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.

Was it for Love or Money?

The last eighteen years of my life in the United States were spent shepherding the development and growth of the Aliquippa Hospital cardiac care unit (CCU).  Preventing deaths of cardiac patients was an almost daily occurrence for me and my staff.  Those were heady days as one medical advance followed quickly on the heels of another, and consequently, death rate from heart attacks fell from thirty to fifteen percent.  If I wasn’t involved with each individual incident, at least those I had trained were.

 For the many hours of service to the unit, I received no financial remuneration, not a nickel; at least not until the final five years when I did receive a token stipend.  I won’t deny though that as the reputation of the CCU sprouted, so did the size of my cardiology practice and my income. 

Since Aliquippa Hospital had no interns or residents, almost nightly a CCU nurse woke me with a question about either one of my patients or that of another doctor.  Three or four nights a week a visit to the hospital was necessary, which made my living a few hundred yards down the road an advantage.  From time to time my visit would entail a time-consuming insertion of an intravenous cardiac pacemaker wire or a catheter into a pulmonary artery to aid the treatment of shock.  These visits were medically fulfilling while frequently yielding significant fees.  Many times I asked myself, “Am I getting out of bed for the money?”  And if it was for a non-paying patient, “Was this one just to ease my conscience?”  I usually answered myself; “I’m doing it for the love of my work.”  But I had to admit that the money and the adulation of the nursing staff didn’t hurt.  There was no way to pass judgment on my motivation, that is, until I got to Israel.

During the first four months of my aliyah (move to Israel), I was totally dissociated from medicine.  My time was consumed with the study of Hebrew. The memory of the previous eighteen years of frequent night visits to the hospital remained pleasurable but finally I experienced the joy of uninterrupted sleep – and obviously I wasn’t being paid for that night’s sleep.  For the ensuing four months I worked an eight-hour day as a senior hospital resident upgrading my skills in nuclear medicine. Subsequently I was appointed Director of Nuclear Medicine at Wolfson Hospital.  The department consisted of one nuclear camera, one technician named Shula, and me.  It was my task to build the department into both an active ancillary service and a teaching facility.  I encouraged the appropriate requesting of nighttime emergency scans; their performance fell to Shula and me.  In time, since I had to be present to interpret the nuclear scan, I excused Shula from helping me.  I also routinely arrived at the hospital each morning an hour and a half before Shula in order either to carry out quality control measures or to begin a time-consuming patient study, all in order that the day’s work would flow smoothly.

And now to my point.  I received a fixed salary with no extras for additional effort.  More than that, after six months passed, I received tenure; my job was guaranteed at least another five years, when I would be sixty-five.  I could have sat back and done very little, even wander into work at ten in the morning and leave at three.  Nor would I have been the first to take concurrent private jobs to earn more than my hospital salary.  Even though I didn’t need to prove myself or answer to anyone, I never took advantage of any of these perks.  And for all my extra work hours and the emergency night calls I received not an extra penny.   A few colleagues praised me.  Others called me a friar, a Yiddish word meaning, “sucker.” 

Again I ask, “In Aliquippa did I get out of bed at night for the money?”  My continued zealousness in Israel indicates, “No.”  And yet as I try to exonerate myself, I have to admit that in Israel, whatever I did, including moving here and taking emergency calls, was predicated on a strong Zionist urge to help build my new homeland.  So I’m hardly off the money-motivation hook yet.

Was I so conditioned by the capitalistic reward-for-work ethic so that even after the reward was taken out of the equation, the work habit persisted?  If so, does that mean that Israeli doctors raised in a socialistic society extend themselves less and justify it because of their poorly compensated and under-appreciated workday?  I have no statistics.  I can only assume that there is no difference between us as to character and that the answer to the last question is, “No.”  My daughter, Raina, who witnessed my medical style while growing up in America but received all her medical training in Jerusalem, validates that assumption as a tireless, underpaid Specialist in Family Medicine. 

In both my Aliquippa and Wolfson Hospital offices, I hung photographs of my esteemed Boston mentors.  Was I afraid that some evil spirit would emanate from them if I didn’t perform nobly?  And I remember two of my Beth Israel Hospital teachers who spent countless unpaid hours with me and other fellows during evening and nights.  We were the children they never had.  

In the last analysis let me be unscientific.  I shall beat my breast no more.  I conclude that I was and remain primarily motivated by the love of my profession.

The Cookie Jar

“Doctor, why are you staring at my breast?  Is something wrong?” Darlene spoke free of embarrassment or admonishment.

Her questions interrupted my concentration as I listened intently to her heart murmur.  As a fledgling doctor for the first time away from the protective network of a teaching hospital, it was difficult to quell my excitement.  I was so thrilled to be diagnosing rheumatic heart disease that I gave no thought to the person or the body that lay before me.  Let me put the event in context to allay any doubts the reader may be entertaining.

During my final year of internal medicine training in Boston, my wife and I were living on a tight budget.  Having trouble making ends meet, I responded to a request sent to all members of the Massachusetts Medical Society for volunteers to make house calls on indigent residents of Boston.  Actually “volunteer” wasn’t quite the correct word for each patient would be required to pay the sum of seven dollars.  Nominal or not, the payment would feed us for two days.  I signed up.

Actually I faced the potential new responsibility with trepidation.  From the moment of my first involvement with a patient eight years before as a second-year medical student in 1946, I had always the security of a backup of a huge cadre of teachers and more highly placed residents, and indeed, the vast support system of one medical school or another.  Now for the first time I would be out in the cold unforgiving world on my own.  I and I alone would be prescribing for a patient with no one looking over my shoulder to monitor my decisions.  It was scary.

Lo and behold on the following Saturday afternoon came a call from the dispatch center asking about my availability.  Receiving a positive reply, they gave me the address and directions to a run-down section of Back Bay, Boston.  I remember that my heart was pounding as I contemplated my mission.

Twenty minutes later I arrived at a two-story clapboard house.  Four warped steps led to the front porch.  Faded yellow paint was peeling around the door.  The doorbell made no sound so I knocked.  A six-year old girl answered and led me up one flight of stairs.  The sparse furniture was shabby.  The mother, who was obviously the patient, reclined listlessly in a cotton nightgown on a couch.  I gestured to her not to get up; she appeared grateful.  I shook her moist, flaccid hand.  She forced a near-motionless smile.

My first dilemma was where to sit.  I pulled a metal chair from the kitchen and sat opposite my patient, a comfortable and yet not unfriendly distance away and began my history taking.  Her daughter sat at a nearby table with a coloring book.

The patient, Darlene, was an attractive twenty-three-year-old, a single parent.  She worked in a laundry; her hands were red presumably from contact with strong soaps.  She had called “the service” because of a severe sore throat and fever.  Aspirin had done little for her.  Inquiring further I learned that twelve years before, she had been hospitalized for rheumatic fever.  She was unaware of any after effects and had no cardiac symptoms.  I spent another quarter of an hour compulsively documenting a complete history.  Her family had rejected her when she had become pregnant out of wedlock.

My next problem was where to examine her.  I could have done so as she sat on the couch but this was in front of a bare window.  Instead I helped her into a disheveled bedroom.  She sat on a double bed and started to take off her nightgown; I indicated that this wasn’t necessary.  I placed my medical bag next to her and started the physical examination.  The first abnormal finding was an inflamed throat with patches of pus on her tonsils, an obvious “strep” throat.  So far so good.  My training was paying off.  As I took out my stethoscope, again she started to raise her nightgown.  “Oh my!” I thought.  “This is far different from a hospital setting with a nurse in attendance or at least nearby.”   I began listening to her heart sounds.  Within a couple of minutes Darlene interrupted my routine with the question that started her story.

If I was embarrassed, this was not the explanation of my excitement for I had heard a loud heart murmur indicative of rheumatic mitral insufficiency, in lay terms, a leaking valve.  Such a great teaching case!  I wanted only to demonstrate my findings to the medical students working in the ward but, of course, this wasn’t a ward and there was no one around to teach.

I compulsively performed a fairly complete physical examination, but certainly no pelvic exam.  I couldn’t help wondering if Darlene pondered what a breast exam had to do with a sore throat or even a heart murmur.  I was relieved to return to the living room.  

“You have a strep throat,” I said.  I doubt if I weighed the impact of my medical jargon as I continued, “You have rheumatic heart disease.  We have to treat your streptococcal infection especially so to prevent the streptococci from spreading to your heart valves.  You must take penicillin pills four times a day for ten full days in order to do that.  Don’t interrupt the medicine even though you ought to be feeling normal within thirty-six hours.”  I was in high gear as though I were confidently completing the last question of a medical school exam.   I wrote out a prescription for forty penicillin tablets, which she could obtain for a minimal fee.

As I rose to leave, Darlene went to the kitchen where she took a cookie jar from a closet.  She reached in and extracted its contents, seven, crumpled dollar bills.  So many thoughts flashed through my mind.  “Was this all the money she had?”  “Could I take three?  Would that humiliate her?”  And finally, “Had I already not been amply rewarded by the validation of my years of training? Wouldn’t taking money from her tarnish our relationship”?  Never before having received a fee from a patient, I was at a loss for an answer.

I put the seven dollars in my pocket, and after an approving glance at the stick-figure drawings by the little girl, I departed.

I’ll never know if Darlene followed my instructions or whether in later years she had her valve successfully replaced or whether her daughter went on to become a famous artist.