During one evening shift in the emergency room as a second year medical student in Center City Philadelphia, a young 13-year old African American girl was brought in with an acute abdomen, hemorrhaging from the vagina with fetal tissue visible at the cervix, the opening to the uterus. It was 1973, and Roe versus Wade had just been passed by the Supreme Court with a 7-2 decision giving a woman the right to privacy under the due process clause of the 14th Amendment of the constitution. This extended the right to a woman to have an abortion until the age of fetal viability. It overturned and voided a Texas state law of criminal abortion.
For this young girl in front of me the law was too little and too late. It was never clear what the circumstances were that led her to a back alley in North Philadelphia, where some uncaring and untrained profiteer put a coat hanger inside her cervix and uterus to cause the abortion. She was left septic, hemorrhaging, with a perforated uterus and ruptured intestines. Septic shock is never a good thing to have or to watch. Her medical team, of which I was just a non-participant observer at the time, struggled for days to keep her alive. It was an eye opener for me - an emergency hysterectomy, removal of tubes and ovaries, bowel repair, IV antibiotics, days in the ICU before her senseless death at the age of 13 from septic shock. Almost everything I had studied and learned as a sociology major in four years of college was embodied in this one destitute young woman in front of me for days; poverty, illiteracy, family dysfunction, lack of contraception and access to good health care, sexual abuse, social ills, profiteering, and abortion. All of society’s terrible problems were brought to bear on this one young woman. It was a horrible thing to see and watch, and left an indelible impression on me that I carry with me to this day. It was at that moment that my thoughts about caring for women began to crystallize. Hopefully as the years went by, Roe V Wade would bring this all to an end. In my mind the Supreme Court got it right then. No Court since then has seen fit to overturn this momentous decision and hopefully none ever will. “Settled law” is the term used now, and settled it should be no matter who sits on the Supreme Court now or in the future. To overturn this law will send our country and our women back into the Dark Ages.
During my second year of training at Pennsylvania Hospital I spent three months in what was called a Family Planning Rotation, where we discussed contraceptive options with patients, performed permanent sterilization in the form of tubal ligations on those women who no longer desired fertility, and performed pregnancy terminations on women who requested the procedure. During the day we attended the Family Planning clinic, prescribed birth control, placed IUD’s, fit diaphragms, discussed permanent sterilizations and scheduled and performed tubal ligations.
We also learned the ins and outs of surgical abortion training, an integral part of our training program. Since Roe V Wade was now the law of the land, abortion training was critically important to learn how to size an early pregnant uterus, what various kinds of procedures we needed to learn and perform depending on gestational age, and how to manage and deal with potential complications. Anyone could have opted out of this training if they had objections but in our program no one did while I was there. Early abortions up to 12 weeks, the first trimester, were handled in the outpatient surgical suite under a brief general anesthetic and a procedure called a suction D and C. Second trimester abortions were done by intra amniotic prostaglandin induction of labor that required learning how to perform amniocenteses, placement of a needle and catheter into the pregnant uterus through the abdomen, instilling a medication into the uterus to cause labor and subsequent delivery of a stillborn premature fetus. For me it was all part and parcel of caring for women. There was no judgment as to circumstances that brought these patients to us. But at their request, and within the guidelines of the law, we learned the skill of providing a safe, simple service that preserved their fertility for later years when the women were ready to have children. All the women followed up with us in the Family Planning clinic. It was as it should be to guarantee women good health and reproductive care and rights. There were no advertising of services, no protests, and no mishaps and loss of fertility and life as I had experienced a few years earlier in the Hahnemann emergency department.
First trimester pregnancy terminations were already a routine part of our practice in Phoenix when I arrived. One of my partners had been medical director of Planned Parenthood during his first year in Arizona. He established a referral network for pregnancy terminations in the city. Our group was one of a number of providers for early pregnancy terminations. In those days Planned Parenthood did the counseling, the testing, and made the referrals. Over subsequent years they eventually hired physicians in house to do the procedures and stopped referrals to the community physicians, a business decision with which I disagreed. It seemed to me that money became more of a motivating factor for the organization rather than counseling which had been their charter. But so be it. That was their decision.
My partners chose long before I arrived to do only first trimester pregnancy terminations that were performed in the office under a local anesthetic and sedation early in the morning before regular office hours. This was a progressive move for me since in training all the procedures I had performed were accomplished under a general anesthetic in outpatient surgery. So I quickly had to develop in office skills at sedation and local anesthesia, and operating on and talking to patients who were awake. It was a valuable skill to have learned quickly in private practice that came to serve me well for the future, as well as lessen risk for the patient. There was no advertising for these procedures. There were no protests outside the office. Patient privacy, protection, and comfort were important to us. We gave each patient the time, counseling and comfort needed to make sure of her decision without the stress of people carrying placards and harassment. We followed up with the patient three weeks later with a routine exam, a pregnancy test to make sure it was negative, and contraceptive counseling. Many of these forever-grateful women became life long patients of the practice and we became their obstetricians over the years.
Not long after my arrival in Arizona, Senator Barry Goldwater and his wife sponsored a party at his home in Paradise Valley, Arizona to benefit Planned Parenthood. A six term US Senator and former Republican Presidential candidate against Lyndon Johnson in 1964, he was the true father of Republican conservatism and a Libertarian. He always frankly spoke his mind. Although I rarely agreed with what he said politically I admired him for his honesty and patriotism, in short supply nowadays. So I chose to go to his home. As most folks did not know and as today’s conservative and Tea Party Republican’s would vilify him for, he and his wife Peggy were strong supporters of Planned Parenthood, a woman’s Right to Choose, and keeping “the damn government out of people’s bedrooms” as the Senator so aptly put it. This was consistent with his Libertarian and personal philosophy. One reason he lost the Presidential election was because he did speak his mind and not everyone liked what they heard, but he was true to his beliefs and honest which I greatly respected. Today’s Republicans would do well to read their history books.
So three months into Arizona I found myself inside Senator Goldwater’s beautiful home on a mountaintop overlooking the city. His wife spoke and they were gracious hosts. We had free roam of his house so my wife and I poked around. We were strolling, cocktail in hand down a long hallway when the Senator appeared from inside a room. He introduced himself and asked us if we would like to see something special. He took us into his Gun Room lined with cabinets filled with rifles and guns of all sorts. He pulled out a ladder, climbed it (he wasn’t a young man then), opened a cabinet, took down a rifle from the top cabinet and put it in my hands. I was polite, non-gun supporter that I was. After all I was in his home. There wasn’t much I could do but take it. He asked me if I knew what I was holding. Other than ‘ a rifle’ there wasn’t much else I could say. He proceeded to explain to us that it was the best rifle ever made, one used by the ‘Red Chinese” as he called them, in t
he early 1900’s. And so my introduction to Arizona continued.
One of the hospital committees on which I sat was Credentials. This committee reviewed and gave hospital privileges to new staff applicants. One monthly meeting there was an application from an OB GYN doctor, well trained, an Army veteran, applying for staff privileges. His credentials were in order and there was no reason to deny him admitting privileges. The only concern for me was his letterhead on normal size stationary with his name in such large bold face print that it consumed about 2/3 of the page. I had never quite seen professional stationary like that before and it raised a red flag for me. As it turned out he performed late second and even early third trimester abortions. He was one of the only physicians in the State of Arizona who did so. He pushed the limits at all ends and wasn’t one of my favorite people on earth. He was all over the news in the subsequent months. There were always protesters in front of his office. He loved the attention. One day I saw him in the operating theater changing room, bullet vest on and holstered pistol under his arm. This was his chosen life. Years later as I followed his career, he was accused and convicted of sexual molestation of a patient and wound up in State prison. For some reason I wasn’t all that surprised. Fortunately, he was a unique person.
As to the women who sought abortion, there was truly nothing they had in common other than they had an unwanted, unplanned pregnancy. They came from all walks of life; the rich and the poor; the black and the white; the professional and the non- professional; the religious and the agnostic; the pro choice, and the Right to Lifers. Yes, it was interesting to see some folks come off the picket line for the service we provided when it affected them. Whatever stereotypes there are out there about women who seek abortion should be forgotten. Pregnancy is a momentous decision in anyone’s life, whether an unwanted or wanted pregnancy. It should not be forced on anyone for any reason whatsoever, for there are truly few things in life that are so life altering. Thus to legislate against a woman’s right to choose is society forcing a woman to do something that she may not want nor be able to afford financially or emotionally, and worse may be ill prepared to handle. Bringing a child into this world to either a set of parents, or a single parent, through coercion is no way to begin a life. It will not bode well for the unborn individual. I give the utmost respect to those women who are able to have enough foresight and courage to make this difficult decision. No one but them, in consultation with their health care provider, their families, and their significant others should be interfering with an individual’s right to make this decision. Senator Goldwater was able to see that, and so should everyone else from the conservative side of politics that think they know what is best for a woman and seek to legislate their beliefs into a part of life where legislation does not belong. The Supreme Court got it right when it said we are all entitled to the right of privacy under the constitution. For any future providers of women’s services, it should be known that this is a skill, like any other medical skill, that should continue to be taught, learned, and provided with privacy and dignity for everyone concerned.
Chapter 8 Business of Medicine
Medicine is an art. It is medical science. And it is a business.
When I first started medical school, I really hadn’t given that any thought. I just assumed I would manage to make a living somehow. One of the unique things Hahnemann did with us as freshman medical students was early on require us to spend an evening a week in a family medicine or primary care practice somewhere in Philadelphia that they had prearranged for us. We were to do nothing other than sit and observe.
I was sent into the heart of Italian South Philadelphia to the home office of a general practitioner. One could almost taste the Philly cheese steaks from across the street, and only imagine the fresh pasta with gravy followed by a cannoli cooking in the row home kitchens next to his.
(Cheese steaks – the best!)
(Good Cannoli’s)
He had a small waiting room and a large office with an even larger desk behind which he sat, with me off to the side in a chair saying nothing and observing everything. I was wide eyed. He did it all himself without a nurse. The patients were all his friends and neighbors, would sit in front of his desk, he would hug them, make small talk and chat, take their blood pressures, find out what was new in their lives, and then finally talk a little medicine with them. Sometimes, but not always, he would even examine them. When all was said and done, they would get up and give him a $20 bill. He reached into his pants pocket and pulled out a large green wad of cash. He gave them change to one degree or another. This was my introduction to the business of medicine. I decided then and there that I was never going to talk to patients about money. There had to be some better way. What it was I didn’t know, but I was going to figure it out.
As an intern and resident, I was paid a salary by the hospital. It was meager but combined with my wife’s wages we made about $30,000 per year between us by the end of my fourth year of residency. Thanks to my parents I had no debt, unlike many medical students today. Since we spent $1000 /month on our apartment, it left us enough for food, an occasional movie and cheap wine, and a few meals out. Nothing left to save. We both walked to work, easy to do in the city. When we left Philly to go to Phoenix, I had signed a three year contract with increasing salaries guaranteed as long as they liked me, the practice continued to grow, and they wanted me to continue to work. Our needs were meager, were met and afforded us enough to start a family.
One of my partners controlled the purse strings when I was an employee. I had no idea how the business of medicine worked, the process of medical insurance, managed care, payroll, or anything to do with money other than when to expect my paycheck, and how to correctly mark for the billing office whatever procedures I did so that the practice could somehow bill and collect for my services performed. As an employee it was best this way anyhow, since I had my medical practice to build and concentrate on, the family medicine residents to teach and mentor, and my oral Board examinations for certification for which to prepare. I also had a baby on the way.
After three years as an employee, I was given the option of buying shares of the medical corporation and becoming an equal share holder, which entitled me to equal salary as my other two partners minus the cost of the buy in. We did not work on a productivity basis. It was assumed we would all work equally hard, and bring in equally as much money, so we all got an equal salary. This was the “corporate culture” I bought into, and I had no problem with it. The only difference between us was I got less vacation than my partners, but over time that equalized too. I chose to go to the bank and borrow the cost of the buy in so that I could immediately make the same salary as my partners. My wife and I had never borrowed so much money before. Nor had we ever had that kind of salary. When it came time for the banker to come to have us sign the papers, it was a short time after I had rather seriously injured my back during a fall from a hammock onto a brick patio (my fault but we needn’t go there). I had been bedridden on narcotics for two weeks and I could barely walk. My wife, two small kids and I were holed up at a local hotel with a special weekend deal and a nice pool for the weekend, a nice place to recover. So the banker nicely enough came to the hotel to have us sign the papers. He knew nothing about my back. Perhaps he found it strange that I didn’t stand when he came in the room, and remained seated in the chair the whole time. I wasn’t about to let him know that I couldn’t walk, for if he did, he probably never would have given me the loan.
Over time, when I became a partner in a thriving business, I learned more and more about the business of medicine. One of my partners ran the whole business from his office, and the other had nothing to do with the business side but was more entrepreneurial. Everyone contributed in his own way. But it was an old fashioned way, though successful, of running a modern medical business, probably the same way his Dad had run his medical office years earlier in Philadelphia. No computers, checks written by hand, invoices paid by hand writ
ten checks, scheduling done with a pencil in a large schedule book, etc. Medicine in general, and Phoenix in particular, was changing drastically. The ‘Golden era’ of medicine had ended. I was only slightly privy to catching the tail of this age of medicine when I was in residency. We residents used to call some of the surgical procedures the ‘blue plate special’. Exam under anesthesia, D and C, hysterectomy, salpingo-oophorectomy (removal of tubes and ovaries), lysis of adhesions, and anything else that could be listed separately, each one of which came with a separate reimbursement. The more one could list, the more one collected. That is what brought an end to the “Golden age of Medicine”. Physicians ruined it for themselves. But that was the past. I had to learn the system going forward.
Assume the Position: Memoirs of an Obstetrician Gynecologist Page 11