I have 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.

Here 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 invited.

A Frugal Physician Prescribes

Common Sense and Enthusiasm

Shortly 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 office.

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.”

Short 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?

Medical people - 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 wall.

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 excitement.

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.”

Dr. 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 minimum.

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.

Fortunately 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.

On one 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.”

I 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.

Nonetheless, 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 methods.

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.

I 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 well.

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.

Yet, 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.

Common 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.

Medicine 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 ahead.”

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.

Medicine 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.”

Maybe 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

Putting 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.

“Physicians are 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.)

Medical 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 Frugal Physician.

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 time.

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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