Last Doctor Standing
The Quixotic Tale of a Small-Town Doc’s 40-year Battle Against the Death of American Healthcare
Once Upon A Time In Woodstock
America is full of myths. It’s rife with symbolic ideals & purist visions that have either faded quietly away or never really existed. And in contemporary America, one of those idealized visions has become more mythological than ever: the small town doctor.
He’s the guy whom everyone just called “Doc” on the TV shows. He seemed to know everybody in town and all of their problems (but was, of course, eminently trustworthy). He made house calls. And when the town’s less fortunate residents came into his office penniless, he’d care for them anyway; no one in need was ever turned away. He was also a de facto therapist when necessary, a secular clergyman for the clergy-less, the deliverer of new life, and sometimes, a last companion before death.
He said things like, “I remember when your mother was born,” and when you nodded hello as you passed him on the sidewalk, he’d pull you aside and ask you how your ailing aunt was getting along, privately providing a word of assurance or advice. When bad news had to be given, there was no one you’d rather hear it from, no one else whom you trusted to tell you the dire truth. And when some injustice sprouted in the local medical community, he could be counted on to fight against it—often leading the charge when change was needed, breaking barriers and setting higher standards.
Back when communities were still communities & medicine was still more the domain of the devoted individual than the profit-driven corporation, the small town family practitioner was a vital part of the social fabric. He was someone whom—over a lifetime of doctoring—could have a profound impact on the community & the lives of its people.
During the last 60 years, the town of Woodstock, Illinois has been lucky enough to have had a few such doctors, men who actually fit that mythical description almost perfectly. Family practitioners like the late, beloved Bernie Neuschiller & “Bud” Stahlecker—two genuine small town doctors who both helped mentor another real-life “Doc”: a Filipino immigrant who arrived in Woodstock in 1972 at the age of 31, Dr. Leo Araneta Reyes, my father.
The Trusted Foreigner
When he joined the Kishwaukee Valley Medical Group in April of 1972, my dad was McHenry County’s first & only foreign-born doctor (of the non-white variety, at least). Considering the many varied tones of brown that fill the white jackets in most medical facilities these days, that’s a little hard to imagine. But it’s true—he was the first doctor in McHenry County who had to gain the trust of his patients despite having one of those funny accents. It probably helped that in addition to having one of those funny accents, my father is also actually very funny, period.
That’s one of the first things any of his patients is likely to point out—his goofy & determinedly-unique sense of humor. But his comedic side is more than mere entertainment that helps people relax, it has aided in giving him a vital quality that so much of modern medicine seems to lack: it has helped to make him human. For most of his patients, my father has not been an authority figure doling out marching orders, he’s been a trusted, life-long advisor & caretaker—one whom you listen to because you know he has your best interests at heart, and because he’s good at what he does, very good.
He’s not only very good, but he’s also been extraordinarily committed. In fact, he’s been committed in a way that many of today’s “primary care physicians” probably couldn’t imagine. For example, for the entire 40 years that my father has been practicing medicine, my parents’ phone has had 2 lines: the home phone and my father’s office line. This means, for most of those 40 years, if you phoned his office at 3AM with an urgent (or not-so-urgent) problem, my dad—not some service or machine—would usually answer the call. And he did, lots & lots & lots & lots of times.
He’s typically calibrated the tiredness of his voice to the significance of the problem. If you were calling with an urgent matter, he was instantly awake & alert, assuring you that you were right to call. But if you were calling with a sore throat that could’ve waited until morning, he mumbled through his advice in hopes that you’d understand this could’ve waited until morning. Nonetheless, you still got your counsel, straight from the doctor, at 3AM—even if he yawned his way through it. (He’s used a similar verbal strategy when answering office calls during the dinner hour—matching his audible mastication & grumpy terseness to degree of urgency.)
If one of those middle of the night calls was particularly serious, he usually wouldn’t just foist you off on “urgent care” & the anonymous emergency room staff. He’d get out of bed and drive down to the hospital to check on you & make sure everything was being handled properly—to let you know, someone is actually paying attention to everything here, someone you trust & who actually cares. That’s probably the primary element missing from medicine today: trust. My father has spent 40 years building that trust with his patients in myriad ways, but most of those ways could probably be reduced to one simple description: being there when they needed him.
The Weight of Death & Life
In some cases, when those middle of the night calls came, there was nothing actually left to be done. But even then he would drive to the hospital, arriving at someone’s bedside so that, as they departed this place, they might feel that comfort: someone is paying attention to everything here, someone I trust & who actually cares. When I was a kid living in the house where the phone would ring in the middle of the night, I’d sometimes get out of bed after my father left—watching TV (if anything was on) in the dark family room while I waited for him to return. And when he would come back after one of those calls, I could always see it in his face. The weariness of having just seen someone off from this world.
Because he began his practice as a pediatrician (until all the kids started quickly growing up & refused to see another doctor) that someone whom he’d just said goodbye to was often a child, and I could see how that sadness weighed on him most heavily. And when a death was long anticipated, he helped people along that journey however possible. Once, with our car fully packed for a long summer road-trip, my father made one last stop before we left town—taking time to visit with & say goodbye to a long-time patient who was near the end of her battle with a brain tumor—someone whom he didn’t think would make it until we returned. He was right, and her husband later told my dad how grateful she was that he had come to say goodbye. This kind of act by him was, as you might expect, not uncommon.
I think my father has probably been present at the death of more humans than most primary care physicians today might ever expect to witness. And I think this actually matters. Because over the years, the weight of this, the meaning & fickleness of being and its ongoing impact on my father has partly inspired that extraordinary commitment. He has developed a deep understanding of how important these tasks that he undertakes actually are in the lives of his patients, and has always viewed his role through that prism.
His ever-widening, existential perspective on being had, in fact, been on prominent display for almost two decades on the wall of his waiting room: a National Geographic poster of the universe photographed by Hubble, a wide array of galaxies in a spectacular display of colorful, illuminated whirls & dots against the blackness. My father added one thing to the poster—a tiny red circle capturing a bit of the Milky Way accompanied by his handwritten text: You are here.
The Humanist
This kind of universally-framed & purist view of doctoring has not just been an ephemeral element of my father’s medical practice, it has produced a wide array of concrete results for his patients & community over these 40 years. He began implementing his humanist vision early on, founding (in 1974) & helping to manage the county’s first free Well-Child Clinic through the McHenry County Board of Health. The clinic gave—and continues to give—poor families in the community a place where their children can receive regular check-ups & school physicals for free (instead of only receiving healthcare when it’s absolutely necessary—and costly). For more than three decades, he spent half of his day off working for free at the clinic (always a rebel, he was usually off on Thursday instead of the more traditional Wednesday).
And my father’s sense of charity has not been limited to his work outside of his office. Particularly after he began his solo practice in 1981, my dad has often used an unofficial sliding scale when it’s come to fees, payment schedules & even payment methods. Working in a rural farming community, it has not been uncommon for my father to accept various forms of livestock & produce as an actual form of payment for his services. I can’t tell you how many times he came home with fresh eggs, vegetables, or various animal or fish parts that were either the bounty of such an exchange or a simple expression of gratitude for his care. (Whether or not he actually paid taxes on such forms of payment, I’m not in a position to say—I just ate the stuff.)
If you didn’t have any money or any product or service to barter, that was almost always okay too. The exception might be someone like, say, a local attorney who—thanks to a recent ugly divorce—was technically bankrupt or had his assets tied up at the moment, and thus might request some kind of deferred payment or fee relief. (Whether or not the increasingly negative impact of such lawyers’ litigation on practicing medicine influenced such decisions, again, I’m not in a position to say.) In most cases, however, these kinds of requests came from the genuinely needy, and in all of those cases my father never hounded anyone for payment. As someone who spent many summers working behind the front desk at his office, I heard over & over through the years: that’s fine, just pay whatever you can when you come in next time, don’t worry about it.
One of the benefits of a private practice like my father’s is that it’s essentially like running your own small business (albeit a specially-licensed one). You could control almost everything in the process: how much you charged for services & drugs, what services & drugs you provided, patient-billing, staffing, scheduling, office-management—virtually all aspects could be executed directly & only by you if you chose to do so. And my dad chose to handle everything—and I mean everything—himself.
A common sight in our family room, for example, was my father sitting at his big, antique roll-top desk, sorting through a drawer or two of billing files from the office. Every month he culled through all of his patients’ billing statements himself. Which might seem like a waste of an overly-controlling physician’s time, but this process had a purpose: it allowed him to judge each patient’s billing situation individually.
For those with outstanding balances, but whom he knew were doing their best to pay & were good for their word (or in dire circumstances) he didn’t send a bill—knowing it would only add more unnecessary headache to their financial stresses. And although he did eventually forward some of his most delinquent accounts to a collection agency, he never did so with his poor or needy patients. (This monthly billing process was often a family project—after sorting out which bills were to be sent out, my sisters and I would form an assembly line at the kitchen table: folding the bills, stuffing envelopes & licking stamps. I’m sure these days we’d all be prosecuted for violating HIPPA laws.)
My father also used his popularity with drug reps (combined with more family-based assembly lines) to help out his patients. He wasn’t much for the pre-paid out-of-town drug company junkets (which he never attended, not once) but he was big on snagging as many free drug samples as humanly possible. And he didn’t just give out a few free samples to patients here & there. On weekend evenings we’d sometimes form another one of those kitchen-table family assembly lines, popping all of the drugs out of their little sample packets, counting them up, then packing them into & labeling little full-prescription-containing boxes. He’d stock these in his office pharmacy beside the not-so-free prescriptions and give them to patients who could not afford to pay for necessary drugs.
(Both his flexible-billing and his home-managed pharmacy recall some aspects of Jimmy Stewart’s “It’s a Wonderful Life.” The former evokes the soft-hearted approach of the Bailey Savings & Loan, while the latter might raise concern over the possibility of pharmacist Old Man Gowan’s nearly-fatal drug-mixing mistake—but I promise, my father exercised plenty of quality control when overseeing this kind of family labor.)
And this propensity for providing free services has not been not limited to his sliding scale. There were plenty of freebies that were built into his fee (or in these cases non-fee) structure. Free blood-pressure checks. Free re-checks. Consider this in today’s world. My father has always only charged for an initial diagnosis (in non-chronic illnesses, obviously). That means that even if you came down with a nasty case of whatever and required 3 or 4 visits for follow-up treatment after the initial visit—all the re-checks were free.
And if you came in for a “mere” consultation—essentially, if you were a regular patient seeking a second-opinion or consultation on the diagnosis of another doctor—those were also provided entirely free. He’s done these things his entire career. When was the last time you walked into a doctor’s office for anything and weren’t charged (or had your insurance company pay for) something. (Or how about the last time you breathed free-of-charge in the presence of one of those lizardly lawyers—one of the few “respected” professions that is at least as focused on obfuscating the truth as it is on clarifying it.)
This reputation for big-heartedness combined with the fact that my father was among McHenry County’s first multi-lingual doctors (speaking English, Spanish & some Filipino dialects) helped make him, for a long time, the primary source of medical care for much of the county’s Hispanic community. In the early days of his practice, those kinds of minority groups were almost invisible to the community-at-large. This under-the-radar patient population was comprised mostly of not-always-documented migrant farm workers or employees at places like the local Claussen Pickle factory.
For these people my father’s office often served as a small sanctuary in a community in which they might prefer to go unnoticed. This is because he made them feel the same way he made all of his patients feel: someone is paying attention to everything here, someone I trust & who actually cares. And in the case of these outsider communities, he made them feel something else that he was uniquely-qualified to say: I understand where you’re coming from.
My father spent most his childhood in the tiny Filipino oceanside village of Ipao on the island of Samar. Although his own father’s relatively prestigious job as a ship captain & harbor pilot gave them a comfortable lifestyle compared to most of their neighbors, his was still an extremely modest upbringing. To illustrate this he sometimes reminded us that, for much of his childhood, he only had one real store-bought play-thing: a small toy tank (in addition to his ever-fluctuating collection of marbles). His humble youth has helped to give my father a genuine empathy for those with the least—a quality which may be the one I admire most in him.
The Quixotic
The other quality of my father’s that has probably most inspired me over the years has been his incessant quixotic-ness. Although—contrary to the true definition of quixotic—he has actually succeeded in taking down many an ill-intended windmill over the years. In fact, there’s not enough room here to detail here all of the various injustices that he has stubbornly (& typically quite annoyingly, for his foes) sought to correct over the course of his long side-career as Woodstock’s Physician/Agitator-in-Chief.
But there are a few epic jousting battles that need to be mentioned in order to show just exactly how agitating my father has been. And by looking at these battles against the backdrop of America’s evolving social & healthcare landscape, we can see how my father’s career has been shaped by his fight against the forces that have attempted to diminish that landscape.
By the end of his first decade in Woodstock—the early 80s, as he was beginning his solo practice—the town had begun its transformation from a truly rural community to an almost-suburb of Chicago. This meant that a lot of change was coming quickly to a place that had been very much the same for decades. This uniquely-dynamic setting helped two oddly disparate cultural tides to create a kind of perfect storm at Woodstock Memorial Hospital.
One of these cultural tides could be seen coming a mile away: a backlash against those increasingly brown-skinned-filled white coats at local medical facilities (and their cornucopia of funny accents). McHenry County was no longer the lily-white pond that my father dove into in 1972.
Weary from a long recession and feeling more disempowered in this changing social landscape, many people in these communities were also feeling that these forces of undesired & negative change were at work within their local hospitals & clinics. Healthcare was becoming more costly & de-personalized, and access to good care was becoming more difficult—particularly for the poorest or sickest. Essentially, the downward curve in American healthcare toward today’s broad disfunction had begun.
Although the large & complicated forces that were truly driving this change would take decades to become clear, people still needed somewhere to focus their frustration with the system at the time. Institutionally, insurance companies beame one of the early targets for patient venom. But individually, as misdirected as it was, this frustration was sometimes focused on simply the most visibly different element of their care: all these doctors with the dark skin & the funny accents.
Patient discomfort with their foreign doctors, however, wasn’t the real cultural problem in places like Woodstock’s Memorial Hospital. Even if they grumbled about it, patients didn’t actually have the power to affect staffing, organizational & healthcare decisions. But this cultural-clash extended beyond patients & doctors—it also existed within the hospital’s own medical & administrative personnel. In some of the staff’s eyes, this seemingly-sudden influx of outsiders was more like an invasion—another sign that the rest of the world was forcing itself into this once well-sealed dominion. To makes things worse, these invaders could be pushy. And they sometimes had their own way of doing things, viewing problems & approaching solutions—often creating a fundamental chasm of communication.
One of the factors that has helped my father to be an effective agent of change over the years is that, early on, he chose to really become an American, and not hold too tightly to his foreign roots (holding tightly to those roots was something that most of those early immigrant doctors tended to do). He didn’t remain a cultural outsider, didn’t focus his social & professional circle around fellow foreigners.
And so, even though he was defintitely one of those pushy invaders (maybe the pushiest) he didn’t suffer that chasm of communication. He understood how to work the system, push its buttons & oil its machinery. This helped to make him a fantastic coalition-builder even though he had arrived on the scene as an outsider. In fact, he had done such a good job of assimilating that his patients occasionally complained to him about all these foreigners at the hospital. When he would point out that he too, in fact, was a foreigner, they would often look surprised and remark something about how he wasn’t really a foreigner—which of course makes no sense, but it did to them.
(Another example of his personality’s impact on his appearance—and his goofy humor: sometimes when sitting behind his office desk he’d ask patients to guess how tall he was. They’d often guess somewhere between 5' 8" & 5' 10". No matter what they guessed, he’d usually say they were right. In truth, he’s 5' 4".)
So when this anti-immigrant backlash began to bubble up at Woodstock Memorial, my father was in a unique position to help smooth the institution’s transition to a more multi-cultural future. Unfortunately, there was that other half of the perfect storm—the really weird tide that helped turn a common tale of culture clashes into a made-for-TV melodrama.
Ever heard of EST? If you’re under 40, probably not. Back in the 70s & early 80s EST (which stands for Ehard Seminars Training) offered seminars & courses that supposedly trained your mind to experience being with more “satisfaction” & clarity—freeing you, for example, from past entanglements. Imagine a super-70s, New-Agey, Zen-poser, pseudo-psychological Scientology (without all of the conspiracy, wrath, enslavement, idol-worship, mind-control, science fiction, bizarro-technology, Ponzi-scheming & utter-creepiness that makes actual Scientology so awesome).
How does EST become a part of our story? Let’s just say that hospital administrators & their minions are, by design, rather influential people in those hospitals that they administrate. And let’s say that one of those hospital administrators was becoming a big EST-folk, and he started recruiting & knighting fellow EST-folk among his minions, and together they all started to build a little EST kingdom in the hospital, and then they began making proclamations from their kingdom about how everyone ought to join them & maybe they added that this was a little more than just a very good suggestion. And maybe, suddenly, staffing & organizational decisions (which ultimately define healthcare ones) are being influenced by just exactly who is & who isn’t part of the kingdom.
Now let’s say that this newly-growing kingdom happened to look a lot more like that lily-white pond that my father first dove into a decade before. Can you see where our little fairy tale is going here? Where the tale went & where it might have gone was determined in great part by my father. Deftly (& inexhaustedly) using those trust-building & coalition-creating powers that he had garnered over his first decade in the community, my father led a long, gory, but ultimately successful battle that resulted in the ouster of the entire EST-ified administration, and helped to begin a new era at the hospital in which the administration & medical staff fostered a long, productive relationship (one that my father continued to mediate & lead for years to come).
This relationship certainly produced its own myriad mini-dramas over the ensuing decades, but it nonetheless allowed the hospital to do a mostly excellent job of serving the community & its ever-diversifying populace during that time. In fact, it wouldn’t be until two decades later that the hospital would require another jolt of revolution (again spurred by my father) to help bring the institution back to the community. But we’re getting a little ahead of ourselves in the three tales my father’s quixotic quests…
The 30-Year Windmill
New Age-ism & xenophobia aren’t, of course, the primary forces that have driven American healthcare off the tracks over these last three decades. That special, dystopian place in our national story is jointly held by the pharmaceutical giants, healthcare conglomerates, voracious litigators, and the now-massive insurers-cum-healthcare-providers (there’s a hyphenated evolution that has just shoot me now written all over it).
I have worked deep inside a pharmaceutical giant, witnessed first-hand the carnage wrought by voracious litigation & suffered the misfortune (as all of us have) of being subsumed by our modern system of corporate “healthcare providers” & medical conglomerates. One thing can be definitively said about all of these entities: generally speaking, they don’t give a shit about you. In fact, generally speaking, as institutions—these entities don’t even really know you exist.
Nor do they really care if you exist. You’re simply a consumer, and given the nation’s ever-burgeoning population, there are always certain to be plenty of those. Of course, if you’ve been subsumed by one of those modern healthcare systems, they’ve got a number somewhere that corresponds to you. Your name & a bunch of data is tied to that number. And often, when that data is analyzed in such a way that your number is no longer likely to produce the most important number—a profit—then they simply declare your number no longer suitable for consuming their product.
Or they price the product so absurdly as to ensure that if—by some miracle—you actually can afford it, they’re still likely to make an excellent profit by the time everything’s said & done (or by the time you’re done, which can often come as a nice bonus for them if you’ve become too costly to treat). Or they make it look to you like their product is affordable, but really they’re just charging someone somewhere else something unnecessary or exorbitant to make up the difference. (Lucky for them, that someone else is often the government—where you can pay somebody in power, via very legal campaign contributions, to essentially authorize the trumped-up purchases, thus reducing the bullshit costs’ needs to appear legitimate).
Now think again abut my father’s dogged commitment, sliding scales & ample charity—doesn’t it make you want to send every executive at every insurer-cum-healthcare-provider straight to the back of the unemployment line, forever? This battle writ large across America between big corporations & small private medical practices was writ small between my father and the ever-growing conglomerate healthcare entities that swallowed up much of the medical community in McHenry County during the 80s & 90s.
And there’s an important lesson to be learned in my father’s quixotic & ultimately lonely quest to keep his practice independent from the yolk of corporate America. The lesson: during this dystopian transformation of American healthcare from a deeply personal interaction into a purely business-based exchange, one group above all others had the power to possibly stop, or at least reshape, this transformation—doctors. And they didn’t. (Although no one could accuse my father of not trying.)
Why didn’t doctors stop this? Greed. Laziness. A dire lack of commitment. How did this happen? Look at it this way—you can’t sell something if you don’t actually, like, have it. This is why your insurance company wasn’t always (as is common today) synonymous with your healthcare provider. The product in this case is the actual service of providing healthcare— which is what doctors like my dad “sold” to people. Back then, doctors like my dad were paid (sometimes) by insurance companies, but they weren’t typically employed by the insurance companies or entities affiliated with them (or some other conglomerate).
Thus, the insurance companies couldn’t “sell” healthcare, because they didn’t provide the actual service. And big medical institutions like hospitals couldn’t monopolize services, because they didn’t employ all those other doctors like my dad. But as the 20th century sped to a close, healthcare conglomerates & other consolidated entities (with the help of deregulation, loose corporate oversight & massive corporation consolidation) began to grow larger & more powerful. These large corporations often combined the role of insurers with the role of large medical institutions (essentially, private hospitals). This helped to turn insurers into actual providers, managers & sellers of healthcare services—and helped to give other emerging healthcare conglomerates greater reach in the marketplace. These were the HMOs & other massive “managed care” entities that grew like weeds in the 80s—systems that a patient could either explicity join or that they were connected to through their insurer.
But in the early 80s, there was still a broad web of smaller, independent healthcare providers who served a large & vital portion of a community’s medical needs. Many of these were all of the solo private practices like my father’s & Dr. Neuschiller’s, doctors who handled everything from general family practice to all specialities imaginable. As long as you didn’t need surgery, hospitalization, or some highly-specific procedure that required high-risk, large or expensive equipment, you were still most likely to see a doctor who worked at (and probably owned or co-owned) one of those independent private practices—either solo or as part of a group.
Of course, that’s no longer how healthcare typically works. Now almost everyone you see is employed by the same system & corporation that you pay your monthly premiums to or that you’ve chosen to affiliate yourself with. And if you dare to see someone outside of their “network”—it’s probably gonna cost you. And it’s probably gonna cost that out-of-network doctor, whose likely to have a hard time getting paid full price by your provider for the services that he actually provided. Of course, the faux provider will almost certainly make a profit on the transaction. Otherwise, by corporately-dictated definition, they’d just charge more or simply wouldn’t allow it.
In other words: Don’t go outside the network. This monopoly on services, access & payment options by gigantic entities that only have one goal (making bigger & bigger shitloads of profit) has been—guess what—definitely not a good thing for the American healthcare system, nor the people it purportedly “cares for.”
And this didn’t happen overnight. Even after those big insurance providers, big medical facilities & healthcare conglomerates began to merge & grow, they still couldn’t sell you all of the services that those private practices provided. In order sell that stuff too—and truly assemble their soul-crushing monopolies—they needed to do one very specific thing: gobble up as many of those private practices as possible.
These corporations needed to make all of those doctors theirs—to transform as many physicians as possible from competing small business owners into malleable, manageable, cost-efficient, revenue-generating employees. Of course, the private practices that were most vulnerable to the pressures of this new marketplace, and thus, the easiest pickings for these massive corporate entities: solo doctors—the one-time backbone of local healthcare, the tradition that nurtured those essential, community-based physicians like my father & Dr. Neuschiller.
And when my father finally, somberly closed the doors of his private solo practice in June of 2012, he also shuttered McHenry County’s final bastion of that tradition—his was the county’s last private, independent solo medical practice. He was the last doctor standing. And there is no one left to carry the stethoscope.
Most of the other solo doctors fell quickly, as did many of the private group practices. The 80s & 90s saw doctor after doctor go for the gold. Why not? The corporations were offering big checks to buy out their businesses, they’d continue to get now-regularized annual salaries, all the headaches of actually running a business would be out of their hands, they could work fewer hours, and have more security, less risk. Plus, they wouldn’t have to keep fighting with the insurance companies to get paid half the time—after selling-out, most of them were the insurance company (or they were part of a conglomerate entity that could fight their battles for them, and could do so with a lot more leverage).
For the doctor who really just wanted to be a regular 9-to-5'er—except with a fancier title, a lot more money & more people to boss around—this was the perfect gig. And apparently this had come to describe almost all doctors in America during the 80s & 90s.
McHenry County was no exception. In fact—it was a shining example of the slow, methodical, greed- & unaccountability-driven process that has desiccated private (and in particular, solo) medical practices during the last quarter century. All across the McHenry County, one-by-one almost every independent solo and many of the group practices eventually sold out. And thus, all of these previously-indepedent physicians handed over ultimate control & domain over all healthcare & service-providing decisions to their new profit-driven corporate employer.
Despite the many increasing pressures that came with remaining autonomous & independent, my father held fast against the quickly-rising tide. And he was in a unique position resist—at the height of his practice, he had the largest patient-base of any solo doctor in the county. In the end, he wasn’t really worried about losing business to these growing entities (which many doctors were) but all of this consolidation was having another detrimental affect on solo practitioners: it was driving up the cost of doing business.
In the same way that box store chains & their gargantuan leverage has driven down the box stores’ costs, but helped make it more costly for mom & pop shops in the same lines of business—these consolidated healthcare entities began to put the squeeze on private practices. My father was already working on relatively small margins and usually needed to see huge numbers of patients daily just to keep the financials on target. (During all those years, he never made a truly juicy doctor’s salary, but living in the rural Midwest then was cheap & we were always very comfortable. Nonetheless, my father has never built any kind of fortune nor embellished his lifestyle excessively—they still live, for example, in the house that they bought in 1973).
He would sometimes see (I’m not kidding) 45 patients in one day—going 9AM–6PM, taking an hour break for lunch, and seeing about 1 patient an average of every 10 minutes. Although 10 minutes might not sound like a long appointment—my father’s strong diagnostic skills, experience, long-term patient relationships (which lead to the kind of finely- & innately-tuned internal patient histories that are vital to good diagnoses) and his ceaselessly energetic approach still made him one of the best doctors in the county. (An assessment supported by his vast, devoted patient-base.)
And he needed to be, because seeing 35–45 patients a day (and doing it well—nothing hurts a private doctor’s business more than service failures, which often lead to people unnecessarily getting sicker, dying, and, of course, filing suit) this was the only way he could remain profitable—and thus, the only way to have the strength to remain independent from those corporate entities. This is primary battle that my father fought for those 30 years as a solo practitioner: the battle to keep his practice alive despite the rising tides, to keep that tradition of the small town American doctor from becoming the myth it is today.
Of course, he could’ve combatted these market forces better by raising his fees more (which he did over the years, of course, but never as much as he could have—he was always one of the most inexpensive doctors around). Or maybe he could’ve actually started charging fees for all of those things like re-checks & consultations (which he never did). But that wasn’t how he wanted to play this all out. He just didn’t think it was right. And that was the freedom that his independence gave him, a freedom he relished: the ability to always do what you think is right. Or another (maybe more red-blooded American) way to put it: you can have my private practice when you pry it from my cold, dead hands.
Leo’s Last Stand
In the end, they didn’t have to pry my father’s private practice from his dead hands (my father is still very alive) but they did pry it from his exhausted & red-ink-stained hands. The ironically (or cynically) named “Affordable Care Act” might also be called the “Unaffordable Doctoring Act.” That is, if you define actual doctoring to be what my father did, rather than the load of crap you often get in an average interaction with the healthcare system today. Yes, it’s true—in a very concrete way, “Obamacare” hammered the final nails in the coffin of my father’s private practice. All of the other nails, of course, were mostly put in place by exactly the same forces that now deride Obamacare for its inherent foolishness. But these Obamacare foes aren’t arguing for any real change in the system, they just want the same crappy system to be managed mostly by the massive corporations instead of the massive government.
The Rebublicans opposing Obamacare helped to establish the consolidated, corporately-driven system that has destroyed healthcare. And Democrats who support Obamacare are simply (& perversely) saying they want that same crappy system to now cover more people, and they’re asking the government to manange the extra costs involved—which of course the government is going to do horribly. Thus, Obamacare has merely governmentally-sanctioned & expanded the reach of our corporately-dominated, dysfunctional system. And all of those corporations now simply have a whole bunch of new guaranteed consumers, most of whom the government will find a way to pay for.
Hip-hip-hooray! It’s win-win if you’re one of those big corporations that have helped destroy healthcare! (Although—darn-it-all!—it could’ve been win-win-win for them if only the Republicans had gotten their way.) And for doctors like my father, Obamacare was a quick & succinct “See Ya!” For example, all of those extra costs that come with the now-mandated (no exceptions) electronic record-keeping (all of my dad’s files had always been recorded by hand, converting them would’ve cost a fortune) were by themselves more than enough to quickly drive my father’s margins into the red—let alone all of the other added costs & competitive disadvantages built into the “Unaffordable Doctoring Act.”
Maybe the stupidest things about this electronic record-keeping nonsense: it’s likely not even the diagnostic step forward that everyone makes it out to be. In addition to writing about my dad, I also happen to write a lot about the brain. One of the primary purposes of that writing is to help people better understand why the individual human brain is still far better at certain tasks than any system we can currently devise. One of these tasks: medical diagnosis. Genuine & long-term continuity of care (like my father has provided) helps to give a doctor’s brain possibly decades of pattern data related to specific individuals, which makes these doctors much more likely to make difficult and/or early diagnoses of critical medical problems.
In our system now—this bureaucratized, compartmentalized, overly-specialized version of “managed care”—we have essentially tried to replace these doctor’s brains with those electronic files (& crappy, diffuse multi-specialized-doctor-consulting systems) that everyone thinks makes things more efficient. People believe that by “digitizing” this information & sharing it between institutions we are somehow creating a more complete & useful picture of the patient. But these systems are not designed to see the patterns in this data in the same way that a human brain is. In other words, this kind of electronic-record-keeping & multi-doctor system can never replace my dad’s brain. Which is nominally kept in all of those written files, but whose diagnostic patterns are only truly discernible within my father’s mind.
Thus, I think we’re ultimately losing a lot of diagnostic wisdom (not to mention pure processing power) in using these new electronically-based, managed-care systems to replace a system that was built primarily on individuals who provided a wider range of general care to their patients with greater continuity for a longer number of years. Basically, we think we’re going forwards, but we’re really going backwards. Which ultimately probably isn’t the best way to “reform” healthcare.
Nonetheless, before the weight Obamacare helped to ultimately collapse my father’s private practice, he took one last & impactful stand against the de-humanizing forces of corporate medicine. It was a final, quixotic battle cry that had broad repercussions locally.
Shortly after the turn of the century, 30 years after he’d first formed his long relationship with Woodstock Memorial Hospital, my father began an open & vocal rebellion against the institution that he’d often fought for & once considered home. To make a long story as short as possible, the slow erosion of patient-focused standards of care that was becoming evident everywhere else was also happening at my father’s hospital.
By 2000, the institution was no longer the independently-standing Woodstock Memorial Hospital, but had become part of one of those conglomerate entities: Centegra Healthcare. This entity was not a true HMO (Mercy Healthcare primarily filled that massive role across most of the county) where your insurer was also your service provider. But as part of a larger conglomerate, once-Memorial/now-Centegra had begun to take on all of the hallmark behaviors of such an organization—primarily, and most detrimentally, a de-humanization & over-bureaucratization of services.
After a long string of such de-humanizing, health-threatening (and merely incompetence-filled) experiences by his patients (& by himself) at Centegra, my father decided that he’d had enough. And he knew that he needed to do something dramatic in order to make his point, to spur real change one last time. Thus, on a cold, snowy February morning in 2001, my dad set-up a card table on a spot of public land right beside the driveway entering Centegra Hospital, and he held up a sign that said “IF IT CAN HAPPEN TO ME, IT CAN HAPPEN TO YOU!”
(The sign had actually been printed-up the night before by a patient—a local copy-shop owner—who saw my dad working on a hand-made version in his office. After asking my dad what he was doing, the patient replied, “I’ll make your sign for you, Doc.”)
The card table was stacked with self-copied color pamphlets that detailed recent incidents of incompetence & indifference that my father’s patients & he had encountered. The point of his sign was simple & direct: if this place treats me & lots of my patients like a jerk, then it’s pretty likely that they’re gonna treat you like a jerk too—and we don’t have to take it.
But my father wasn’t interested in merely symbolic acts, he was interested in acts that could change things. And so he’d carefully calculated his protest: prior to that day, he’d contacted local media sources that had grown to trust him. He knew that the sight of a well-respected, 60-year-old physician (a long-time community stalwart) sitting in the February cold by himself for 8 hours (on his day off) handing out pamphlets protesting his own hospital was going to make a great story. It did. Everyone picked up on it—for weeks his campaign for reform at the hospital was all over the local papers. The crazy doctor had lit his bonfire of change.
He used the momentum & the public-support generated by his protest (& the ensuing publicity) to help build another one of those fierce, diverse coalitions that he’d brought together so many times in the past. And once again, after a long, exhausting, gory battle, my father & his rebellious soldiers of change ended up victorious—ultimately ousting another administration, and sparking a broad, comprehensive reform of the way that the hospital engaged patients (and in the way that it evaluated the quality & nature of those engagements).
One more time, my father had helped to bring his hospital back to the community. And on this occasion he had really played the part: as that short, shivering, Filipino senior-citizen sat out there alone in the cold on that February day, you could almost picture his horse beneath him & his lance in hand—charging full speed at that monolithic windmill.
Doc Hollywood
Despite all of his crusades & his non-stop work ethic, my father has always seemed to be doing one thing above all else while practicing medicine: enjoying it. As far as I have ever been able to observe, my father has loved being a doctor (at least as much as his patients have loved him). And in particular, he has loved being a family doctor. He’s been enamored with finding ways to live up to that mythical ideal of “Doc”—and has increasingly treasured the fact that, over the last 40 years, that’s exactly who he’s become.
Even when he was in the midst of one of those fierce battles with his corporate or medical foes, he has clearly enjoyed his role as an underdog & agitator—as someone who’s been trying to stand-up for the patients or the hospital’s less-appreciated, but vital, employees. (In fact, these are certainly among the times that he’s relished most.)
In terms of priceless, unforgettable, inspiring & truly-sobering moments, my father’s career as a family practitioner has given him an unimaginable wealth of experiences. This is what he has been working for—not the profits from being a doctor, but the experiences from being a doctor, and the deep satisfaction from knowing he’s truly played that role in the way he believes it should be played.
In other words, no matter the struggles, my father has cherished what he’s done every day. And over the course of his long career, some of the days he’s undoubtedly cherished most were those spent playing a unique, one-time role: Doc Hollywood. My father never actually took his practice to Hollywood, but in the late winter & spring of 1992, Hollywood came to him. More accurately, it came to the streets of Woodstock.
Thanks primarily to the late director John Hughes, in the 1980s my hometown of Woodstock (and in particular, its historic, cobblestone, downtown Square) became the setting for a handful of scenes in some popular films. These cameo appearances, however, were nothing compared to the stardom that would befall downtown Woodstock in 1992. It’s probably safe to say those months contained the most electric days that Woodstock has seen in the last half-century.
The town (and again, in particular, it’s historic Square) had been chosen to stand-in for Puxatawny, PA—the setting for Harold Ramis’ upcoming film, “Groundhog Day.” What thrilled-Woodstockians (Bill Murray is gonna be hanging out right here!) couldn’t know at the time was that this mysterious movie coming to town would actually become one of those rare films that seeps deep into our collective consciousness. “Groundhog Day” isn’t just a movie anymore, it’s a whole…thing—a cultural trope, a common metaphor, an existential concept.
And that’s part of what makes my dad’s involvement with the production (which we’ll get to in a moment) so kind of perfect & serendipitous. The warm, life-loving, generous, righteous, community-committed & down-to-earth human that the film ultimately shapes Bill Murray to be—that’s the human that my father has always sought to be. And although I know it’s not really true—in my heart, when I watch the end of that film, I feel like Murray is channeling some version of my dad.
How was my father able to infuse his spirit into the production of the classic film “Groundhog Day”? Well, big movie sets & productions are kind of like their own microcosmic towns, and—as we’ve been telling you ad nauseum—every small (or microcosmic) town is made better by that vital community resource: a small town doctor.
Thanks in part to those qualities & connections that made him such a good coalition-builder, my father was able to snag one of the best roles made available to the locals: set doctor. Because so much of the production was actually being done in Woodstock, most of the cast & crew took up local residence during filming. Thus, as the production’s designated physician, my father treated almost everyone in the cast & crew (& some of their families) for just about anything that came up while they were in town.
This meant that during those few months he was on set or treating a production member in his office (and in some cases, in our home) almost every day. Through these almost-daily interactions my father was able to infuse his spirit into the film simply through practicing his uniquely compassionate & human (and even back then, outdated) form of doctoring. And let me tell you, these people loved him.
For many of these non-small-towners, my father’s intensely-personal, committed (& highly-competent) care was a rare, unexpected, but much-appreciated bonus to their time away from home. Some of the cast & crew even continued to call my dad for advice & consultation years later, although most lived on one of the coasts. Just as he had in the real town where he practiced medicine, my father had made an oversized impact on this microcosmic town within his town. I wasn’t alone in this observation. Over the course of the filming, he also befriended the producers. And a few years later, while the two men were back in L.A. sharing some drinks together & remembering the movie, they spontaneously called up my dad—just to tell him again how much everyone loved having him around the set.
For my father, this all gave him an invigorating & exciting chance to play “Doc” for an entirely new (& star-studded) audience. And it gave a little boy from a small Filipino fishing village a chance to be a part of something that he likely didn’t imagine being a part of as he tramped along the beach with his bare, brown, sandy feet. He even got to have his moment on set as a celebrity among the celebrities when—near the end of the filming—some of the cast & crew surprised my dad on his 52nd birthday with a cake & some gifts (including one of his favorite mementos from his 40-year career: a framed “Happy Birthday Doc!” t-shirt signed by all of the film’s stars).
So sure, Bill Murray isn’t really channeling my dad in those final scenes of the movie, but I still feel like—in his own way—my dad helped to make that town-within-his-town a little warmer & better place, which—in its own way—helped to make that fictional small town that’s flickered across so many screens glow a little more…warmly. When I watch the movie (which I love) I like to think of my father somewhere in the wings, smiling at his good fortune—at this great experience. And although I’m obviously a little overly-prone to feeling this way, I like to think that—if I look closely—I can see a little of my father on the screen too.
Great Doctors Never Fade Away,
They Just Keep Showing People What To Do
If life itself were always like a movie, my father’s decades of defiance would’ve eventually helped to galvanize his fellow doctors countywide—then led them all to make some epic stand against the gluttonous gobbling-up of their practices (& souls). Alas, greed (& laziness) makes for good gobbling. And in America today, there always seems to be some price for which one is willing to be consumed.
Nonetheless, although this story & the thousands like it in all of the once-small, once-communities across the nation are, collectively, a genuine tragedy for American healthcare—for my father, this is really a story of triumph. In the end, in this quickly-fleeting world we can only do what we can do. And my father has— without a doubt—quite clearly done all that he has been able to do over the course of his 40 years in private medical practice. And he has done it with amazing, inspiring & life-long success—in spite of all of the unique challenges posed by the ever-evolving, growingly-hostile landscape & his stubborn commitment to his increasingly old-fashioned ideals.
And it would be wrong to interpret my father’s retirement from his private practice as a sign that he has finally given up the fight. He closed his practice because, after Obamacare became law, he simply couldn’t afford to keep it open anymore. Nonetheless, he remains as vigorous & motivated (& hyperactive) as ever.
His continuing role in Woodstock’s medical community is one that he’s actually been performing for a number of years, but which will now consume all of his professional energies. This role (Orwellianly-dubbed Utilization Managment, which he does for once-Memorial/now-Centegra) is actually an extension of the many tasks that he has performed for the hospital over the decades in myriad positions: attempting to improve the effectiveness, efficiency & quality of healthcare.
Of course, if you’re going to sell any of these concepts to one of those corporations today (concepts that might—gasp!—be considered actually patient-focused) then you’d better end your sentence with the clause: which will increase your profits. Thus, Utilization Management (UM) is ultimately a way for Centegra (which is not yet itself an insurer, although it’s still hoping to be someday) to save the money lost when insurers refuse to pay for procedures, consultations, etc. that are ultimately deemed unnecessary, inefficient, or not capable of producing useful results. (Which is very vaguely like the insurer looking out for the patient, but in a pretty weird way that’s essentially an almost accidental result of trying to improve margins & eliminate waste—which really doesn’t sound much like doctoring.)
Although the need for these kinds of efficiency reviews has always been a useful & necessary part of hospital management, its über-importance in today’s medical facilities (& the actual nature of my father’s role today in UM) gives us one last, quick lesson in what medicine has become.
Basically, what my father does is talk to the 5 or 6 doctors who might’ve consulted on (& possibly ordered procedures or tests for) one specific patient case. These doctors all likely became involved, in part, through those diffuse webs of specialization & consultation triggered by the mechanisms of today’s “managed care” systems. (Systems that are, as much as anything else, designed to use these multiple-consultations as legal cover & to mitigate litigation risks.)
In many cases, it turns out that all of these doctors were not actually needed to arrive at the result. In fact, 30 years (or 3 months) ago my father would’ve likely achieved the same result essentially all by himself—maybe making one quick call during the first appointment to confirm something with a colleague (who would make this brief phone consultation at no charge) before settling on a correct diagnosis. In addition, all subsequent follow-up treatment with my father would, of course, be free. In our modern system, all 5 or 6 of those doctors get paid, often multiple times. And every likely-unnecessary, ass-covering test or procedure—which my father probably wouldn’t have ordered—also earns (& costs) somebody something somewhere.
Part of my father’s job now is to explain the obvious diagnostic unecessariness (& possible harm) of all of this to all of those doctors, and to provide them with a more useful model for how patient care is actually supposed to work. The corporation’s goal here is reduce the waste (& financial damage) produced by this kind of inefficiency. But my father’s goal is ultimately a much more medically fundamental one: teaching doctors how to be doctors again (or scolding them into remembering).
What have doctors become? Many have become…like lawyers. At least in the way that they’re always trying to log some hours on that new account. An interesting thing about most of the doctors whom my father now reviews & manages: these are not those corporately-employed physicians, but members of private group practices. Remember, Centegra still isn’t an HMO. This means it’s essentially still just a very big (& somewhat spread-out) hospital that’s corporately connected to a number of other massive healthcare entities. Thus, they still don’t provide the entire suite of services locally that a system like, say, Kaiser Healthcare does in California.
And when Centegra needs to go outside of its own system for services, it’s essentially engaging with what’s now left of that once-broad web of private practices. (Think of the Statue of Liberty at the end of the original “Planet of the Apes.”) And these guys these days often try to latch themselves onto cases (and the resultant fees) like their ambulance-chasing legal doppelgängers.
To make things even more perverse, the way in which these doctors often sell to corporations like Centegra the need for their services is to remind (or warn) the corporation that by not engaging them, they might be opening themselves up to some kind of legal risk. In other words, their excuse for bilking the corporation is to mitigate the risk of that corporation being bilked by one of those voracious litigators. Did you hear the word patient in those sentences anywhere? I mean, seriously, Holy Shit!—is this what healthcare is now? And did Obamacare & the Supreme Court really just say, Fan-fucking-tastic! More for everyone! ??
Having been left nowhere else to apply his lifelong wealth of doctoring wisdom, my father is now essentially trying to use that wisdom to impart the most basic & ancient of medical of concepts on today’s doctors: first, do no harm. This is necessary because those lawyerly, new-breed doctors have interpreted that dictum so literally (& obtusely) as to believe that doing no use is still okay as long as you probably are doing no harm. If he succeeds, my father might make some of these fee-chasers understand that when you’re a doctor, doing no use on purpose (especially when you’re charging for it) is the really same thing as actually doing harm. (Although my real feeling is that if you need to explain this to a doctor at all, yours is probably a fairly Sisyphean task.)
~
As my father prepared to close his doors for good, he went about emptying his old office of all the tools that he once used to treat people—all of the silvery instruments whose shine had long grown dull, the boxes of tongue-depressers & gauze, the empty pill-boxes once destined to hold free meds, the well-worn stethoscopes & blood pressure cuffs, the rolls of clean paper meant to be unfurled across examining tables, even the 30-year-old examining tables themselves, everything was carried out piece-by-piece, most of it by my father himself. All of the partly mundane, partly magical objects that once stuffed every crevice of that space (a space that contained, over those years, so many significant moments in so many lives) were all waltzed quietly & unceremoniously out the door, leaving behind an echo that hadn’t been heard in three decades. (This process was, in a way, my father’s own bittersweet “retirement party”—since he stubbornly refused any attempts to throw him an actual, and well-deserved, ride-into-the-sunset gala.)
This process also meant that all of those non-medical files—primarily, those (mostly) meticulous billing ledgers that recorded decades human interactions—were unpacked from their drawers, boxed & packed into the corners of my parents’ basement. And as they made this transition to their new & final home, many were given one last glance by my mother. Although I have (shamefully) neglected to detail her role in everything here, she has been my father’s long-time silent-partner in all of this quixotic-ness & do-good-ing.
As a registered nurse (she met my father at Mt. Sinai Hospital in Chicago, where she was in nurses’ training & my father was a resident during the 1960s) over the years she often filled the role of both nurse & receptionist at the office—conveniently providing some very-cheap/sometimes-free & guaranteed-competent labor when necessary. She also strongly supported & encouraged (almost) every act of generosity by the “family business” (it was also her job to once-in-a-blue-moon help remind my father that sometimes generosity can undermine longer-term goals, like staying afloat).
As my mother stole those nostalgic glances while filing away a life-time of labor, she glimpsed reminders of my father’s years of compassion. There in the margins of each patient’s billing ledger were the evidence of the kind of data that doesn’t make it into those modern systems. These were my father’s handwritten notes, recording those things most of us would rather forget: temporarily laid-off—hold, lost job—hold, divorce—hold, in jail—hold. These were the notes that helped my father to know who was sent a bill, and who, frankly, just needed someone to give them a break, so they could catch their breath & try to get their life back together—and more times than not, that someone included my dad.
And this sort of kindness is something that most of my father’s patients have never forgotten. Because my father closed his office in the month of June, he decided to unofficially declare July 4, 2012 as his own day of “Independence” from the dogged fight to keep his private practice alive. In response to this declaration, one of his patients sent a sweet, sad message that partly read: “We congratulate you…but your ‘Independence’ means our ‘Bondage’ to doctors who really don’t know who we are or why we are the way we are. You are the sole survivor, the Dr. Welby we all knew & loved.”
If EST didn’t ring a bell, then Dr. Marcus Welby (aka, the late actor Robert Young) probably doesn’t do much for you either. All you really need to know is this: that too-good-to-be-true small town “Doc” so often mythologized by American television—Dr. Welby was the 1950s TV prototype. And in the end, evoking that myth is the best way to begin describing (or understanding) my father’s career as a doctor.
The most essential parts of that myth are elements like making people feel what my dad’s patient said above: that he really knows who they are and why they are the way they are. And when those people are most afraid & vulnerable the myth is about making them feel that other frequently-needed comfort: that someone is paying attention to everything here, someone I trust & who actually cares.
Making people feel these things is only tangentially related to making a profit. Yet it is crucial to making a great doctor. And even though our current system might involve 5 or 6 doctors (& their fees) in a single simple case, none of those doctors is likely capable of making the (often-suffering) patient feel any of those aforementioned things. And yet, we will behave as if this system works as long as it continues to produce huge profits for an ever-shrinking number of already obscenely-wealthy people. Welcome to 21st-Century America!
Although this war, for now, appears to be over—and the good guys lost—I’m still here to say that I’m ridiculously proud of what my father has done over his career. And that we should all be glad he’s done these things in the way that he has. It’s one of the reasons why I wanted to write this: because by telling his story, I’m sharing my father’s model, the fundamental principles by which he believes medicine—that ancient & vital science & art—should be practiced. Even though he looks like the end of the line for that mythical small town “Doc”—who knows? There’s still a future out there. And there has to be some group of youngsters in some future generation that might read about people like my father and think—hey man, that’s the way we should do things.
And maybe one of those future kids will someday hang a poster of the universe on the wall of their office—a place, like my father’s, that not actually an office at all, but really one of those sanctuaries where people can feel safe, and cared for, and human. And maybe, as a tiny little tribute to my father’s story, that future-kid-cum-future-Doc will circle a little bit of the Milky Way and write beside it: You are here. Reminding himself & his future patients that their time on this planet is fleeting, and what they do with it actually matters.
Which is why it actually doesn’t matter if that little future scene ever plays out at all—not in terms of measuring my father’s contribution to our fleeting time on this planet. Because everything he’s done already has mattered, to thousands & thousands of people whose lives he has made better—hundreds of whom are actually alive today because of something he did. And there are, of course, hundreds more who left this world in greater peace & comfort because of something he did.
In the end, that all seems to make my father’s career not just a model for other doctors, but a model for all of us. My father has always been the best man I’ve ever known. Which doesn’t mean he’s always been perfect, it just means that he’s actually tried to live his life as that man. Talking about & doing are two very different things, and even though he’s always loved talking, my father—like one of those Clint Eastwood gunslingers in one of those old spaghetti westerns—has never really needed to say a word.
###
To read more by R. Salvador Reyes: http://www.rsalvador.com
