his look he reminded me at once of his blond-haired daughter, absolutely unruffled. The shoulders of an ox. You the doctor, he said. Come in.

  The girl and the small child were beside him, the mother was in the bedroom.

  The baby no better. Won’t eat, said the man in answer to my first question.

  How are its bowels?

  Not so bad.

  Does it vomit?

  No.

  Then it is better, I objected. But by this time the mother had heard us talking and came in. She seemed worse than the last time. Absolutely inconsolable. Doctor! Doctor! She came up to me.

  Somewhat irritated I put her aside and went in to the baby. Of course it was better, much better. So I told them. But the heart, naturally, was the same.

  How she heart? the mother pressed me eagerly. Today little better?

  I started to explain things to the man who was standing back giving his wife precedence but as soon as she got the drift of what I was saying she was all over me again and the tears began to pour. There was no use my talking. Doctor, you good doctor. You do something fix my baby. And before I could move she took my left hand in both hers and kissed it through her tears. As she did so I realized finally that she had been drinking.

  I turned toward the man, looking a good bit like the sun at noonday and as indifferent, then back to the woman and I felt deeply sorry for her.

  Then, not knowing why I said it nor of whom, precisely, I was speaking, I felt myself choking inwardly with the words: Hell! God damn it. The sons of bitches. Why do these things have to be?

  The next morning as I came into the coat room at the hospital there were several of the visiting staff standing there with their cigarettes, talking. It was about a hunting dog belonging to one of the doctors. It had come down with distemper and seemed likely to die.

  I called up half a dozen vets around here, one of them was saying. I even called up the one in your town, he added turning to me as I came in. And do you know how much they wanted to charge me for giving the serum to that animal?

  Nobody answered.

  They had the nerve to want to charge me five dollars a shot for it. Can you beat that? Five dollars a shot.

  Did you give them the job, someone spoke up facetiously.

  Did I? I should say I did not, the first answered. But can you beat that. Why we’re nothing but a lot of slop-heels compared to those guys. We deserve to starve.

  Get it out of them, someone rasped, kidding. That’s the stuff.

  Then the original speaker went on, buttonholing me as some of the others faded from the room. Did you ever see practice so rotten. By the way, I was called over to your town about a week ago to see a kid I delivered up here during the summer. Do you know anything about the case?

  I probably got them on my list, I said. Russians?

  Yeah, I thought as much. Has a job as a road worker or something. Said they couldn’t pay me. Well, I took the trouble of going up to your court house and finding out what he was getting. Eighteen dollars a week. Just the type. And they had the nerve to tell me they couldn’t pay me.

  She told me ten.

  She’s a liar.

  Natural maternal instinct, I guess.

  Whisky appetite, if you should ask me.

  Same thing.

  O.K., buddy. Only I’m telling you. And did I tell them. They’ll never call me down there again, believe me. I had that much satisfaction out of them anyway. You make ’em pay you. Don’t you do anything for them unless they do. He’s paid by the county. I tell you if I had taxes to pay down there I’d go and take it out of his salary.

  You and how many others?

  Say, they’re bad actors, that crew. Do you know what they really do with their money? Whisky. Now I’m telling you. That old woman is the slickest customer you ever saw. She’s drunk all the time. Didn’t you notice it?

  Not while I was there.

  Don’t you let them put any of that sympathy game over on you. Why they tell me she leaves that baby lying on the bed all day long screaming its lungs out until the neighbors complain to the police about it. I’m not lying to you.

  Yeah, the old skate’s got nerves, you can see that. I can imagine she’s a bugger when she gets going.

  But what about the young girl, I asked weakly. She seems like a pretty straight kid.

  My confrere let out a wild howl. That thing! You mean that pimply-faced little bitch. Say, if I had my way I’d run her out of the town tomorrow. There’s about a dozen wise guy
s on her trail every night in the week. Ask the cops. Just ask them. They know. Only nobody wants to bring in a complaint. They say you’ll stumble over her on the roof, behind the stairs, anytime at all. Boy, they sure took you in.

  Yes, I suppose they did, I said.

  But the old woman’s the ringleader. She’s got the brains. Take my advice and make them pay.

  The last time I went I heard the Come in! from the front of the house. The fifteen-year-old was in there at the window in a rocking chair with the tightly wrapped baby in her arms. She got up. Her legs were bare to the hips. A powerful little animal.

  What are you doing? Going swimming? I asked.

  Naw, that’s my gym suit. What the kids wear for Physical Training in school.

  How’s the baby?

  She’s all right.

  Do you mean it?

  Sure, she eats fine now.

  Tell your mother to bring it to the office some day so I can weigh it. The food’ll need increasing in another week or two anyway.

  I’ll tell her.

  How’s your face?

  Gettin’ better.

  My God, it is, I said. And it was much better. Going back to school now?

  Yeah, I had tuh.

  Michael Weingarten

  HEALERS: THE PHYSICIAN AND THE MORI

  Just when a doctor or nurse thinks he or she might have the answer to a patient’s medical problem, the patient blows a hole in the solution, taking the caregiver’s ego right along with it. Michael Weingarten understands the cultural context of the patient’s life, respecting and honoring the processes of diagnoses and treatment and their place in the patient’s life and treatment.

  But the issue is more complex and goes beyond mere acknowledgment. It requires that we also consider what happens to the patient’s culture when it is relocated to another world. For both patients and practitioners, understanding these issues for the vast foreign-born populations of this country is highlighted by this simple story.

  MICHAEL WEINGARTEN is the director of the Department of Family Medicine at the Rabin Medical Center near Tel Aviv and editor of the Israel Journal of Family Practice.

  I was thirty-three; she was sixty-six. I had been in my new practice for six months and Naomi had been to see me at least a dozen times already. Hers was one of the few faces I could put a name to. She had come to Israel from Yemen in 1950, flying through the darkness of a clandestine airlift. Overnight she crossed the centuries between the medieval culture of her childhood and the modernity of her new and progressive young state.

  Her file was fat with tests which failed to solve the enigma of her recurrent abdominal cramps. I told her I thought it pointless to order any more. She was silent but looked relieved. “What now?” I ventured. “I don’t know,” she replied. I asked if she had been to the mori (a traditional Yemenite Jewish rabbi-healer). She had, of course, but had been shy to talk to me about it. Actually, she said, the mori wanted me, the doctor, to write him a note to say that he could go ahead with his treatment. He wanted to give her makweh over all the upper part of her body. I knew all about makweh by now; 70 percent of my Yemenite patients had scars from this healing method—branding by red-hot iron nails. They had it for sciatica—on the side of the ankle; for renal colic—in the loin; for impotence—on the forehead. I thought it was an admirable caution of the mori to check with me first, so I wrote the note for Naomi, who was looking quite apprehensive. “Do you think it’ll help?” I asked.

  “I don’t really know, Doctor,” she answered. “In Yemen it certainly would have worked, but here, in Israel, God has taken the right to heal away from the mori, and He has given it to you, the doctors. But you’re not so good at it.”

  PART FOUR

  Physicians Must Be Dutiful

  PHYSICIANS must feel obliged to collaborate with other health professionals and to use systematic approaches for promoting, maintaining, and improving the health of individuals and populations. They must be knowledgeable about the risk factors for disease and injury; must understand how to utilize disease- and injury-prevention practices in the care of individual patients and their families, and in public education and action; must actively support traditional public health practices in their communities; and must be advocates for improving access to care for everyone, especially those who are members of traditionally underserved populations. They must understand the economic, psychological, occupational, social, and cultural factors that contribute to the development and/or perpetration of conditions that impair health. In caring for individual patients, they must apply the principles of evidence-based medicine and cost-effectiveness in making decisions about the utilization of limited resources. They must be committed to working collaboratively with other physicians, other health care professionals (including administrators of hospitals, health care organizations, and systems of care), and individuals representing a wide variety of community agencies. As members of a team addressing individual or population-based health care issues, they must be willing both to provide leadership when appropriate and to defer to the leadership of others when indicated. They must acknowledge and respect the roles of other health professions in providing needed services to individual patients, populations, or communities.

  David Hilfiker

  from NOT ALL OF US ARE SAINTS

  Is a physician dedicated to working on behalf of the poor wasting his professional education? “Why,” the author of this piece is asked by a distinguished professor of pediatric surgery, “should a person go through four years of medical school and at least three years of postgraduate hospital training to take care of problems that are so obviously social and societal in nature?”

  Writing about serving the medical needs of the poor in Washington, D.C., physician David Hilfiker observes that “one of the first things a doctor of poverty medicine gives up is the power the physician wields within the American medical system.” Hilfiker’s ruminations and stories demonstrate powerful advocacy “for improving access to care for everyone, especially those who are members of traditionally underserved communities.”

  DAVID HILFIKER wrote Healing Wounds about his practice in rural Minnesota. In Not All of Us Are Saints, Hilfiker describes his practice among the poor in Washington, D.C., where he moved in 1983.

  The absence of clear guidelines is virtually the hallmark of medical practice among the poor. “Poverty medicine” sometimes seems related to the rest of American medicine but more often it plunges me headlong into a world for which my medical school training never prepared me. There are, of course, varieties of poverty medicine: Doctoring in Appalachia will look different from doctoring in Washington, will require one set of skills in a Harlem walk-in clinic and another in a Florida migrant worker camp; nevertheless, these varieties have more in common with each other than any of them do with mainstream American medicine.

  It is not the diseases that are different. Though heart disease and cancer kill a disproportionate number of poor people, the illnesses are the same in the suburbs as in the inner city. Because they frequently lie concealed behind well-constructed façades, addictions to cocaine or alcohol are less noticeable in upper- and middle-class neighborhoods, but substance abuse with all its consequences is a part of any physician’s practice. Though the stresses of suburban and inner-city life may be very different, the stress-related illnesses—headaches, stomachaches, back pain—are the same on Belmont Street and in rural Minnesota. The strictly medical, scientific training a doctor needs to practice among the very poor is essentially the same as preparation for any other primary-care practice.

  It’s not the science that is different.

  Kathy Bartlow is a severely alcoholic, forty-year-old white woman in our neighborhood. Sober, she is one of my favorite patients, actively attending AA, trying to help her neighbors, earnestly working toward her own recovery. Drunk—as she is this particular afternoon—she is a nightmare.

  Kathy has a seizure disorder, but I have never been able to determine wh
ether all of her “spells” are genuine seizures. The regularity with which she starts twitching and shaking whenever I begin to refuse some drunken demand of hers seems more than coincidental. Today she wants to go to Sibley Hospital to “dry out.” A year ago, when she came to the clinic with pancreatitis and impending delirium tremens, we finagled her admission into Sibley, a wealthy, private hospital in far-northwest Washington that had recently agreed to accept a small number of nonpaying patients from our clinic. Kathy loved it. Now, a year later, she has decided for the umpteenth time to quit drinking and—although she has no acute physical illness at this point—wants to be readmitted to Sibley for detoxification. Since Sibley is not a detox center but a hospital that, as an act of charity, allows me to admit the occasional indigent patient, I feel I can’t risk alienating the hospital staff by admitting Kathy (who is loud and demanding when drunk) just for detox.

  “I don’t think that’ll work out, Kathy. The hospital is just for when people are sick. What you need right now is detox. Let me call down to detox and see if they have a bed. Maybe Lois could take you down there.”

  She sits disheveled in the corner, her short, tight skirt muddy and pushed up high on her thighs. Spittle hangs from the corner of her mouth. She straightens up and teeters on the edge of her chair, trying to look me in the eye but seeming to lose focus. “I ain’t going to that hole. I wanna go o’er ta Shibley!” She slurs her words in what seems like a parody of drunkenness.

  I notice that the side of her face is beginning to twist and distort. “Well, I don’t think that’ll be possible, Kathy. But we have to get you help somewhere.”

  She suddenly screams, “You gotta help me, David!” Still sitting in the chair, she lunges forward, grabs my hand, and hangs on hard. “You gotta help me.” She stares into my eyes and then loses focus. Suddenly she lets out a grunt, halfway between a moan and a curse. Her face stiffens in a hideous grimace. She flops back in her chair and begins sliding down to the floor. (Is it only my cynical imagination, or she is gently lowering herself with her arms?) Reaching the floor, she seems to position herself carefully with her head between the chair and the wall and then begins shaking irregularly, spit frothing on her lips in what is either a seizure or a remarkable imitation of one.