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MEMOIRS

A Medical Odyssey
by Franklin Friedman, MD

We arrived at Ellis Island in 1947. It was Residency training after military service was a unique experience,
two years after the end of the Second especially with a wife and kids. The urology department was not
World War. It was three years after the unlike the military. Your chief was “the Boss” with life or death
destruction of our families in Hungary power over your life. Your family was secondary. Training was an
and five years after evading the Germans apprenticeship. At every level you had a resident below you and
in Vichy, France. We were sponsored by above you. In the Chief year you were in complete charge, working
a relative in Ohio to come to America, a with attendings but only if you needed the help. No time off to
small nuclear family. Life in America was spend with the kids, no time off to be at their deliveries, you had a
not easy. We spoke Hungarian and French. calling and a responsibility. And that attitude was deeply ingrained.
We moved around quite a bit. One of our I was on call when my fifth kid was born at Backus, and I had just
homes was in Colchester, Connecticut. The big city was Norwich, enough time to sneak in and out the delivery room.
my first encounter with the “Rose City.” We ended up settling in
Hartford, CT. My mother worked as an LPN at Hartford Hospital. The great change occurred in 1998 when Medicare mandated that
an attending had to be physically with you. This act fundamentally
Sixteen years after arriving at Ellis Island, in September of 1963, I produced future generations of docs who had never practiced
started my medical education at Albert Einstein Medical College in independently. In the Chief year you were totally independent. Some
the Bronx. Medical school in 1963 was a special, almost magical thrived, others folded or stayed in academics.
place. It was a combination of Parris Island and a most rigorous
university. The prevailing theme was that medicine was a calling, The transition to practice was similarly unstructured. Medicine was
not a job. And the calling entailed responsibility. a calling. Money was not the “raison d’etre”. Making a living would
happen. You either went into a group or started an independent
November 22nd 1963, John F. Kennedy was assassinated. Calls private practice. If you wanted to delay things for a year, you could
were made for cancellation of first semester exams. Answer: get an academic job, a level just above the Chief year. You did not
Medicine is a calling and responsibility. You will face adversity all know anything about the business of medicine. When looking for
your life. Suck it up. Get back to work. Final exams were not to be a job you had to beware of physicians that would employ you and
canceled. never grant you a partnership.

Medical school was tough, but you slogged through. Most people These concerns were not paranoia, but very real. The first group I
made it. What direction to take from here? You thought you had worked with in Florida, two urologists, decided that they were not
plenty of time to decide. The best students went into internal busy enough to offer me a buy-in after a year. A guy I had interned
medicine. with in Jackson Memorial Hospital in Miami, Jeff Goldblatt, told
me they needed a urologist in Norwich, CT. There were already two
Almost everybody’s future was decided by the government and the urologist in town. With four kids and one on the way, I briefly left
Vietnam War. Medicine was a calling and responsibility and you my family and moved 1500 miles to Norwich. I started a practice.
complied with the draft. No business consultant. No hospital guarantee. They could not
care less. On April Fool’s Day 1976 at 12 Case Street with the help
We were the gap generation, too old to fight the war, but too young of Jeff Goldblatt’s nurse, and one week’s help from a nurse from
a physician to avoid the war. We had to go into “the service”, no the Florida practice who flew in, I was up and running. The family
matter your personal handicap was. You could avoid war for two or moved two months later on June 1st, and our fifth kid was born in
five years depending on the lottery decision of the Berry Plan in your November. My income the first months was $26,000, mostly from
second year of medical school. Some of us were lucky. I enlisted assisting the wonderful neurosurgeon, Dr. Mario Sculco. I had no
in the Air Force as a flight surgeon, actually a general practitioner cases booked from Thanksgiving to New Year.
to pilots stationed in US. Other physicians were not so lucky, such
as the William W. Backus radiologist who served in Vietnam and
was exposed to Agent Orange and died a few years later from lung
cancer.

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MEMOIRS

These beginnings were not unique in the world of private practice. through the medical executive committee, the hospital board, and
I built a business like an small business entrepreneur, just like department chiefships in two or three-year stints.
the guy who builds a bodega, butcher shop, or a restaurant. I
moonlighted in the ER at Lawrence & Memorial two 16 hour shifts Then the fundamental changes in medicine occurred and private
a month and at Seaside Clinic for handicapped kids, two mornings practice began to die. The Medicaid population in my practice rose
a month. from 10% to 50%. Government regulations increased the cost to
practice, while reimbursements were cut.
The business of medicine was viciously competitive. You had to
visit all the doctor’s offices to curry their favor, to obtain referrals. The sale of Backus Hospital to Hartford HealthCare sped up the
Some people used golf and social events to foster business demise of private practice. Independent hospitals, fearful of
relationships. I did not have the time and did not play golf. In the financial collapse, joined mega corporations. Hartford HealthCare
beginning, you were expected to use referral docs as OR assistants and Backus Hospital expanded and controlled primary care, the
for the 20% assistant fee. There were very few tight knit groups. hospitalist service, and specialists, killing most private practices
The competition among the surgeons reflected the various ethnic in Norwich. The few docs who avoided being swallowed up were
groups in town; Wasps, French, Irish, Italian, Polish, Jewish, and in practices that had a good payer mix, or in a field of medicine
Greek. largely independent of hospitals such as ophthalmology, ENT,
or orthopedics. Some doctors were bold enough to open their
The competition did not deter the arrival and successful practices of own outpatient surgical centers to avoid financial collapse and
Asian MD Sully Ahamed, and the Texan, Tom Bell MD. integration into Hartford HealthCare.

With time and perseverance, I came to realize that patient care Today we live a world of mega corporations. The goal is a valuation
superseded other life commitments. The community embraced of 10 billion dollars, large enough to be capitated and self-insured.
me and others like me. Ethnicity was celebrated in families, but Docs running small businesses have vanished. We are now
ultimately professional and social friendships trumped any religious employed by corporations and reimbursed by RVUs.
and cultural differences.
When I arrived here from Europe in 1947, the local environment
The relationship between the hospital, the community, and the was replete with small factories whose modus operandi was the
physicians was a special one. When we arrived in 1976, the docs piece work system of manufacturing. Paying factory workers by
had to live in town to properly take call for emergencies. Living the number of widgets they produce, with bonuses that were less
in Norwich created a bond between patients and physicians, and and less attainable, as the workers were in effect burned out and
among physicians themselves. Your kids went to school here, your replaced by new workers.
kids played in the church league at St. Peter Paul. You knew the
neighborhoods, you read the local paper, and you knew the issues. Medicine is now dictated by RVUs and bonuses, incentives to bring
When you went to Stop and Shop people said hello, and your kids in more business, downstream income derived from facility fees
noticed. and lab testing and procedures. What a change! We were taught
that medicine was a calling and a responsibility, and you sucked
Then when the emergency department was developed and the it up and did the right thing, and worked hard to care for the sick.
local coverage rules were changed, docs could live in the suburbs. What you did was immeasurable, but immeasurably valuable. You
The docs never intimately learned the Norwich neighborhood. would make a reasonable living from your hands on care. Debt from
Professional relationships and friendships frayed, mirrored on a schooling and business upstart were easily paid off in 5-10 years.
national scale with the balkanization of our society.
Nowadays, docs are $250,000 in debt after medical and training,
Doctors were an integral part of the administration and board. The they worry about RVUs and the sweatshop work environment and
relationship between docs and the administration has always been the financial viability of mega hospital corporations. This structure
contentious. However, it reflected physician involvement in quality dissuades you from establishing roots in the town in which you
of care, strategic planning, and financial affairs. Most docs rotated practice. Today’s generations of employees, you are always looking

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FALL 2018 33
MEMOIRS

for your next job, the next hike in pay. Medical school has to be Finally, I think that we will inevitably transition to a single payor
more affordable so that young doctors are not paralyzed financially Canadian type health system. The emphasis will shift from
from the beginning. So that severe financial decisions do not reimbursement on the basis of volume of work and testing and
deter them from their calling and responsibilities, and establishing procedures, to a capitation type of system which will entail different
community bonds. stresses of delivering less care, for greater profit.

There are bright spots to build on. The new organizational structure The interim step now currently thrust upon us is a valued based
will be more able to meet the expanding population and their system rewarding lower costs and incurring new stresses for
medical needs. In the hospital, the hospitalist service is much more doctors. Hopefully this will allow physicians and allied healthcare
efficient in hospital care. The role of mid-levels is evolving to fill the workers to focus on their calling rather than paperwork.
void of primary care. The educational training and preparation of
PAs and APRNs should be more rigorous. Oversight by physicians is I have the good fortune of working with a scribe to help me navigate
essential. In time PAs and APRNs will be better integrated into the the trials and tribulations of EPIC, the Byzantine electronic medical
treatment team. record system. This bright young man is an enthusiastic pre-
medical college student, a native born Pakistani–American, with a
Unlike a generation ago, the work force is increasingly diverse with complex family history of his own to tell. He is the new face and
more women and minorities and foreign educated doctors. This the old face of the medical odyssey, tomorrow’s physician who feels
change is good, since it more accurately reflect our diverse Norwich a call and responsibility in the learning and practice of medicine. n
population.

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