Better than Money

One of the delightful aspects of adopting a new life in Israel was the move from a fee-for-service payment system to a fixed salaried one, delightful even though entailing a drastic reduction in my income. It was like returning to the days of my medical training when hospitals paid minimal salaries while providing years filled with rich doctor-patient encounters, unencumbered by that ugly word, money.

Whatever the reasons, I was uncomfortable having a patient put money directly into my hands or even discussing fees. I avoided these whenever I could by referring the patient to my secretary. Did I feel guilty thinking I was rewarded enough just by being allowed to provide my services? Or was it my worry that maybe my fee was too high or maybe that I had misjudged the patient’s ability to pay. Or maybe I was tapping into the ill-conceived notion that just talking with a patient didn’t merit a fee. One surgical colleague didn’t charge a patient for his consultation unless it was followed by an operation. He rationalized, obviously incorrectly in my opinion, “If I didn’t operate, I didn’t do anything for the patient.” Matters were greatly alleviated for both the patient and me, when insurance carriers, Blue Shield and Medicare, began paying most of my fees. The following patient put me to the test.

Roland Jasper at age 53 had an attractive, debonair flair as he offered a firm handshake across my desk. “A born salesman,” I thought. In answer to my opening question, “What can I do for you,” he replied, “Not much. It’s just that I’m going across the country to promote and sell encyclopedias to families and schools. It’s very profitable but also very exhausting work. Though I’m feeling fine, I wanted a general checkup to make sure.” At the conclusion of my study, which included routine lab work, a chest x-ray, and an electrocardiogram, I suggested that because of borderline high blood pressure he should lose ten pounds, go easy on salt, and, by all means, quit cigarettes. The multitude of oral medications now popular for hypertension was not in vogue at that time. He agreed to try to comply – he didn’t display much enthusiasm – and said, “See you when I get back in a couple of months.”

On the way out, he stopped at my secretary’s desk and gave her ten dollars as the initial payment on his $110 bill. For the remainder he gave her a post-dated check, cashable two weeks later.

At the appropriate interval the check was deposited. Lo and behold, the following day the bank manager called to inform me that the check had bounced “for insufficient funds.” He continued, “Let me tell you, David, this Jasper guy is a con artist. He’s passed bad checks all over town. I even lent him a few hundred dollars on the basis of his previous year’s tax return, which I later discovered was a fake. Welcome to the club.”

Approximately six months later Roland, without an appointment, popped his head past my office door saying he had palpitations and a severe headache. “Please, can you help me?” The patient I was examining was startled by this rude intrusion. I excused myself to her and went into the waiting room.

“Yes, but on condition that you pay up your old bill and put down another fifty dollars toward your next bill.” I didn’t like myself, sounding so mercenary, but I wasn’t going to let him take advantage of me a second time.

“I can give you fifty dollars now and another fifty tomorrow. The rest, I really can’t say.” That bit of honesty was a step forward.

Something about his expression told me “Con man or not, I believe him and besides, this time he looks sick.” I said, “OK. Hold on for about ten minutes until I finish up with my last patient.” As I turned around I noticed him handing a fifty-dollar bill to my secretary. I mused, “I bet it’s counterfeit.”

As Roland sat on my examining table, I was tempted to begin by discussing his morals. His fearful facial expression dissuaded me from that. Instead I took his blood pressure. 230/130! I checked it repeatedly, in the other arm as well, without noting any significant difference. Among other findings were warm, moist skin and a heart rate of 125/minute. I said to myself, “So what if I’m conned out of a couple hundred dollars! This case is my meat.”

I immediately thought of a severely overactive thyroid, causing “thyroid storm.” Untreated, this can be quickly fatal. Against this was the absence of either a goiter or protruding eyes.

My second choice was an adrenal tumor called “pheochromocytoma.” (The adrenal glands sit on top of the kidneys.) I listened with my stethoscope over his kidney regions and sure enough, there it was: a murmur suggesting the tumor’s increased blood flow. I didn’t have time to congratulate myself for in the next few moments Roland began gasping for breath. Liquid in his lungs was audible without a stethoscope. Sitting him up helped somewhat as did an oxygen mask. I gave him an intravenous injection of a strong, rapidly acting diuretic. Roland was considerably improved by the time the ambulance came to take him to the hospital.

Within two more days urine chemical testing and computerized tomography confirmed the diagnosis. Conservative medical treatment resolved Roland’s symptoms but cure would come only from surgical removal of the tumor. For that I wanted him to be in a medical center for the operation requires a team of experienced, highly qualified surgeons, anesthesiologists, and specialists in hypertension. I had already learned that Roland had hospital insurance but like me, his doctors would have to enjoy the medical experience for monetary remuneration would exist on paper only.

The surgery was successfully performed in a Pittsburgh hospital. Other than the discharge letter from the operating surgeon I lost all track of Roland. Statements of money owed to me were returned, “addressee unknown.” We gave up. Seeking the aid of a collection agency long ago in other trials had lost its appeal for me; it was an angry, fruitless gesture. Satisfaction from a quick diagnosis and cure of a rare disease were to be my reward.

It was five years later that the man with an attractive, debonair flair walked into the office. Roland told my secretary that he just wanted to say, “Hello.” She escorted him into my office. We shook hands and, without any greeting, he handed me a brown paper heavy bag. “Look inside,” he ordered. To my chagrin there were a several handfuls of silver dollar coins. “This is a first payment,” he said. “Believe me (I didn’t) there will be more.” Then, departing, he called back over his shoulder, “And thanks, Doc.”

After the door had closed, I took one of the coins and bit it. Though it stood the test – I wouldn’t have been surprised if it had been chocolate – I thought I should do the same for the whole collection. In today’s competition of “one upmanship” both Roland and I were “one-up,” he for recovering his health at a bargain price and I for having a story to tell my grandchildren.

A Doctor in the Family

This chapter could be titled mea culpa or the Hebrew parallel, “al het,” asking forgiveness “for the sin ... .”   Though not sealed in any oath equivalent to that of Hippocrates, an admonition not to treat one’s own family is nearly as binding.  And yet, many times there were extenuating circumstances, which placed me in a compromising role I could not avoid.

Take for example my treating my wife, Marcia, for “the flu.”  In the fall of 1954, we were living in Boston while I began a two-year fellowship in internal medicine at Lahey Clinic. Marcia developed symptoms typical of an upper respiratory infection: low-grade fever, sore throat, coryza, and a non-productive cough.  I listened to her lungs with a stethoscope and heard no abnormal sounds.

The following day when her temperature rose and her cough became productive, I threw in the towel and called a seasoned internist-colleague.  Within a couple of hours he examined Marcia and heard moist crackles – rales – in one of her lungs.  “I believe Marcia has pneumonia, Dave.  Let’s take her to the hospital for a chest x-ray.”  And, of course, the diagnosis was confirmed; Marcia was hospitalized and quickly recovered on penicillin therapy.

It is possible that the “rales” may have developed between the time of my exam and my friend’s.  More likely, thinking wishfully, I tuned them out.  And therein lies the inescapable truism: as physician to one’s family, the doctor’s judgment is faulty.  He will go to the extremes of denial, wishing away any abnormal findings. Accordingly this relationship is to be avoided whenever possible as will be re-enforced by other examples that follow.

I was one of three internists who treated heart patients in Aliquippa.  The other two are now dead so I can freely claim that I was the most experienced and up-to-date with newly developed techniques.  It therefore seemed logical to me to be my mother’s doctor when she developed heart trouble.  The relationship worked well for several years until one day in 1971 when my mother was 84 years old.  Over the telephone I could hear that she was in severe congestive heart failure.  I called an ambulance; we arrived at Mom’s house almost simultaneously.  We sat her up in the ambulance stretcher; this gave some relief.  As soon as she was in a hospital bed, I began the then state-of-the-art therapy.  First order of treatment was to put an oxygen mask on her.  I then applied tourniquets to her legs and arms, which lowered the work of her heart by reducing the circulating blood volume (not to worry, the tourniquets were removed at set intervals so that no extremity went without circulation for too long). This should have worked.  A nurse administered an injection of morphine to try to relax my mother’s frantic breathing efforts.  I then gave an intra-muscular injection of a mercurial diuretic again to reduce the fluid, which was backed up in her lungs.  Lastly, I injected intravenous aminophylline to relieve bronchospasm.  I won’t say I was proud of myself but I was self-consciously aware of the nurses watching me take control of the situation with such dispatch.

The only problem was that nothing I did seemed to improve my mother’s dire condition.  I was at a loss for something more to do for my mother who would soon die.  A “code blue” announcement went forth over the loudspeaker system, which would bring more help.  I don’t know who was inspired to initiate the call but within minutes in rushed Dr. Horto, our Turkish anesthesiologist.  He assessed the situation in less than a minute and within another, without asking my permission, inserted a tube through my mother’s mouth into her trachea.  Immediately he began pumping oxygen under considerable pressure.  This would force fluid from the breathing spaces in her lungs into the blood stream, making room for exchange of oxygen and carbon dioxide.  Within two to three minutes my mother’s breathing was easier and much less bubbly.  Her previously blue nail beds began to pink up, indicating improved oxygenation of her tissues.  (If my mother had been fully aware, removing her meticulously applied fingernail polish to expose the underlying innate color would have angered her.)  Within five minutes of Dr. Horto’s treatment, Mom opened her eyes and smiled at me.  Because of the tube, she couldn’t talk but it was evident that she was out of trouble.  Within ten days she was fully mobile and was discharged home.

Where had I failed?  It was obvious that I couldn’t bring myself to carry out the most significant therapeutic measure on my own mother; it was just too invasive.  Mom lived reasonably active another three years until her heart failure returned, that time not to be reversed.  Within hours she was dead.  As she was dying I spoke with my brother, Jerry, a superb physician, who asked, “Are you ready to let go?”

I replied with a choked, “Yes.”  I would not have been three years earlier.

The issues are clear.  With my wife, wishful thinking blunted my diagnostic acumen.  With my mother aggressive action on my part was unthinkable, too disrespectful, too unfilial.  My role as a physician was subverted.

At least I did act appropriately, albeit harshly, when Mom at age 82 caused a traffic accident in which her car was nearly totaled; she got out of the car and, adjusting her hairpiece, asked a passerby to call her son.  It was painful for me to take the driver’s license away from my mother but I gritted my teeth and did it. (Ff turnabout is fair play, my children did this to me last month!) She was less accepting when two years later, I took control of her checkbook.

My daughter Amy was not always easy to read.  As I look back on her short life, I have to admit that I, we – Marcia and I – more than once questioned her judgment as when at age six, she shouted that a suitcase had just fallen off our car luggage rack; 100 miles later she was vindicated.  So when she rather casually claimed a broken leg from what I witnessed as a rather gentle fall while skiing, I had her sit while the rest of the family finished our ski afternoon.  To placate her when we arrived home, I took her into the x-ray room of my office and x-rayed her leg.  I couldn’t believe the result: a long spiral fracture of the tibia.  I was in no way exonerated when both the ER nurse and, subsequently, the orthopedic surgeon asked, “Which leg?”  Fortunately no harm came to Amy by the several hour delay in my making the diagnosis, not even significant pain.  Both of these incidents did give her leverage in subsequent disagreements with me.

A judgment error for which I probably will never forgive myself also concerned Amy.  It was the morning after we had retrieved her from Hampshire College in Amherst, Massachusetts.  Afflicted with manic depression, Amy had made superficial cuts on her wrists.  She called us from the infirmary to say that she felt like jumping out of a window.  Marcia was at her bedside within hours while I arrived some time later by car.  Immediately on our return home we made an appointment for the following morning with a psychiatrist in Pittsburgh, thirty miles away.  That morning Amy was acting strangely; that was the only description I could apply.  As we got into the car, she was acting somnolent and “acting” was what we thought was the explanation.  I wavered between going directly to my hospital one minute away and proceeding on to Pittsburgh, an hour away.  I elected the latter.

By the time we got to the psychiatrist, Amy was in a deep slumber.  He ordered us to proceed directly to a nearby hospital where remnants of sleeping capsules were aspirated from her stomach.  Amy lay in a coma for two days during which time I didn’t budge from her unit; I had to be there when she awoke or if further complications were to develop.  She did eventually recover; I didn’t.  It is obvious that my judgment was terribly impaired.  How could I think it was just another of Amy’s tricks?  Or was I afraid to confront the staff of my hospital  – where I was "infallible" – with the reality of my mentally sick daughter? 

The most recent incident of questionable professional conduct occurred in reference to Marcia’s resolve to donate a kidney to her niece.  The final decision regarding her acceptability and ultimately the surgery were in the hands of a team in New York.  She received instructions for arranging a preliminary battery of tests here in Israel.  In addition, forms for a complete history and physical examination were to be completed by a doctor. Marcia had no family doctor and certainly no one could document as complete a history and as expeditiously as I.  I therefore undertook the responsibility.  I assiduously performed each examination as objectively as possible. It took concerted effort to fight the desire not to find any abnormality. Certainly I could not overlook any finding that might jeopardize Marcia’s life should she undergo the nephrectomy.  The only important finding was borderline high blood pressure. I was not concerned but reported it accurately.

When the surgeon who was responsible for Marcia approached her, it was obvious that he was riled up over something. Immediately Marcia saw him as an adversary who would prevent her from saving her niece’s life.  “We never use a sixty-six-year-old donor unless it’s for her own child. And does your husband not know how unethical it was for him to do your history and physical?” Marcia listed my professional qualifications, all irrelevant.

By the time the surgeon took Marcia’s blood pressure, she was in a rage and her blood pressure proved it. “Your husband lied! Your blood pressure is not 160/80.  It’s 200/100!”

 “Do you think my husband wants me to die?  Let someone else take my blood pressure in another hour.” She was terrified of further antagonizing him, lest he disqualify her as a donor.

Well, the surgeon was not entirely wrong about my completing Marcia’s examination.  But not only did he not seek an explanation, he didn’t suggest having a colleague redo the exam.  Eventually she went through the surgery and with no untoward effects, her niece was restored to good health, and a year later the surgeon was looking for a new job.

Every once in awhile when I’m berating myself, I wander back in my mind to 1967 to our family trip to Israel.  We were at a swimming pool in Eilat when Danny, age four, cut his forehead.  The cut was about one centimeter wide but deep.  We rushed him to a local clinic where the nurse indicated that no doctor would be available for another hour.  Hearing that I was a doctor, without checking my credentials, she handed me a sterile suturing kit.  With the help of a local anesthetic I deftly applied two sutures.  I was pleased with my handy work but much more so when Danny said, “Gee, Dad, you’re a great doctor.”

When A Doctor Tries To Be Robin Hood

It was not one of my better days when Don came to see me.  I had agreed to his request to see him after office hours when no one else would be present.  He sat heavily into a chair opposite my desk.  Saying nothing, within seconds his eyes watered.  I had absolutely no idea what was to follow.  As fellow internists Don and I had been friends for over ten years, frequently substituting for one another on weekends and extended vacations.  He was devoted to his patients and they, to him.  Though generally passive, he could be counted on to support any hospital policy innovation that would improve patient care. 

I waited for him to begin the conversation.  “Dave, you know I’m a good family man.”

“Oh, my,” I thought.  “He’s having an affair.”  I really didn’t think of Don as having much libido.

“And I go to church every Sunday.”

Again to myself, “that could mean all kinds of sins.”

“I’m in trouble, big trouble.”

Now I knew the answer.  Though I wasn’t his doctor, he had mentioned his being a diabetic.  This plus the fact that he was a heavy smoker and a sedentary chubby added up to coronary heart disease.  Surely he was going to tell me that he had developed angina pectoris, chest pain typical of that diagnosis.

Was I wrong!  “You know I’m a political conservative.”  How well I knew that!  A year after I started my practice in Aliquippa, Marcia and I invited Don and his wife to our home to watch the Democratic Convention on television.  Adlai Stevenson to our delight was to be nominated.  Don thought him to be a liberal “egghead.”  Within minutes we politely, though reluctantly, shut off the TV.  “And you would be right to think that I agreed with our medical society which opposed doctors being involved with Medicare.  Once we had little choice but to go along with their fee schedules, I knuckled under.  But it annoyed me that there was a significant deductible fee that patients had to pay out of their own pockets.”

“Don, I’m at a loss to know what’s upsetting you.”

And then came the confession.  “I got caught trying to beat the system.  I’m being accused of committing fraud.”

I was still in the dark.  “Well, did you commit fraud?”

“Yes and No.  When I did an electrocardiogram, I billed Medicare for two examinations which compensated me enough that the patient didn’t have to pay me anything.”

I was irate but managed a poker face.  I had to keep remembering that Don had come to me as a friend, as a confidant.  I couldn’t turn on him.  “But, Don, even if your reasoning might be politically understandable, in a climate where doctor after doctor is being found guilty of bilking the government for services never supplied, how could you be so naïve to think that you could get away with it?”

How well I knew the paranoia of the system. Only three months before, I had received a letter requesting (that is, requiring) chest x-ray films of ten specific patients for whom I had billed Medicare.  In addition I was asked to send for each of the ten patients the indication for the x-ray study and a copy of my written report.    Subsequently, my x-ray films were returned with a note thanking me for my participation.  Not all doctors were similarly praised.  A few received court summons; either they were unable to produce the requested films or chest x-rays were fraudulently produced as proven by testimony of patients who denied under oath of having x-ray studies performed.

Don had no answer for me.  Instead he anticipated the shame of having his crime sensationally disclosed in large print in the local newspaper.  “Can you imagine how the newspapers will rake me over the coals?”  A defense that he tried to help protect his patients’ finances would be ridiculed.

And then Don spewed one catastrophic scenario after another.  “Will I be put in jail?  Will there be an open court trial?  Will my kids be ashamed of me and will their classmates taunt them?  Will I go bankrupt?”  And finally, with chin touching his chest, “Maybe I should just kill myself.”  At that moment my anxiety took on a new dimension.  With Don’s permission I called his wife, Beverly, and asked her to come to my office; she had been too humiliated and terrified to accompany Don. 

“Do I have to, Dave?”  It was obvious that she was crying.

“I’m sorry, Bev.  You don’t have much choice.”  Then to Don I began proposing a plan of action.

“Is your friend, Lionel, also your lawyer?”

“Yes.”

“I suggest that I call him now and arrange an urgent meeting today.  OK?”  With resignation, Don nodded approval.  “Then I think you should set up a meeting with your tax consultant.  If he’s also your financial advisor, so much the better.  I think you have to sit with him with a sharpened pencil and see exactly what you have to worry about in case your income should drop.  And don’t hide any assets from him.”  I made both calls.

By the time all was arranged, Beverly arrived.  In contrast to Don, Bev was slender, looking even thinner as she sat in the chair, a twin to Don’s.  There was no question that their ordeal, which was just beginning, had taken its toll.  She was wearing a wrinkled housedress and no make-up; her hair hadn’t felt a comb since the court summons had arrived early that morning; normally every hair was in place.  She sobbed continuously.  “What are you feeling,” I asked?

“I wish I were dead.”  It was quickly made evident that Don would have no support from this quarter.  All I needed was a double suicide.  A vision of their two orphaned children flashed through my mind.  I needed help.

I knew that Don and Beverly were active members of their church.  Furthermore I admired their Pastor, enough so that he had been a guest at our Passover Seder the previous year.  “If you feel up to it, I would like Reverend Walters to see you now while you are waiting for your appointment with Lionel.  He could see you in the privacy of my office or his, whichever you prefer.”  The idea pleased them.

“Call Reverend Walters and we’ll do whatever he wants.”  As it turned out, Reverend Waters was free and chose to have them come immediately to his study.  For the time being I felt that I had covered the major components of the support system that Don and Beverly would need.  Surely psychiatric help would come later.

Don rose first and helped Beverly stand; there was almost no tone in her body.  Don and I embraced, but distantly.  Beverly gave me a limp hand handshake.  They shuffled to the door and departed.

Predictably, the next day a front-page headline read, “Government Accuses Local Doctor of Fraud.”  The reporter raised cogent criticisms: “Why didn’t the good doctor just absorb the loss of the deductible himself?”  (“The good doctor” is always spoken with derision.)   Or, “If he didn’t approve of Medicare, why did he participate in the first place?”  (Doctors had the option of billing patients directly and letting them collect what they could from Medicare.  The guaranteed payment, albeit partial, was too tempting to ignore.)  The writer had done his homework, choosing to link Don with the growing number of doctors convicted of lining their pockets with money by fraudulent Medicare claims.  There was no defense on Don’s behalf or any mention of his stellar medical training or professional skills.  There were no quotes from his loving patients, only comments of townspeople anxious to spew their contempt for doctors and their inflated incomes.  Don had been warned in time by his lawyer not to speak to the press. 

When I went to the hospital that morning, I inquired of the nurses if any of Don’s patients needed help from me.  They informed me that he had made rounds at 5:30 AM.  That was a good sign.  As soon as I had finished tending my hospital patients, I called Don’s office.  The secretary informed me that Don had her cancel all his appointments for the day.  I then called his home.  After at least twenty rings, I hung up. I couldn’t blame him for not answering.

I drove to his house. A television station vehicle was pulling away as I approached.  The only indication that Don was home was a car parked in his driveway with a clerical symbol on its windshield.  I knocked. After a brief delay, a child’s voice asked, “Who is it?”

“Dr. Chamovitz,” I replied. There was another pause before the door opened. Reverend Walters was the first to greet me. 

“I’m so glad to see you. Don’s not feeling very well. He wouldn’t let me call you.”

Don was sitting in an easy chair, smoking a cigarette, “to soothe my nerves. Dave,” he said apologetically.  Beverly sat next to him, her hand on his.  “I’m OK. Just a little indigestion from all the turmoil. The phone never stops ringing.”

“Then take the phone off the hook,” I said for starters. “Now tell me about the indigestion.”

“Oh, it’s nothing new. I’ve had it before. Maybe too much to drink before I went to bed. I just couldn’t get to sleep.”

“Don, please stop being your own doctor and tell me your symptoms.”

“Well, you know. I just had this vague feeling in the middle of my chest last night. A few good burps after Alka Seltzer and I felt better. It came back a couple of times but I’m feeling alright now.” I paid attention that Don did not run his fingers up and down the middle of his chest as he described his discomfort; that would have reassured me that his problem was related to his esophagus and not his heart.

“Don, I know you don’t want to be seen in public but I’m taking you to the hospital now for an electrocardiogram and blood tests.”  He followed me without protest; Reverend Walters remained with Beverly who just stared into space.

Suffice it to say that Don spent the next two weeks in the hospital recovering from a mild heart attack, doubtlessly precipitated by the stress of the impending criminal investigation.  A “No visitors” sign on the door of his private room shielded him from casual spectators wanting to gloat over the downfall of a pillar of the medical community.  I did permit members of his professional support system to visit freely but no one from the prosecutor’s office.  I was pleased that his minister didn’t interpret the heart attack as divine retribution for Don’s “indiscretion” though Don did. And he knew full well that this wouldn’t be the end of his punishment.  “Maybe since I’m recovering from my heart attack, I’ll manage with whatever else is thrown at me, God willing, not a jail sentence.” 

And survive he did. An out-of-court settlement imposed a fine of triple the amount of money Don had received illegally from Medicare and a one-year ban from Medicare payments. A few of his very loyal Medicare patients paid his fees out of their pockets; most transferred to the care of other doctors.  Fortunately, I never benefited from Don’s loss; had I done so, our relationship might have been tainted.

Although not outgoing by nature, Don thereafter avoided all social contacts. He fulfilled his medical obligations and came only to mandatory meetings. No one asked him to prepare conferences or to give a lecture, not wishing to impose upon his flagging energy level.  He did give up cigarettes and took walks late at night, timed to avoid his neighbors. He declined a psychiatric consultation. For the next five years before leaving town for good, he continued to express to me his feeling of having been abused by the community he was committed to help. “After all,” he persisted, “all I did was try to protect my patients from an abusive payment system.” 

Robin Hood to the very end.