Tyranny

“You’re fired,” not by Donald Trump, but by Dr. Kurt, a middle management medical administrator at Allina Health Care System. For 23 years, from age 51 to age 73, I was a PCP, a primary care physician extraordinaire at East Lake Street Clinic in Minneapolis. East Lake served an ever-changing inner city population. The euphemism, ‘Hennepin County Hospital South,’ gave East Lake Street Status relative to the county hospital. We were figuratively and literally one stop up from ‘the bottom.’

To work at ELS you need to be dedicated to the less privileged, less educated, less motivated, less compliant, less healthy, less skilled, more drug and alcohol addicted, more criminalized, more mentally and physically ill, more jobless, more poor, more on welfare, more diabetic, more diseased, more obese, more prone to violence, without being patronizing, without being judgmental, with an open heart and head. Otherwise you’re toast, you are going to fail and you might as well move to the suburbs!

As a student at the old Kings County Hospital in East Flatbush, Brooklyn, I already had experience with a place like ELS. How well I remembered the dingy, poorly lit 10 bed wards filled with groans of suffering patients. A famous saying around Brooklyn was “if I get shot, take me to Kings County” – and many in the neighborhood did get shot.

Next it was on to Michael Reese in Chicago’s south side, followed by Mt. Zion Hospital in the Fillmore in San Francisco during the height of the Haight and LSD. I routinely got high on second-hand marijuana smoke on daily rounds through Mt. Zion’s wards – it was all very Cheech and Chong.

After earning my medical license, my first work was found in Central MN, with its post-glacial lakes and rocky soil, its poverty, its tacky fishing resort and its tar-paper shacks.

Then my odyssey took me to Truk Islands in Micronesia, driven by my love of the sea and a romantic vision of escaping to the South Pacific ala Paul Gauguin. The Trukese didn’t consider themselves poor if they had a breadfruit and a pandanus tree, land with brackish soil to grow taro, a piece of the barrier reef to fish on and most of all, a multi island extended family to rely on.

In ELS, my patient population included African Americans, Native Americans, Somalis, white blue-collar workers, newly minted immigrants of all races, drug addicts of all races. All of these were my ‘extended family.’ I gave to them and they gave to me. I studied their varied lingo, their mannerisms and made them my own. I ‘stole’ their pearls of wisdom and made them my own. I became, over time, intimate with my patients, redefining the definition of ‘medical boundaries’ and making our relationship the meeting of souls: naked, open, always with as much humor as could be injected into often catastrophic circumstances. I became my mentor, Gabriel Kirshenbaum, the Don of Williamsburg, Brooklyn.

At age two and a half, Kirshenbaum charged head-long into my life and instantaneously inspired me to go into medicine. A huge bear of a man, gruff, alert, always moving forward and always out to make you better, to protect you even from yourself, even if he had to sacrifice himself to do it. And who, in all of Williamsburg, no matter white, black, Jewish or Christian, didn’t love the irrepressible force that was Kirshenbaum. G-ds tool, an avatar, a Kabbalah Tzadek, a Jewish Saint.

As much as I proclaimed, as a young man, that I had to make a choice between theatre and medicine, there really was only medicine. I had stage fright; I feared forgetting my lines on opening night and never recovering from the trauma. Yet theatre was always on my mind.

This why the examining room became my stage, ad-lib my style, my patients my co-thespians. With each new patient I expanded my repertoire. I kept thinking of my exam room as my medical ‘house of illusions,’ where reality played out.

“Did the cardiologists tell you how long you have to live?” I asked a patient once.

“Well, they said I was late stage and I guess that means not too long.” He had hypertrophic cardiomyopathy, a condition of an ever-enlarging heart that finally cannot pump blood – he was ‘end stage,’ having maybe 1-3 years to live. The condition was inherited: his daughter has it, his uncle died from it. The ‘cure’ is cardiac transplant, but he was being denied a transplant because he was positive for Hepatitis C. At 55, overweight, living on SS disability checks, he was depressed and had given up trying.

My job was to provide a ray of hope, not only for him, but through him to his daughter. The University of MN was less rigid in its transplant criteria. If his Hepatitis C could be cured, if he stopped smoking, he could be a transplant candidate. “I don’t know if I can do all that, go to the University and start all over,” he said to me.

“What about your daughter?” I asked.

“She won’t go to a doctor. She’s 16 and won’t listen to me, but she knows she has it.”

“If you die, she’s next.”

“I suppose so.”

“What if you somehow make it, somehow get the transplant and live?”

I met with him every month or more often. He went to the university. “They say they have transplanted other patients who got their Hepatitis C cured,” he told me.

It took time, but he gradually stopped smoking with the help of E-Cigs. The treatment of Hepatitis C was undergoing a revolution. “I really feel fortunate, the G.I. people at the University said they could pretty much guarantee they could cure my Hep C.”

Now his original doctors say they can transplant him too if he gets cured of his Hep C. “I know my daughter is watching what I’m going through. It seems to be helping her deal with it.”

The dance goes on. Will he make it to transplant and will it be successful? Hope, encouragement, that’s my role.

“Oh, I am so afraid to die.” Doris Redhorse shudderingly informed me.

“Why?” I asked, “Are you afraid to go to Hell?”

“No, no, I just don’t want to die like my older sister did. She had diabetes too, but didn’t take care of herself. I want to take care of myself, but you know I had to move out of my house and had all my medicine stolen. I didn’t even have money to buy my insulin or syringes.” Doris was 60 years old, modestly overweight, and all but homeless. Her type II diabetes had been out of control for years. Her fear of death was all but paralytic. She stopped drinking alcohol 5 or 6 years before but still smoked. She was ready to change, fear was driving her, but she has no road to travel on.

Doris and I hit it off. Through it all she still loved to laugh. “You know when we were kids we would hide my grandfather’s shoes. His memory wasn’t too good, so he would get blamed for misplacing them and then get all angry. We’d sneak ‘em back right under his chair. Boy, did that confuse him even more!”

“How about the Barking Walleye,” I said, not fully understanding the Native American reference. But just mentioning it makes Doris laugh.

“You know Jewish people believe animals are made to talk to tell G-ds truth. A carp in a barrel in a Jewish market in the Lower East Side in Manhattan told a Latino worker that the ‘End of the world was near,’ scaring the dickens out of him even though he didn’t understand English. He ran to get the Jewish owner of the shop and when the carp told him the same thing the frightened owner killed the carp!! Whose world did end?”

We both laughed.

Doris Redhorse slowly gave up cigarettes, she lost a few pounds and went faithfully to see the diabetes educator. She takes her insulin regularly, now. She sees me monthly to share jokes. Her last hemoglobin A.C. was 7.6 – down from 12. “I can’t believe it, this is the first time in years my diabetes is normal!” And her anxiety is, well, better too.

Sometimes it’s not so easy.

“Please call Dick Young at the Hennepin county coroner’s office regarding Evelyn Chace.” Evelyn was 65, has chronic arthritic pain and was on a modest dose of oxycodone, which she got when she saw me monthly. She was a model opiate-taking patient, clean urines, never a day early for her prescription refills, never asking for medication increases.

“Hello, this is Dr. Zuckerman, is Mr. Young in?”

“Yes, he is, hold on.”

“Hi, this is Dick Young, is this Dr. Zuckerman?”

“Yes it is, how can I help you?”

“Is Evelyn Chace your patient?” I don’t want to answer yes; I know what’s coming.

“Yes.”

“Ms. Chance was found dead in her apartment two days ago. There were a number of bottles of medication in her possession with your name on them.” I must be hyperventilating, because my lips and fingers are numb and I feel like fainting.

“Did she O.D.? Were there signs of trauma?”

“There were no signs of trauma but we haven’t finished the autopsy or the drug analysis yet. Was she ill with any chronic disease that could have killed her?”

“No.”

“Well, I will get back to you in 3-4 days with our results.”

“What pills were found in her apartment, any opiates?” I asked.

“Yes, a bottle of 5 mg oxycodone prescribed by you ten days ago.”

“How many are left in the bottle?”

“About 45.”

Some relief, I had written the prescription for only 90. I figured if Evelyn wanted to O.D. on oxycodone she would have taken them all.

“Thanks, Doc,” the coroner concludes.

I try not thinking about Evelyn – it doesn’t work. If she O.D.ed on oxycodone, well – I have been down this road before. Ten years ago a patient went into withdrawal when she couldn’t get “enough” dilaudid from me. She had been shooting the medication instead of taking it by mouth. I never noticed the needle tracts. The Board of Medical examiners raked me over the coals even though the patient lived, even though I monitored her and had no previous problem with opiate prescribing. It was two years of hell.

After hearing about Evelyn, I didn’t sleep the next three nights.

“Hello, is this Dr. Zuckerman?”

“Yes.”

“This is Dick Young from the coroner’s office. The autopsy on Evelyn Chase is finished.” Here it comes. Heads or tails I think to myself. My stomach anticipates the worst.

“What did you find?”

“The patient had a lethal level of Methadone in her serum. She died of a Methadone overdose.”

My prescription hadn’t killed her. I vow to never give any patients opiates again. But I will.

“I have to be on disability, I have been working for thirty years for peanuts, with no man to help me. Can’t you get me disabled?” Caroline, my 60-year-old patient asked, demanded.

“Physically you ain’t there, mentally you might make it,” I say. “I’ll take it, I know I’m crazy.”

And Caroline did make it. I referred her to psychiatry where she got certified. Caroline carried her work ethic into her disability retirement years, taking her medication compulsively, exercising, coming to her appointments. She manages her SS payments and thanks me for “making her crazy,” and for the most part she is.

My Ethiopian patient returns from a trip home with a gift for me, a carved wooden bowl inlaid with pieces of porcupine quills. I now know porcupines live in Ethiopia. Another patient proudly presents me with two lbs of canoe-harvested wild rice, another with warm pastries baked by her husband that I waste no time heating up and eating. Others send me cards, “Thank you for being our doctor all these years,” or “You saved my life,” or “I can talk to you,” or “My husband, may he rest in peace, loved coming to you,” or “You are the funniest and best doc I ever had, don’t retire, my husband and I need you!”

My health is good, my brain still facile, I can do computers, eMR, well enough I feel. I am ‘booked solid’ a month in advance. I feel at the top of my career, the most accomplished as a human being. And then suddenly it is over, I am fired, at a time when I feel the most capable of being a PCP. The corporate megalith, Allina, that has bought our doctor-run group has other criteria than patient allegiance, patient satisfaction. I am at first bewildered by the computerized score sheets that claim to quantify the quality of my care and my patients’ satisfaction (patient experience is the new title). I am told I am unprofessional (for first time in my 60 year work career) and overly negative, buck authority and “have few friends in administration.” It feels like its character assassination – why? Well, a little, but well informed bird says I communicated about a pet concern of someone in power, in a manner that was inappropriate, out of “chain of command.”

I protest, East Lake Street is not the suburbs. I write a poem extolling East Lake Street (Ode to East Lake Street Clinic) that echoes Emma LaZarus. “The new Colossus,” I reproduce “letters to the staff at Allina,” from Ken Paulus, CEO, Rod Christianson, Medical Director, and others, requesting “feedback” from the rank and file – to no avail. The request for feedback is a ruse. I come to realize the doctors in administrative roles have truly gone over to “the Dark Side.”

Dr. Kurt is no longer my colleague, I cannot deal with him as such. If he spouts intellectual dishonesties, that is what corporate talk demands and he will obey. The corporate computer generates gobbledygook reports based on inscrutable alchemist’s formulas.

Socrates’ choice, to be ostracized, or sentenced to death by the cup of Hemlock. I chose “retirement,” at least from Allina.

I am angered by being cornered into giving up my practice, my patients. “Stephen Zuckerman, they are not your patients, they belong to Allina,” I’m told. My patients rail against my being fired, vote me savior, likeable and funny – all to no avail. I hate Dr. Kurt for his cold bloodiness. His indifference to all but his concocted reality ignores my relations with my patients – yet I thank him. He has freed me from the tyranny imposed by my vision of my needy patients. I could never abandon them until I was invalided or the grave opened up to suck me in.

Since the Allina buy-out, my work days have been tainted with the angst caused by the badgering of the likes of Dr. Kurt. I bite my nails and cuticles, I eat knosh food (caramel corn, tortillas chips, dried fruit for constipation, jelly beans, roasted, unsalted cashews) incessantly and avoid lunch to lower the daily caloric count. I really don’t want this type of practice anymore!

As for the Allinas and their Dr. Kurts, I feel they are building a square wheel, which will give them a lot of bad headaches and, worse yet, screw up their “bottom line.” New schemes will be invented, the same culprits will scramble to stay in power, but that’s no longer my concern, I suppose.