Commentary| Volume 129, ISSUE 7, P653-654, July 2016

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Once Upon a Time in American Medicine

  • Lawrence M. Tierney Jr.
    Requests for reprints should be addressed to Lawrence M. Tierney, Jr, MD, Department of Medicine, Medical Service, VA Medical Center, 4150 Clement Street (111), San Francisco, CA 94121.
    Department of Medicine, Medical Service, VA Medical Center, San Francisco, Calif
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Published:December 21, 2015DOI:
      Late in my father's life, we occasionally traveled along the southern Connecticut coast on my visits home. These rides were memorable, despite his disability from Parkinsonism, as he reflected on 50 years of solo practice, in our New England home, helped by my saintly mother. I later learned much more about his life, through relatives, former patients, and observations. It remains a contrast to the current climate in medicine.
      Why this son of Irish immigrants chose to enter medical practice remains unknown. He attributed acceptance to a hitchhiked ride home from college and a conversation with a driver who was a faculty member at the medical school he later attended. After internship, he started practice in our home, caring for his mother dying of ovarian cancer there, in hospice fashion. His practice included minor surgery, obstetrics, pediatrics, internal medicine, and psychiatry. He joked that skill in the latter was especially important. His versatility was exemplified by one Christmas Eve during my childhood, when he delivered 4 babies, delaying the arrival of Santa Claus at the Tierney household.
      Christmas equaled compassion for my father. My mother told me of a poor family in our hometown, with a young daughter dying of osteosarcoma. He never charged fees for such patients; indeed, all clergy, as well as health providers, and families, were afforded the same courtesy. The dying child was thrilled by a Christmas tree and presents that found their way to her home, without fanfare.
      Another anecdote from prewar years concerned a child running home from school at lunchtime, who was struck by a car outside our home. My father rushed to her attention—attending to what was a ruptured bladder—and a local reporter overheard her say, “Please don't let me die.” Dad assured her he would not. Wire service publication resulted in hundreds of letters offering assistance from all around the country. This girl grew to womanhood, and again Dr. Tierney attended her, delivering her 2 babies.
      Shortly before volunteering for service in the South Pacific in World War II, my father had become one of the earlier physicians to use penicillin in America. He had a patient, an executive at a local defense plant, who was in extremis with Staphylococcal bacteremia and knee arthritis. Dad had read about a “wonder drug” confined to military use, and, hoping for a civilian exception, phoned the article's author in Boston. Thirty thousand units of penicillin were placed on an express train, and at the New Haven station, the conductor handed my father the medication, which he rushed to the hospital. Not knowing how to administer it, he chose intra-articular injection, 20,000 units; a nurse had dropped one of the 3 10,000-unit vials. The next day, the patient was afebrile, conversant, and thoroughly well, to my Dad's amazement. This perhaps resulted in his skepticism about complicated clinical studies, having seen an example of a single patient unambiguously proving a point.
      He seldom spoke of World War II. One exception concerned the occupation of Nagasaki with the US Marines shortly after war's end, and the scenes of devastation and horror he witnessed there. His corpsman had a Geiger counter, reading all it touched as highly radioactive, its significance incompletely understood then. How this affected him psychologically was uncertain to me, but it was an experience that reaffirmed the wisdom of his choice of a profession emphasizing man's humanity to man.
      Upon returning, he worked in his practice with daily house calls and nighttime office hours, but also as the town epidemiologist and medical examiner. He took and developed radiographs in our home, performed numerous after-hour minor operations, and was available around our kitchen table for consultation at off hours.
      I thought he had keen diagnostic acumen, a sixth sense as much as a substantial command of medical facts. One of my uncles suffered episodic abnormalities of mental status, which occurred only on Saturdays. Before an angiogram—the only means to image intracranial pathology—my uncle was held without breakfast. My father, visiting him in the hospital, found him disoriented, although it was mid-week. He obtained a blood glucose, which was in the 20s, leading to discovery of a resectable insulinoma. Why symptoms on Saturday? It was the only day of the week my uncle did not take lunch to his job as a contractor, and thus prolonged periods of fasting occurred only then. This was clinical reasoning writ large, long before the term entered the medical argot.
      A striking example of his astuteness resulted from more pro bono work as the physician for a newly minted local high school football team. He attended all games, his sideline presence in camel hair overcoat a familiar sight. At one, the star quarterback was injured on a play; my father walked onto the field to attend to him. The supine quarterback reported tingling in the fingers of both hands. Against coach objections, he ordered the young athlete to be immobilized and brought to the hospital, where a C6/7 fracture dislocation was found. I deeply admired the calmness under pressure a half-century before the problems associated with sports trauma became adequately emphasized in the medical news.
      In all the years I had observed him, he was excited most by the release of the polio vaccination. Having cared for many children with neurological polio during summer months, this report was the thrill of a professional lifetime. I recall sitting in the backseat of the family car, returning from a spring vacation, while my father kept changing radio stations to hear the news repeatedly, over the objections of my brother and me.
      I thus had the impression of a physician who used intuition, knowledge of families, and skill in history and physical examination, amidst a limited diagnostic repertoire. There was little health insurance; yet, if patients could not afford their care, they need not pay for it. Hospitalizations were inexpensive; payment in cash was used otherwise. Hours were punishingly long; call was nightly, vacation coverage difficult to find. Indeed, he occasionally commented that medicine was similar to the priesthood, with life being devoted completely to one's calling.
      Medical ethics was an emerging discipline then, but my father's constructs were exceptional. He declined to do ear piercing, stating that even a minor “mutilation” of tissue for strictly cosmetic purposes violated Hippocratic dictums. Abortion was illegal and dangerous but often sought. Yet, there was a trained obstetrician in our area who performed them safely, and I suspected that my father referred patients despite ethically and religiously opposing the procedure. He knew too well the consequences of back-room procedures and believed patient well-being trumped all other concerns.
      So it was that despite his own remarkable physicianly skills, he was aware that new developments, including heart surgery, dialysis, vaccinations, and the like, would lead to the betterment of patient care. The future, if more complicated sociologically, would certainly hold more. He balked at the concept of the “good old days,” recognizing them as being rapidly outdated.
      There are countless other local episodes that my family and I recalled, but medicine can travel far afield. Recently, an attending physician in one of our clinics phoned, asking me to see a patient. Ordinarily this meant an interesting clinical story or a notable physical sign. This individual was a young man from the same hometown as the Tierney family, and he had been delivered by my father. He added that my father also delivered his 4 older sisters. The senior Tierney had told the mother that if this fifth child was a boy—the family's wish—there would be no charge for the prenatal treatment and delivery. Here was another reminder of the joy that one practitioner took with medicine. It inevitably leads to thoughts of the debt I have, and I expect many similarly unsung caregivers like him abound in the modern practice of medicine.
      What might the parent think of the child? So it was in the 1980s, when he and my mother visited us, that he spent a day observing our academic activities at the San Francisco VA Hospital. He added occasional comments about experience with polio, tetanus, and typhoid. When I asked later what he thought of life as a clinician-educator, he answered: “I understand most, not all, of it; one thing quite clear, however, was that what you do … beats work.” This was an apt summary of academic life vs that of solo practice for half a century. While we are unlikely to see the likes of the senior Tierney, his legacy for today's physicians is a timeless one, a model of timeless charity and caring.