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Transcript: John D. Davidson, 1977

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This is Archives Oral History interview number 32 with Dr. John D. Davidson, member of the Washington University School of Medicine class of 1952. Dr. Davidson is presently Assistant Professor of Clinical Medicine at Washington University School of Medicine and Director of the Division of Hyperbaric Medicine at St. Luke’s Hospital in St. Louis.  This interview was conducted on May 13, 1977.

Dr. Davidson, would you tell us a little bit about your childhood and your family life here in St. Louis?

I was born here in St. Louis.  My father was a pharmacist who came to St. Louis back in about 1909 to go to the old Barnes Medical College.  In those days medical school, pharmacy school, and many other things were all combined in one.  As a matter of fact, my father is fascinated by a picture of the medical center here in 1912 which my wife just put into that booklet that was published.  He can remember transferring books from the old Barnes Medical College to that house that used to be on the corner where McMillan Hospital now stands.  So our family has been around here for a long time.  My father had a pharmacy in the neighborhood, halfway between Barnes and St. Luke’s Hospitals many years ago and has been here in the community all those years.  So I was raised in the front of the drug store, so to speak.  My early association with medicine was that of knowing many of the physicians in the neighborhood in a little bit more than just a patient relationship.  I went to the local public school in North St. Louis and went to Soldan High School, which is hardly more than a couple of minutes away from here.  I was born in the neighborhood so I’ve been around this particular couple of square miles most of the last half century.

The fact that your father was a pharmacist – do you think that had a great deal of influence on your deciding to go into medicine?

I’ve thought about that and I wonder if it did.  It would seem logical, but I really don’t know that it did.  My original reasons for going into medicine as far as I can recall – as I reach the age of reflection and introspection – I think my original reasons for going into medicine were basically religious ones.  Because I had to make the decision as to whether I would go into the clergy or teaching or medicine.  Those were my interests when I was an undergraduate.  Although I started college as a premedical student, the other two fields were always lurking right at the heels.  I think I made the decision to go into medicine as a way of synthesizing all three together.  Medicine was one way in which I could be a teacher, and some of my religious motivation for thinking of going into the clergy could be handled and solved in medicine.

In what way?

Well, Jesus  said, “Inasmuch as ye have done it to the least of one of these, my brethren, even so have ye done it unto me.”  And I have an opportunity to fulfill that day by day, whether I say it to myself consciously or not.  I must admit, I think it’s probably gotten me into a little bit of trouble on occasion over the past 25 years.  Maybe I should have been a little hard-nosed and Christianity shouldn’t have gotten in the way of my good judgment.  But as I said, this has been a time of reflection and these are thoughts that I don’t dwell on and I really haven’t had the opportunity in life’s busy world to think about these things.  But I’ve made a point about it at this particular moment, in realizing that I was going to be asked some questions about it.

Before the interview started you were telling me that you thought that you might have been a little bit provincial, living in your neighborhood, going to school here, going to Washington University and the Medical School.  Could you share some of that with us now?  [And] the fact that your children have had close association with Washington University.

I’ve thought about the fact that I’ve been provincial in that I was born and raised in the neighborhood and my father knew the neighborhood and was a pharmacist and went to school here in St. Louis.  My wife is an alumna of Washington University.  My son is starting a Washington University School of Medicine residency and is currently in school here as an extern at St. Luke’s Hospital.  And I have a daughter who’ll be getting her doctorate from the Dental School in 12 months.  I have another daughter who’ll be going here to summer school within a few weeks.  I guess I’ve tried to say to myself, “Are you really provincial and do you not have good sense and [is that] why I have not gone out to other places?”  I reflected on that a little bit.  I have left the community.  I was in the Army and overseas and after I finished my residency here at Washington University I went to the National Heart Institute on the east coast and did research for a couple of years before I came back here.  I guess perhaps it’s not that I’m inherently provincial.  I think perhaps that I’m just lucky and that the Lord has blessed me in that, frankly, I’ve been a lot of places and I’ve seen a lot of places and I’m impressed with the quality of life and the quality of scholarship and the friendliness of the people here at Washington University.  I was impressed during my residency, for example, at the genuine concern for me on the part of my elders, the people who were my instructors.  And now, after I’ve been out of medical school for 25 years, some of these men who were my instructors and professors are my colleagues and personal friends, with whom I practice medicine.  I guess maybe I was just lucky that the Lord dropped me into a sea of scholars and gentlemen and I truly appreciate it.

Who were some of the professors that had the greatest impact upon your four years here as a medical student?

I think that’s difficult to answer.  I really don’t know who the ones were that had the greatest impact upon me personally because there wasn’t any one that had any great effect in molding me.  I have a lot of memories, pleasant ones.  Some of the most famous people, deservedly famous people, were truly giants in their fields.  I knew this but I didn’t have any illusions about them as human beings.  I knew many of their foibles and I knew that they had one foot of iron and one foot of clay right from the beginning, apparently.  I was impressed by the quality of instruction in general and was fortunate in knowing and having contact with people like the Coris [Carl and Gerty Cori] and Evarts Graham and Barry Wood and Carl Moore.  But I didn’t have any close personal contact or any molding experience by any one that I can remember.

Was there any professor that had an impact on you so that you decided to go into cardiology as a specialty or was that a personal interest of yours?

No.  In a way I almost backed into it.  I went into Internal Medicine because it was the closest thing to the old-fashioned concept of a physician or a personal physician that really was in keeping with modern, good, scientific medicine at the time that I did it.  I ended up going into Cardiology because I ended up going to the National Heart Institute for my fellowship and staying there doing research for a while after I finished a year’s fellowship there.

My training in Cardiology was really not in clinical Cardiology at all.  It was primarily basic Biochemistry and they could have put the name Cancer Institute or Arthritis and Metabolic Diseases or anything else you wanted over the door and it would have been just as fitting, because we were doing primarily biochemical work.  When I came back to St. Louis to go into practice I ended up doing a practice of general internal medicine but in which now after 25 years, perhaps 80 percent of my practice is Cardiology because I feel comfortable with it and everything else gets referred to people who know more about various subjects.  I refer fewer cardiologic patients because I feel more comfortable with them.  So, I guess that ends up that I’m a cardiologist.  But there was not then a burning desire to say, “Gee, I know all about the left ventricle or the mitral valve,” or, “Isn’t that great?  I’m going to specialize in it.”  There’s a lot of the “path of least resistance” in many lives, in many of us.  Perhaps there’s more of it than several of us want to admit – but I’ve admitted it.

Going back to medical education now.  Do you see any significant differences between medical education today – 1977 – versus the medical education that you received in the late 1940s or early 1950s as far as the approach that is taken to present the material to you?  [Or] maybe in the philosophy of the professors?

Yes, there are some changes.  I suppose they’re all to the good in the sense that they are attempts – genuine attempts – to see what the problems have been and where there have been shortcomings, and genuine attempts to make changes.  I’m certain that there must be some mistakes along the line.  I can remember that as a medical student I didn’t have anyone two or three or four years immediately ahead of me with whom I had a close personal contact, such as an older brother, who could tell me why I was doing various things at the stage I was doing them.  I remember in Anatomy, which was basically a memory course, I said to myself, “Well, I put my faith in these people who tell me that this is what I need to know,” and I memorized it.  And then throughout the freshman year and throughout the sophomore year I did not have a sense of knowing why I was doing what I was doing.  Because it did seem divorced from what I knew clinical medicine was like from contact with my own personal physician and [from] my father’s contacts with his friends and associates.  And it seemed far afield from what I knew of answering the telephone in the drug store and talking to physicians on the line and seeing what they were prescribing and what they were doing to try to help the people that I knew.

I think that the change in medical education – a lot of it – has been to get rid of that which I sensed through my first two years in medical school here.  It was not until I started clinical medicine that I realized in what way bacteriology and pathology and pharmacology and anatomy were important.  There was a tremendous amount of anatomy, for example, that one learned that I have forgotten because I don’t have any daily use for it.  I know my own son, as a medical student, had much less gross anatomy than I did.  I’m sure he’s not going to be any worse as a physician.  But what anatomy he will have to know he will learn because he will have behind it the motivation of saying, “This is what I’ve got to know”, and he’ll go after it, depending on his specialty and what he does day by day.

I think that there’s been a reorganization of medicine in medical education to take the medical student and give him clinical exposure early so that he actually knows what a patient is like if he is not a person who has had some contact with medicine or patient exposure.  Also, there’s been this concerted effort to make sure that as a student learns basic sciences he’s learning why he’s learning the basic sciences.  So he can also be selective and not learn many things too well that are really not going to be germane to his needs and his life.

How much emphasis was put on the study of the application of the social sciences and the humanities in your medical education?  There was a book published about four or five years ago describing establishing of about 10 new medical schools and in reading this book I found out that these schools, from the very beginning, were going to incorporate within their curriculum the emphasis of the humanities and social sciences, bringing in theologians, psychologists, anthropologists, and there would be interaction between these professionals as well as with the scientists.

First of all, there was very little of that when I started medical school, or during my medical school career.  We had courses that were not strictly anatomy and physiology and pharmacology.  We had a brief course in medical jurisprudence, we had a course in statistics and we had some lectures – a couple of lectures – in medical history.  These were things which were minor.  During a course in psychiatry in our sophomore year, one of the few things in which I excelled in medical school in my preclinical years, we turned in what would now be called a weekly paper which would do for anthropology, psychology or English.  And that was one of the few places where they said I seemed to excel.  But that was a minor part, a very, very minor part of it.

On the other hand, I had the impression of my classmates that they were very, very well-rounded people who had good educations, good general educations, before they ever came to this school.  The vast majority of them had gone to excellent universities, had a four-year bachelor’s degree and had graduated at the top of their classes and had already spent four years getting a good general education.  I think the school had planned it that way and their philosophy was: “We have now here a group of well-educated gentlemen.  Now we’re going to teach them to be physicians.”  I think there’s a lot to that and I think maybe that’s the way it ought to be.  I don’t want to just say, “Well, that’s the way it was and that’s the way I had it and I think that that’s right.”  I think there’s a lot to say for that system.  For example, I was a philosophy major; my major was philosophy and psychology although I also had a major in zoology by the time got my degree.  I’d had a little extra time – as a matter of fact, I had all my credits toward a master’s degree also by the time I started medical school because I got out of the Army in June of one year and of course applications for medical school for that September class had to be in long before that and I had almost all my credits for medical school at that time.  So I ended going to school another summer and complete academic year before I ever started medical school and I was able to accumulate credit in fields that I was interested in.  Which ended up that a good bit of it was in psychology and philosophy.  I had the impression, knowing my classmates, that there were a great many of them who were not oriented strictly to the physical sciences and didn’t know anything else about anthropology or economics or history.

After you completed the four years here in medical school, you served an internship at St. Louis City Hospital.  Could you describe your experience there a little bit?

Yes.  That was the Washington University medical training program at City Hospital.  At that time there were three internships offered by the University, two of them at Barnes and one of them at City.  City Hospital was a very important, integral part of the graduate training program, more so than it is today because at that time there was no VA Hospital, there was not the training program that there is at places like St. Luke’s Hospital, where there are other affiliations and there have been for a couple of decades now.  At that time City Hospital was a very important part.  For example, our junior medicine was taught at City Hospital.  I went there because it was a place of some excitement – the sicker patients were there, so to speak.  A little more responsibility was given.

The heads of the medical service at City Hospital included Robert Glaser, or “Bobby Joy” as we called him – Robert Joy Glaser, and Tom Hunter.  Dr. Hunter is still, I believe, the Dean at the University of Virginia.  And I think that Dr. Glaser is President of Stanford now, if I’m not mistaken.  At any rate, the supervision was quite good.  We were extremely busy there and we were taking care of acutely, critically ill patients.  There were a lot of drunks brought in off the street with pneumonia every night and the emergency room was a very busy place, with heads cut open and automobile accidents and we delivered babies in the driveway, and so forth.  Perhaps one of my reasons for selecting City was that it offered that excitement.  I’m not sure – it’s hard to look back in retrospect and really be objective about oneself.

Would you tell us about your assistant residency in medicine at Barnes from 1953-55?

Yes, that was a delightful part of my life.  Being an assistant resident in medicine allowed one to be a little more of a scholar and a little more of a gentleman than the internship allowed.  It was there that I had a lot of contact with the private physicians who worked at Barnes.  One had much more time to go to conferences as an assistant resident because the intern was the one who had to do the longer workups and write the orders and so forth.  I enjoyed those years very much.  I learned a great deal.  As I look back on it, however, the thing that I learned or appreciate the most, was the warmth and the friendliness of both the full-time and the part-time faculty.  Perhaps that has a lot to do with one of the reasons that I came back to St. Louis and one of reasons why I feel like maybe I’m not really provincial.  Maybe it’s just that I’m lucky.

What interested you in applying for the fellowship in Cardiology at the National Heart Institute in Bethesda, Md.?

That was a strange combination of circumstances.  I had been in the Army overseas before I went to medical school.  But at that particular time they were drafting physicians.  And there was a mistake made in my draft board.  They said [to me], “You have not served enough time as a non-commissioned officer.”  I was actually only an acting non-commissioned officer in my time in the Army.  And they said, “We’re going to re-draft you as a physician.”  And I objected and said, “You can’t do that.”  Well, because this was hanging over my head I had a very difficult time as I was a senior assistant resident looking around to think what I wanted to do – take a fellowship or whatnot.  Various people just didn’t want to talk to me if I couldn’t tell them if I could take the job or not.

Actually, an extremely funny thing happened.  I went to the National Institutes of Health and looked over various job positions and was offered several of them.  The one that I picked was with the Heart Institute, partly because I was impressed with the people I met there.  Luther Terry, who later became the Surgeon General— When people think about “the Surgeon General says you shouldn’t smoke”, they’re referring to Luther Terry.  He was a very friendly, fatherly gentleman and he was my immediate superior.  He was one of the reasons that I picked the job in the Heart Institute rather than in, say, the Infectious Disease Institute.

I flew back to St. Louis [and] told my wife, “Well, I’ve got a job at the National Heart Institute and if I take that job, not only is it an excellent one with excellent training, but it will get the draft board off my neck and I won’t have to be re-drafted again.  We were living on Washington Blvd. at that time, not far from here, in a home, by the way, which was my pediatrician’s home and who was the head of Children’s Hospital when I was a baby.  Again, more of my cross-connections.  We had a moving van pulled up onto the sidewalk and they were hauling my furniture out to move us into an apartment on the campus of the National Institutes of Health, when a phone call came and it was my draft board saying, “Dr. Davidson, we’re terribly sorry.  We did make a mistake.  You’re really not up to be drafted.”  Of course, by that time we went ahead and I went to NIH and I was very pleased there.  I was very happy, and as a matter of fact I was offered a position as a career investigator there and had joined what was called the Regular Corps at that time.  I don’t know if they have such things any more, but that was part of one of the stages or steps one would go through before you could be offered a career appointment as an investigator.  I was all set to stay there.  I could have been very happy being a career investigator.  That was the interesting thing about the draft board getting down my neck – [it was] the thing that prompted me to look around for the best possible training away from St. Louis.

What did your work consist of there?  Did you center on just one topic, one area in Cardiology or were you in all areas of Cardiology?

No.  My first responsibility was to be the Chief – I want you to get that down for history to record – I was the Chief of the Hypertensive Study Section.  But as the Chief of the Hypertensive Study Section I was the head of one man – me.  I was the whole department at that time.  A gentlemen named Dr. Henry Schroeder here at Washington University had been instrumental in developing early forms of therapy for hypertension.  He was the first person to demonstrate that by treating hypertension one could actually alter the course of the disease.  This is historically a very interesting thing because prior to that time many people thought that high blood pressure should not be treated, that it was essential – and we still call it “essential hypertension” – to the perfusion of organs with inadequate blood supply that the blood pressure be elevated as artereosclerotic changes occurred.  Dr. Schroeder showed that you could actually prolong the life of people with malignant hypertension by treating the high blood pressure.  Therefore, the high blood pressure was not “essential” to adequate perfusion.

I had worked with Dr. Schroeder, treating many of his patients, and he was the one who stopped me in the hall outside of old 2418 one day and said, “Johnny, how would you like to go to the National Heart Institute and be the head of their high blood pressure research section?”  And I said, “Dr. Schroeder, I don’t know anything about that.”  To which he replied, “You’ve worked with me, haven’t you?”  And he said, “Why don’t you go and talk to them about it.”  And I did.  And they were interested in having what I had learned from Dr. Schroeder be transplanted to Bethesda, Md.  So, actually, high blood pressure was the major field in which I worked at that time, clinically speaking.  I also did some basic science-type biochemical work working on vasoactive amines and trying to develop a method for measuring blood tyrosine and other target things which really seem quite far afield from clinical cardiology.

You were offered another position there.  I think you mentioned why you came back to St. Louis, but could you expand on that a little bit and say something about the association with the faculty members here?

I was very happy at the National Heart Institute and I could have made a very happy career being a career investigator.  We moved back to St. Louis primarily for family, personal and financial reasons.  I had two children in school at the time.  We were living in a small apartment.  Dollars were cramped.  I think I was earning, by the time I left there, $7,000 a year and I’d had over five years of postdoctoral training, and that was part of the reason for saying, “Well, we really ought to go back to St. Louis and I ought to consider going into private practice”, because we were really being cramped for dollars.  I was over 30 years old by that time.  These are all multifactorial systems, of course, and that’s only one of them.  We had parents here and so forth.  But I had no qualms about going back to St. Louis because of the friendly, warm atmosphere and saying to myself, “Well, if I’m going to go back to St. Louis and either be a full-time faculty” (which I considered) “or on the part time faculty of the University—”  Maybe I didn’t say it to myself in so many words, but I felt that I would be warmly received and be among a group of friends who would help me out.

Do you think that it’s the best of two worlds?

It’s an attempt to do that.  And I’ve been very happy with it.  I realize that [by] trying to do some teaching, trying to do a little research, primarily being a private, personal physician and earning my living at it, that I’m somewhat like the man who’s trying to chase three rabbits.  All three may get away and history may show that John Davidson really didn’t do anything very well, but I’m trying to chase the three rabbits, even realizing that intellectually speaking I’m not likely to achieve anything.

Last year Mallinckrodt Foundation, I think it was, awarded you $10,000 to study the effects of a heart attack on a person, and the lack of oxygen and the result that that has on the heart.  Could you describe the approach that you’re taking in this research as well as any result that you have seen?

Yes.  That research has grown out of the fact that St. Luke’s Hospital has a hyperbaric oxygen chamber and I was asked to be the head of that Division of Hyperbaric Medicine.  That title, by the way, is quite long and it’s somewhat akin to my being the Chief of the Hypertensive Studies Section at the National Heart Institute.  It’s very impressive-sounding, but that’s about as far as it goes.  Dr. Burton Sobel, who is chief of Cardiology here, and his colleagues have developed a method for assessing the size of a myocardial infarction.  Therefore, the stage was set for developing methods which could be applied to the patient with an acute myocardial infarction to see if one could make the size of the myocardial infarction smaller than it would have been.  In other words, we now had a yardstick by which we could assess whether or not something was worthwhile.  It would be perfectly logical that if some heart cells were dying as a result of a lack of oxygen when a blood vessel in the heart closes off, then if one could literally squeeze more oxygen under high pressure by literally dissolving it in the plasma, one could tide some of these cells over the critical period and allow them to live.  Then the total number of dead heart cells at the time of myocardial infarction would be fewer and the patient would be that much better off.  We have done some work.  Primarily, the work has been done experimentally in dogs and that’s been done here at the Medical Center and at St. Luke’s Hospital in conjunction – the two working together.

To make a long story short, I think that this research is about to come to a halt because I’m finding out that other things need to be studied before we can go any further.  We’re finding out that we are getting equivocal results.  Occasionally we get evidence of good salvage of myocardium and other times we don’t get any.  It’s about 50-50.  Apparently, the effect of oxygen itself on the experimental animals is such as to produce a marked peripheral vasoconstriction, a rise in blood pressure, an increased load on the left ventricle and increased oxygen requirement – which offsets the good that we do by squeezing more oxygen into the periphery of the marginally oxygenated cells at the periphery of an acute myocardial infarction.  If we could find something which would block the vasoconstrictive effect on the cardiovascular system from hyperbaric oxygen, then we would be all set to proceed at full steam ahead further.  But at the moment I think we’ve gotten about as far as we can go until I can figure out, or until someone else figures out a way of blocking the vasoconstrictive effect of hyperbaric oxygen.

Do you know if similar research is being done any place in the country?

Similar research, yes, but this particular research was ideally suited here because the enzyme method, the CPK method for assessing infarct size was largely developed by Dr. Burton Sobel and Dr. Bob Roberts who were here in the department.  This is one of those things where paths just nearly crossed and I was trying to take advantage of the fact that we had a hyperbaric chamber.  The St. Luke’s chamber is one of the few in the Midwest – the only one in St. Louis.  As a matter of fact, it’s one of the few in the country that’s operational.  Plus the fact that Dr. Sobel came here with his large facility for measuring CPK enzymes and isoenzymes.  The groundwork was here and it was just asking to be done.  The idea occurred to me while lying on the sofa one Sunday afternoon reading a journal article and I said, “I would be foolish if we don’t pursue this.”  The next day I called Burt and said, “Hi, Burt.  This is John Davidson.  What would you think about a research project seeing if hyperbaric oxygen could modify acute myocardial infarction?”  His response took all of two or three seconds.  He said, “It sounds like a great idea.  Let’s talk about it.”  But as I said, the project has come to, as many research projects do, a point where other information has to be obtained before we can really pursue it in exactly the same way in which we’ve been doing it up to this point.

I’d like you to talk about some current problems in medical practice.  In addition to the questions that I sent to you, a few more have come to mind.  Let’s start with malpractice insurance.  Do you think that there is any way that this problem can be resolved to keep physicians from dropping out of the field because they aren’t able to keep up with the high premiums?  Do you think that it affects student enrollment in entering medical school?  Do they think about, “When I get out I’m going to have to pay $100,000 a year for malpractice insurance”?

I’ll answer your second question first.  I don’t think that premedical students ever think of that.  I had one son who was a premed and he didn’t think about it.  I have another daughter who is a premed and I’m sure the thought has never occurred to her.  Another daughter is sort of a premed-predental student – she didn’t know exactly which way she wanted to go – and I’m sure that thought never occurred to her.  Perhaps that’s because it’s not been a problem that we’ve talked about at the family dinner table because malpractice insurance for me as an internist has not really been a major problem.  This is a problem primarily for the obstetrician/gynecologist, the neurosurgeon, the orthopedist, the anesthesiologist.  So it hasn’t touched me personally very much.  I must admit that my malpractice premiums have gone up many, many fold since I started practicing.  I remember when I started practice, my malpractice insurance for a year cost about $80.

An interesting anecdote about that was that when I came back to St. Louis from NIH, I brought some of my own research projects with me and I continued to do some research as a continuation of some work that I’d been doing at the Heart Institute.  This involved radioactive isotopes.  I had my own Atomic Energy Commission license at that time.  Many people who listen to this tape are going to think, “Gee, whiz.  That was the old days.”  This research involved my giving some radioisotopes to humans.  I remember writing a letter to my malpractice carrier telling them that I was going to be doing experimental work, using that word just that way, and in humans and using radioisotopes.  And in that day, just the word “radioactive” had a strange magic about it that implied almost the occult – the mystic and danger.  This was the day of everyone looking to the sky to see if the bomb had been dropped yet.  And they wrote back to me and they said, “No, that’s perfectly all right.”  Fine.  My malpractice insurance was still about $80 a year.

I don’t really know what it is at the moment – my wife pays the bill.  But I know it’s many, many, many times more than that and I think that if I wrote them a letter in a similar vein today telling them that I was doing experimental work in humans and involved in something that had what commonly would be thought danger to it, I’m sure they would raise it.

Back to your other question.  Do I have any idea how the problem can be solved?  The answer is, “No, I don’t.”  I have the feeling that the tide has been turned, however, and that things will get better in this area, largely because of a small law suit in which a lawyer was sued for malpractice because of a law suit that he brought up on behalf of a client which was clearly a nuisance and had no grounds or substance.  This lawyer was sued and the court found against the lawyer – that it was literally malpractice for the lawyer – malpractice of law – for him to bring up some sort of a piddling, nuisance suit.  I think things like that are going to solve the problem.  In other words, a sense of reasonableness, fair play and good judgment in society in general is going to bring it about more that some fiat of a federal regulatory agency or a specific law that is passed.

Have you encountered any problems with Medicare as an agency for the elderly to pay their bills?

The problems with Medicare are really the problems of the elderly.  In general, I like to think of Medicare as a form of insurance, which supposedly it is, and that the patient’s contract with me is still a personal contract [in that] they ask me for my help, counsel, advice, skill, or however they see it, and that there is an obligation on their part to pay me for my time.  In order to try to keep this a person-to-person contact, I try to have an arrangement whereby the patient pays me, and if they have Medicare insurance then they should recoup what they can from their insurance.  Philosophically speaking, I think that is the way it should be done.  Because to me it’s precious, it’s important, that a patient still have a one-to-one, person-to-person contract – literally, that I am the patient’s hireling, that I am their servant.  I am being paid to do their bidding.

Admittedly, a physician-patient relationship is more complex than that and frequently it’s— Let’s leave it at that.  But nevertheless, a physician should think of himself as a hireling of the patient.  When there is no exchange of money and some third party is paying the bill, the patient loses this and the physician loses the concept that he is being hired by that person, and I think that something is lost.  Admittedly, there are many, many good things about this and just to be the devil’s advocate, I’m bringing this up as part of what one would call an old-fashioned but a very good and salutary relationship that has existed in the past.  With many old people, even I give in and fill out the Medicare form and accept whatever Medicare pays for my services and so forth, simply because the patient is senile, confused, has no family to help him fill out the forms, and so forth.  Under those circumstances I break my rules and become flexible.

How do you think the rise in the cost of hospital care is going to affect the medical care that patients will be receiving?  For instance, I have reference to President Carter’s proposed 9 percent ceiling on how much hospital costs can go up within the next year.  Do you see that as a good measure or do you think it’s going to affect medical care?

I don’t want to make a comment as to whether I think that that specifically is a good measure or not, or if some other one would be better, or if 10 percent would be the right thing and so forth.  I don’t even know if that approach is a good one.  Of course, this is something that gives the hospital administrators fits at the moment.  I think that the public awareness of the expensiveness of hospital care is good in that people should be aware that a great many things can be done outside of the hospital which in years past have been done inside the hospital, largely at the patient’s insistence.  Some of this has come about, of course, because of the patient’s saying, “I’ve paid on this insurance for so many years and I haven’t collected anything on it.  Therefore, put me in the hospital to have this test and that test done.”

And we’ve gone through this in the past decade, saying that insurance programs should not pay for people to be in the hospital; hospital studies which need to be done at a facility such as a hospital should, if at all possible, be done on an out-patient basis.  All of us who practice internal medicine have gotten tired, literally, of trying to shove the patients away and try to talk them out of going into the hospital.  And all of us have weakened from time to time and said, “Oh, okay.  I’ll put you in the hospital and do it,” because you can’t function, and also because you’re afraid you’re going to miss something that might be important.

With the issue being put to the public, more and more people will be much more readily accepting of the idea that a great deal of their diagnostic work can be done while they are outpatients and the problem will solve itself to a certain extent.  Treatment within the hospital is going to be more and more confined to the population that literally, truly, requires not being in one’s home, like an immediate postoperative period and so forth.  I think that trend is already here.

I have one last question.  You’ve been out of school now for 25 years.  Has your philosophy as a physician changed?  In other words, did you start out, perhaps, with what you see now as unrealistic goals, saying, “I’m going to be able to cure this disease or cure that disease.  Now I know after 25 years that it’s virtually impossible.”  Or do you think that in 1977 you still have the same goals that you had in 1952?

Did I have some unrealistic goals?  I think rather than put such a harsh word on it, why don’t we call them youthful?  Maybe they’re [not], but it sounds better.  And I think that everyone should have youthful goals.  Was it Browning who said, “A man’s goal should exceed his grasp, or what’s a heaven for?”  If it isn’t that way, maybe you won’t get as far as you’re going to get.  Maybe in my own instance, as I said, I tried to chase three rabbits and I’m probably not going to catch any of them.  But maybe I will accomplish a little bit more trying to chase all three than if I had sat on my hands and tried to do nothing.

One of the interesting things is that my attitude toward patients’ illness has changed somewhat.  And again, this is somewhat colored by the kind of practice that I do.  As I said, most of my practice is Cardiology.  I started off wanting to help people too much, I believe.  I started off with the idea that if I did this and if I did that and if I did the other thing, this patient would be helped.  And it’s become painfully apparent to me that the patient’s responsibility for his own care is very, very important.  Many patients need not to be helped by me, but to be shoved in the right direction and told that their responsibility for their good health is largely in their own hands.  I’ve thought about this in the sense that my practice is, of course, different than that of someone else.  Some people, again to butcher Shakespeare a little bit, “Some people are born sick, some people have sickness thrust upon them.”  But an awful lot of people in our society ask for their own illness.  They achieve illness, if you will.  They eat too much, they smoke too much, they know what they should do and yet they come to me and say, “Doctor, I need help.”  And I have learned that perhaps in their best interests, rather than trying to help them, what I need to do is chide them, spank them, bawl them out, and put the burden of responsibility for their good health right back on their own shoulders.  And also to tell them, “Well, what you’ve got is largely your own fault.”

This kind of thing would not be applicable to the man whose practice is primarily cancers such as lymphoma or other things.  But in the practice of cardiology, overweight and too much salt and too many cigarettes are extremely important.  The incidence of myocardial infarction in cigarette smokers, I think, is something like six-fold [over] non-smokers.  I do get discouraged trying to help people who really are not willing to share their burden of the responsibility or accept the fact that a good part of their illness is their own damned fault.

That’s all the questions I have.  Do you have anything that you’d like to add?

Yes.  I regret that I have to end this interview with a little profanity and sounding like a bitter old man.

Thank you very much.


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