just finished the first draft of my latest writing effort about A
Frugal Physician. The book is meant to give fresh perspectives on the
practice of medicine and hints at ways to reform medical care.
Medicine, like many other parts of modern life, can be made more user
friendly, less expensive and better for everybody involved.
is the first chapter. In the next months as I revise, edit and revise,
I will send out a few more chapters. Your interest and comments are
A Frugal Physician Prescribes
Common Sense and Enthusiasm
after completing the first clinical rotation of my junior year in
medical school, I received an "invitation" to meet with Senior
Physician Dr. Walter Kirkendall, the Chief of Internal Medicine for the
Hermann Hospital and the whole medical school. I had no idea what
prompted the summons, but quickly found out once I stopped into his
Kirkendall was an aging internist, a big guy in a long
white coat with professional glasses sliding down over his nose. He was
a bit of a looming figure and I was just a tyro. He was neither
welcoming nor unkind. Just pretty matter of fact. He didn’t ask me to
sit down. He just got to the point. “Your evaluation for your first
rotation on Medicine was not very good. It concludes, ‘Student lacks
common sense and enthusiasm.’ Let’s see if you can do better in this
next round. I don’t want to hear about a repeat performance.”
and sweet. Well, not really sweet. Not harsh either. Dr. Kirkendall
added something to the effect that the next evaluation would have to
show improvement - or else.
The first two years of medical
school were (and still are) largely classroom work, sitting for hours
listening to generally boring, uninspired lectures and speakers. (If I
had to do it over again, I would skip practically all classes, read the
texts which I would anyway, and find real life experiences to fill the
time I “should” be in the classroom.)
The common refrain in the
Texas Medical Center and other points of training was “Them that can do
do. Them that can’t do teach.” I couldn’t object much. Actually, I
thought the quality of teaching I sat through for almost two decades of
my life had gotten worse instead of better as my education progressed
to “higher” levels.
An anecdote about a professor at our
neighboring school, Baylor College of Medicine, circulated freely if
not accurately, although most certainly with grains of truth.
Apparently, the medical man “taught” a course to a large group (200+)
in an amphiteater-seating auditorium. (I was in one of the first
classes of UTMSH and we 52 had the “luck” to be taught for two years in
cramped quarters on the 11th and 12th floor of Center Pavilion
Hospital, then on the edge of Texas Medical Center.) While his lectures
were poorly received, the instructor didn’t pay heed. His talks droned
on and on and on. But, what was a student to do?
- even students - are rarely spontaneous or innovative, but one student
took it upon himself to make a statement for the whole class. His
friends helped him move a couch into the auditorium prior to a lecture
session. They placed it strategically at the base of the amphitheater
directly in front of the long counter behind which lecturers were wont
to speak and scribble on the equally long blackboards covering the rear
That day as the professor’s drone got oppressive, the
brave young student quietly left his seat and stretched out on the
couch. He was soon asleep. The professor either didn’t notice or didn’t
care. Surely, the students must have found it difficult to keep from
busting out in laughter.
I can count on one hand the number of
interesting professors and classes we had in those first two years -
and still have fingers left over. Only one instructor comes to mind at
the moment. Dr. Guillermo Nottebohm. The Argentine firecracker was a
nephrologist (kidney specialist) who taught classes on internal
medicine. He was dynamic, excited about his work and specialty. He
moved around, tried to engage the people in the seats, and told
pertinent or at least provocative stories. While he didn’t have new
information for us, he presented his classes with some elan and
I recall his recurring pronouncement given out when
students said they hadn’t gotten their reading or assignment done.
Given with his spicy Spanish accent, he said, “My young man, you really
have no excuse. Their is no requirement for medical students to get
sleep. So, you certainly had time to get this work done.”
Nottebohm and a bare few others helped us survive those grueling hours
in our tiny, stuffy classroom. Fortunately even in the first med school
years, we did get away for a few hours each week for one kind of
practicum or another. When we reached the third year, everyone was
quite relieved. Our butt-numbing classroom hours were slashed to a
We then spent practically all our time on one
ward/service or another - six weeks at a stint. The ward team usually
consisted of an attending physician who was the titular head of the
group and appeared at his/her own discretion. Some frequently, others
on occasion. Generally, s/he handed responsibilities over to a resident
physician and an intern. Medical students pulled up the rear and took
directions and orders from everyone. We did physical exams and
procedures, chased test results, made regular rounds checking on
patients, attended our mentors’ needs and whims, acted as go-betweens,
and did whatever other gopher work was delegated to us.
or unfortunately, my first rotation was on the Cancer Ward at the
Hermann (University) Hospital. It was a sad and depressing place for
patients and workers alike. The prognosis for most patients was less
than hopeful. I thought I had done the work assigned and followed the
program. But, I learned otherwise from Dr. Kirkendall. I had opened my
mouth one too many times.
John Rogers, the Medical
Resident on the Cancer Ward, was tightly wound and equally attuned to
the medical orthodoxy. He had obviously not liked some of my pointed
questions, especially when I showed I was unconvinced as to the value
of some of the treatments - antibiotics and steroids, antibiotics and
steroids - which we doled out so frequently and freely.
occasion, I remember him calling me a “therapeutic nihilist.”
Suggesting that I wasn’t enthusiastic about any medical methods. He
wasn’t far from the truth.
By that time, I had developed a
questioning eye and skeptical opinion about many things. I also had
studied enough on my own about other schools of medicine, traditions
and alternatives to object - at least inwardly - to many of teachings
we were expected to accept at face value. Supplemented by my several
years of experience from medical corpsman, xray assistant, vocational
nurse, and medical technologist, I had a broad knowledge base larger
than most medical students and as wide as many resident physicians.
I was also slightly and subtly aware of medical and healing experiences influencing me from “other times and places.”
found that the modern medical guild, probably like older ones, doesn’t
appreciate alternative thinking. When I was in Uncle Sam’s Army, we
were told, “There’s the right way, the wrong way, and the Army way.”
There’s a Medical way, as well.
Chief Resident Rogers also took
it quite personally when patients died, on one occasion painfully and
blatantly blaming the nurses. Death in the medical system is too often
seen as a failure. And with failure, someone needs to take the blame.
But, really! People die, especially cancer patients on cancer wards.
MY problem was “lack of common sense and enthusiasm.” I admit that I
most surely must have frowned inwardly as well as questioning more than
was “right for a newby.” I didn’t have the common sense to keep my
mouth shut when I couldn’t be clearly enthusiastic about standard
I tried to button my lip more the second time around
than the first. (Not an easy task.) That second rotation went much
better - or, again, so I thought - at St. Joseph’s Hospital which was
located in downtown Houston away from the Texas Medical Center. Jim
Peterson, the head resident, was decidedly laid back. He wasn’t out to
shine, just get the job done, take care of people, and move along the
medical corridor. The number two man was an OB-GYN intern who tried to
lighten the load (with laughter) rather than add to it. Further, we
were working on a general medical ward. Death was not a constant daily
threat as it had been at the Hermann cancer ward.
I did my work,
followed the protocols, and made no waves regarding patient care. So, I
was not entirely surprised that there was no further word from Dr.
Kirkendall. However some weeks later, my medical student partner at St.
Joseph’s did say to me, “Did you hear they lost the evaluations that
Peterson wrote for us?” Maybe that was for the good. I will never know.
do know that, then and more so now, common sense and enthusiasm are
essential to a well-rounded life as well as for health and healing.
Despite the seeming opposition of the terms, the two might fit nicely
on a crest designed for a Frugal Physician.
I do have to stop
here because I can’t help but think that we humans are prone to project
our shortcomings on others. I was accused of lacking common sense and
enthusiasm. I have since admitted the truth of the accusation. I wonder
if medicine and its practitioners can stand up to that accusation as
Much of modern living seems to avoid common sense: “Just
follow the regular program.” Express your enthusiasm for something
extraordinary or your objection to the status quo: “Hold your horses.
You are upsetting peace and decorum.” The same ethos seems to hold sway
in the corridors of medical institutions most everywhere.
medicine and modernity must find room again for common sense and
enthusiasm. I suggest that they are two of the keys which will open the
gates to further layers of growth and understanding in the coming era.
sense is a stabilizing force necessary for us all of us, whatever our
pursuits and interests. “Common problems call for common sense.” Common
sense suggests mental balance, the simple gift of discrimination, and
rational perspective. It points to the HEAD - a clear one.
seems to respond: “Things are not so simple as you might think. We have
developed protocols and practices which have proven generally effective
over the years. Learn them and you will be well grounded for the days
Enthusiasm - coming from the Greek en theos and meaning
in God - points to energies of the HEART. To the author, enthusiasm
hints at being on fire, inspired for an unselfish cause.
replies: “Our work is tend and repair the human body. We know nothing
of the soul or God. That is out of our element. If a patient needs God,
call the chaplain.”
Despite such unspoken objections, these two
forces can help expand the dimensions of modern medical care beyond its
present narrow confines. One bringing down-to-earth focus and the other
reaching for everpresent hidden possibilities. “Feet on the ground and
head in the heavens.”
We are all so built - at least
metaphorically. Why can’t future medicine grow in that direction? One
Frugal Physician believes so. “Once a physician, always a physician.”
Drs. Rogers and Kirkendall did me (us) a real favor by helping to point
out these fundamental forces which I (we) can use to direct our steps
in the search for A Frugal Physician.
The epithet “frugal
physician” is an oxymoron just as in a similar vein, common sense and
enthusiasm make for a combination of near opposites. Yet, they have
make for a useful pair.
Here are a few other medical oxymorons, some of which we will consider as we go along:
• health insurance
• health care
• preventive medicine
• fixing health care
• medical intuition
• cutting to cure
• therapeutic tests
• scientific medicine
• medical practice
• real diseases
• real doctors
Frugal and Physician together is clearly unusual and uncommon. A quick
search at Google gives a paltry string of 300 citations out of billions
of web pages. “Frugal physician” references mostly point to ways for
physicians to save money and resources in their offices or how their
lifestyles at home. A large share of results are given for Frugal
Physician medical specimen cups. There is nary a word about medical
people helping their patients to save money.
In the modern
world, the practice of medicine almost mandates substantial costs. Even
to walk into a medical office necessitates leaving several large bills
on the counter or writing a good sized check.
not taught to save money. They are taught to save lives.” I just made
that one up, but it seems to be a relative medical truism in the common
era. (Saving lives is another oxymoron we will survey later.)
people need to know that financial health and physical health go hand
in hand. One reflects the other very commonly and is dependent on the
other more than is often apparent. That is a basic understanding for a
With expensive tests and technology, pills and
procedures taking over larger and larger swaths of medicine, parsimony
in health care is almost unknown. It was known and common once upon a
Common sense and enthusiasm may help us achieve such a
rational and desirable destination again, some day. Frugal Physicians
need to be there before such a state eventuates.
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