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Heirs of General Practice
By John McPhee
Farrar, Straus and GirouxCopyright © 1984 John McPhee
All rights reserved.
When Ann Dorney was seventeen years old, she thought she might decide to become a physician. Looking for advice, she arranged an interview at a university medical center, where she was asked what subspecialty she had in mind. Had she considered neonatology? Departing in confusion, she decided instead to expand her experience as a teacher of mathematics, which, in her precocity, she already was. She had tutored other students since she was fourteen years old, and she continued to do so as an undergraduate in college. She appeared to have her future framed, but then an opportunity came along to spend a four-month work term in the office of a small-town physician. He was a general practitioner, by training and definition, but the year was 1973 and the lettering on the door had changed to "FAMILY PRACTICE." She worked in his office, went with him on hospital rounds, and attended the delivery of babies. She saw each of the other Ages of Man and an exponential variety of cases. The math teacher began to fade again, and she applied to medical schools—nearly a dozen in all. Interviews were required, and she was short of funds on which to travel. For a hundred dollars, she bought an Ameripass, which was good on any Greyhound bus going anywhere at all within a single week. Thus, for something like a hundred and sixty-eight hours she rode from city to city, slept upright, checked her suitcase in coin lockers, took off her jeans in ladies' rooms, put on a dress and nylons, and carefully set her hair before catching a local bus to the medical school. "It was a scene," she says. "It was really a scene." She chose George Washington University. As a medical freshman, when she was asked to list her preferred specialties she wrote "family practice" and left the rest of the space blank. Professors attempted to dissuade her, but they were unsuccessful.
Sue Cochran entered Radcliffe College in 1969, and after two years felt a need to go away and develop a sense of purpose. She went to work for a rural doctor. Her brother, her brother's wife, her sister, and her sister's husband were all on their way to becoming specialists in internal medicine. Her father, a teacher at Harvard Medical School, was a neonatologist—in her words, "a high-tech physician." The rural doctor was her greataunt, who was scornful of specialists of every kind. For decades, the aunt had looked after a large part of the population around two mountain towns, and she passed along to her grandniece not only a sense of what Sue Cochran calls "the psychosocial input into physical illness" but also a desire to practice medicine in a rural area and to concentrate on prevention at least as much as cure. Of her medical siblings and siblings-in-law, she says now, "They think I'm flaky." She goes on to say, "The one who's the most supportive is my father, and even he thinks I'm pretty crazy."
David Thanhauser also dropped out for a time—but, in his case, out of medical school. After graduating from Williams College, in 1969, he spent two years in medical study at Boston University before he quit, in what he now describes as "righteous adolescent anger" —angered by the world and by society in general but more specifically because he could not accept being inside what he calls "the heart of the beast of specialty medicine." In the cancer wards, for example, he felt that "technological medicine was being carried to its extreme while the feelings of people were getting no attention." In the gynecology clinic, women—many of them Hispanic or black—were given pelvic examinations before doors that kept opening and shutting. "You learn good medicine by practicing good medicine," he says. "We were learning by practicing bad medicine." In the same era, Boston revolutionaries his age were saying that while medical students were inside the hospital learning "Band-Aid medicine" a profound malaise was outside the walls. Thanhauser retreated to rural Maine, spent something under five thousand dollars (a legacy from a grandfather) to buy fifty acres of land, and, with hammer in hand, built a small house. He thought he would give up medicine and become a teacher, but meanwhile he found work as a paramedic with generalists in Bangor. Watching these family practitioners work, he saw that they were doing an excellent job, whereas the message at Boston University had been that after people have been treated by generalists in Maine the next stop is Boston, where the damage is repaired. Before long, Thanhauser went back to medical school, but with intent to enter a family-practice residency and return to rural Maine. If such a residency had not been an option for him, his sense of conflict would not have abated and he might have abandoned medicine altogether.
Sanders Burstein, who grew up in a New York suburb, was in medical school when he made his decision, forgoing urology, oncology, nephrology, gastroenterology to characterize his future as "family practice in a rural setting." Paul Forman made the same choice at a younger age: "I knew when I was in high school that I wanted to be a country doc." Terrence Flanagan, after finishing Harvard College, went to western Ireland for a time, and decided there that he wanted to become a doctor and practice in some remote settlement in his native Maine. After enrolling in the medical school of the University of Pennsylvania, he declared his interest in family practice. "Great," said William Penn, but almost no mention was made of the topic for the next four years. At the time of Flanagan's arrival, in 1975, the family-practice office at Penn was next door to the office of the dean; when Flanagan left, family practice was in the basement, and to get into the room you had to ask for the key. When Donna Conkling went into medicine, she had an M.A.T. in English literature from the University of Chicago. As a medical student, she was surprised one day by a resident's saying to her, "You're really smart. Why are you going into family practice?" The question seemed to her to contradict itself. Her opinion was that you had to be smart to go into family practice.
All these people—in the idiom of medical education —matched the same residency program. Specifically, they went on from medical school to complete their training at what is now called the Maine-Dartmouth Family Practice Residency, which functions principally in and close by the Kennebec Valley Medical Center, in Augusta. And so did David Jones, who knew much earlier than any of the others what he wanted to do in life. Jones is the third of five brothers. One is a nephrologist in California. Another is a cardiologist at Johns Hopkins. Their father was for many years an internist at Massachusetts General Hospital. Jones had his own idea, and he had it when he was seven. At that age, he began to say, "I am going to be a G.P. That's right, I am going to be a G.P., with a farm, a stream in my back yard, and one horse." Now, a couple of decades later, Dr. Jones has his farm, he has four horses, including an Appaloosa named Papoose, and the brooks on his land run into the Aroostook River.
While these young doctors were forming and articulating their medical bent—"to give good health care to a variety of people," and "to offer primary health care to people in a rural area"—they all had friends who were choosing things like neuropathology and otolaryngology, and were saying over their shoulders as they headed into their respected closets, "Why go into family practice? It would be so boring." Now that Jones, Dorney, Thanhauser, and the rest of them are out practicing in towns of rural Maine, they tend to remember such remarks with ironic amusement. "People said it would all be routine stuff. I never could understand that. You have an O.B., then a schizophrenic, then a well-baby check, followed by a guy with hypertension and diabetes. There is such a variety. You never know what is going to come through the door next."
Through the door next comes a woman in her upper sixties with her mother. This is not at all unusual. People over seventy bring their parents to the doctor. The daughter wears a red velvet pants suit, and the mother carries a metal cane. The mother looks about with uncomprehending interest.
"Did her eye calm down after those drops?"
"Yes, but first the trouble spread to the other eye."
"How is her appetite?"
"Good. But she won't eat fruits and vegetables. All she wants is sweets."
The dialogue between the doctor and the mother's child is like a dialogue between a pediatrician and a child's mother. Then it changes.
"I haven't been anywhere without my mother for two years."
"How long can you keep doing that?"
"As long as I have to. As long as I feel that I have to. I'll go as long as I can and then I'll quit. When my husband was around, I would get up and make a fire at five in the morning. I could go longer. Today, I don't like to get up and make a fire."
By now, it would be difficult to say which is the patient, the mother or the daughter, but the distinction is irrelevant, for both are patients here. And so, respectively, are the grandchildren and great-grandchildren of the two women. As the doctor moves a stethoscope down the great-grandmother's back, the old woman says, "I have a gizzard, maybe." On this visit, it is all she will say. She has no complaints now. Her hypochondria is gone. Her headaches are gone, and have been for three years. The doctor prescribes a cream for a facial sore. The daughter says, "She is weaker than she was. She doesn't remember five minutes. She always said she was going to live to a hundred and three, and I wouldn't put it past her."
Thirty-two-year-old male presents with warts on his penis. He is, in appearance, a woodsman—beard, bluejeans, moccasins. The prescription is for podophyllin, an extract of the root of the mayapple. Indians were not unmindful of podophyllin. The doctor remarks in passing that some children have growths on their vocal cords that are thought to be warts. The theory is that they got them during birth, coming past the genital warts of their mothers.
Twenty-nine-year-old female presents with lesions of genital herpes. She is pregnant, and due in three weeks. Regular cultures will monitor the state of the herpes. Before labor, her doctor wants to see two consecutive negative cultures or an obstetrician will be called in and the birth will occur by cesarean section. If labor begins while the herpes is still active, the doctors have four hours in which to complete the obstetrical surgery. If a baby is infected by herpes in a vaginal delivery, the chance is eighty per cent that it will be severely and permanently affected or will die.
Thirty-four-year-old man comes through the door with a sheath knife on his belt and a white-lettered black T-shirt that says, "MY BODY IS AN OUTLAW. IT'S WANTED ALL OVER TOWN." His leg is so full of stitches it looks like a laced boot. The doctor unlaces it.
Thirty-nine-year-old female presents with a sore throat—possibly strep, possibly viral. Her doctor knows her, and knows that the sore throat is only the precipitating reason for her coming in—that what she wants is general talk and counsel. Looking over her folder beforehand, he has remarked that "any one of her problems would be enough to keep one person sick." Three weeks ago, she woke up in an ambulance, riding away from a demolished automobile. The bruises she still bears are particularly vivid because of a blood thinner that was prescribed for her when she suffered a pulmonary embolism a month before the accident. She has three children and runs a farm by herself. "The divorce becomes final on Friday," she remarks to the doctor. "Our second anniversary was yesterday." Her family could not accept her husband and made life so difficult for him he left. He is eighteen. Her first husband died of cirrhosis. Like the children, like the second husband, he was the doctor's patient, and often she has said to anyone who shows interest, "Doctor told him if he'd quit he'd live, and if he did not he'd be dead in a few months. He drank, and he died just when the doctor said he would." And now she has a question for the doctor: "Is depression an aftereffect of an accident?"
Following two well babies and a second-trimester mother, a female in her late seventies presents with a basal-cell carcinoma on the tip of her nose, growing like a small rhinoceros horn. She has a wedding to attend in two weeks, and is referred to a surgeon.
Sixty-four-year-old female presents with rashes under her arms and on her face. As before, this is merely the presenting complaint, the precipitating reason for the visit. "It's like hot coals in me," she says. "It goes right down through here, all sloomy, like a burn. It reminds me of the hospital where I had the electric shock." There are times when Oral Roberts talks with her, she confides, and her father is always with her as well. Her father is long dead. Her family has billions of dollars but not even fifty cents for her, she reports. There appears to be nothing that anyone can do to help her. Her list of problems includes but is not limited to paranoid schizophrenia, obesity, lameness, sexual dissatisfaction, hypertension, diabetes, and rash. From each regular visit, however, she seems to go away feeling a little less lost than she felt when she came in.
Smoky, wiry forty-six-year-old female presents with vague abdominal discomfort that she has mentioned before. The doctor suggests a colonoscopy, and explains that the procedure involves the insertion of a three-and-a-half-foot tube. The patient says, "I'm only five feet tall, you know."
Twelve-year-old male comes in with no complaint. He is in apparent good health, and says his mother wants him to have a physical. He removes most of his clothes. His knees are bright red from harvest work. He has made a hundred dollars in two gruelling weeks.
"What will you do with the money?" the doctor asks.
"I'm going to buy a new winter coat," he answers. "And a present for my parents."
After he leaves, the doctor says of him, "He has grown up before his time."
Next patient is the boy's mother, twenty-nine years old. She is graceful, attractive—superficially and deceptively calm. She says she has come in for a gynecological checkup, nothing more. She had a checkup not long ago. When someone comes in for a physical or a checkup,there is often a hidden agenda. "Anything troubling you today? Everything all right?" the doctor asks her.
"I work all the time," she replies. "I don't know how to relax and enjoy myself."
"Was your family like that? Your parents? Your brothers and sisters?"
"They're all nervous."
After a time, she reveals that her husband has left her, explaining that he was going away "for religious purposes." The religious purposes are that in his opinion she goes to church far too much. At home, where they live on welfare payments, it has been his habit to watch television while she almost continuously runs a vacuum cleaner. Two days ago, he returned.
"He was gone three weeks. He got involved with another woman. He said the thing he got into was not meant to be. He did say that. I know we fall into traps. I told him I just don't want it to happen again. I have my church. I will not give that up. I could lean on the Lord. I may sound like a nut, but I believe in God."
The doctor lets her talk. For the moment, letting her talk is about all there is to do. The doctor sees this as his role. Part of his training has been psychiatric. Family practitioners tend to say that a gynecologist in the same situation would package the conversation, make referral to a psychiatrist, and free up the examining room for the next patient. With such remarks, family practitioners sometimes run afoul of the older specialties. In any event, this heavily distressed young woman is receiving the time she really came for. A hidden agendum is painful to the patient. Both the patient and the doctor would prefer to solve it with a pill. There is, however, no pill. "You have got to talk," the doctor tells her. "You and your husband have got to talk. Maybe he feels jealous of your church. The two of you should see a non-religious-related marriage counsellor. If you don't, you're in for trouble ahead. I worry about relationships like yours. Faith alone won't fix them." He says this, but for the most part listens.
Through the door next comes a twenty-five-year-old female who is pregnant, tall, and flourishingly good-looking, and weighs a hundred and ninety-seven pounds. The fundal height is thirty-five centimetres. Five weeks to go. The doctor listens in with a stethoscope and hears sounds of a warpath Indian drum.
Excerpted from Heirs of General Practice by John McPhee. Copyright © 1984 John McPhee. Excerpted by permission of Farrar, Straus and Giroux.
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