L.11.2 University of North Carolina: School of Medicine and UNC Hospitals: N.C. Memorial Hospital Oral History Project

Transcription

1 1 L.11.2 University of North Carolina: School of Medicine and UNC Hospitals: N.C. Memorial Hospital Oral History Project Interview L-0347 Dr. Arthur Axelbank 7 November 2012 Transcript - 2

2 2 Date/Location: Dr. Arthur Axelbank, Family Medicine Siten Patel, MS2 UNC SOM-Chapel Hill Wednesday, November 7 th 2012 at 12:00 pm in UNC HSL Library Okay, it s recording. So we'll start off by asking where were you born and when. I was born in New York City, , okay. Can you tell me a little bit about growing up, like who you were raised by, or did you live with your parents, a little bit about your siblings if there are any? Sure. My original home was in the Bronx in New York and I was lucky enough to have two parents, both of whom who were teachers. My father a high school teacher and my mother a preschool teacher and I'm the oldest of the three children, all boys. My two brothers both currently live in the New York area. I'm one of the only family members that ever moved away from the New York area. The only other thing I'll say offhand is that I realize now, I was able to walk to school my whole life including high school which I find is not very common nowadays and for me that was, I realize now that was something very, very special and my friends could go and we walked and had a very good social time walking to school even up through high school. Yeah, I agree with you. I got a chance to do that too. Did you? Because growing up back in India I did that too so I totally agree with you. It's a fun experience going to school and walking together. I'm glad you got to experience that, good, good. And you said you grew up most of your time in Bronx up until? All the time until I went away to college which was age 18. I went to Albany, New York, for college.

3 3 Good. And do you remember any kind of meaningful recollection while you were a child that kind of swayed you towards the healthcare profession? Not one particular incident but I remember being very interested in science and then became more interested in the science of human beings so to speak and was always interested in how things worked, especially in the body. And so that I think was probably the early and it was pretty early, probably age 8 or 9 that I started saying, oh I think I'd like to be a doctor. I'm sure my parents did not dissuade me, try to dissuade me. Yeah, and you said your parents were teachers. What subjects did they teach or what kind of teachers were they? Yeah, my father was at high school and he taught social studies, history and I guess mostly history and then he also taught English as part of his career and then later on as I grew older, he became an administrator and assistant principal. And that was a stressful for me because he was involved in disciplining the high school kids and I was one also and I felt that he was extra strict with me, that I very strongly had better not misbehave at school more than anyone else could misbehave a little bit but I felt I was much more scared of my father than I was of the teachers at school. And my mother was a preschool teacher. Only thing I'll say about her is she in the middle of her career went back to school to get a Masters which allowed her then to be an administrator and she was a director of a preschool for many years late in her career also. Wow, that's good, well that must have been quite an experience having your father as a principal. I can imagine. And I had a lab accident in high school. I had a lab accident in college too, but in high school I had an accident where we were I really was enjoying the experiment but I forgot to take some precautions. We were grinding up a liver of some animal, I guess calf liver or something, and I had a blender and I forgot to put the cover on the blender and it sprayed the room with pieces of pureed liver, very unpleasant. Wow! So I remember that. That's one thing that stuck with me, but I liked biology and I liked all science.

4 4 Yeah, well, that's definitely a good memory that will probably stick with you for a while, I agree. Anything you probably hated or just disliked? I was not very good in English and writing and I was offered a choice of learning to play the clarinet or to learn to type. And I chose the clarinet which was very much fun and I was sort of musically inclined, but I never learned to type and we didn't know back then that we'd be doing all this keyboarding now. It turned out to be a handicap. And I mentioned my father, who's now deceased, but he tried to get me to take typing. In fact, he invited me to come to night school with him to learn typing because he saw it as important and I was a teenager and I sort of gave it half effort. I never really hung in there and I regret that now. I see. And I kinda you segued into a perfect topic, I was gonna ask you about what did you like to do outside of school so you mentioned clarinet, anything like volunteer work, playing sports or anything else? I did play softball growing up and swimming, softball and swimming, but also yeah, I liked music, clarinet, but also piano and guitar. Oh, cool. So that was it nothing with too much skill but it was recreation. That's good. I mean, you're definitely, like you said, musically inclined so that's great, yeah. You said you like sciences but is there any particular person that steered you towards health care like a teacher maybe or someone that you looked up to? Not really that comes to mind. I mean I always liked my pediatrician who happened to have been a woman and she was a role model for me and I know that my parents really respected her and would often quote her at home. She would say so and so if I would say can we do this well, Dr. Watstein would say do this. And so she became sort of an icon I guess in the family. But I don't recall her being an influence on me too much.

5 5 I see. And do you have, did you have any, I guess, health care professionals in your family like grandfather, uncle, anybody at the moment. My grandfather was a pharmacist, that's all. I had a math teacher that was a very good friend to me, but it was not science or medicine. Yeah, did you go straight to college after finishing high school or did you take a break or? Straight to college. Straight to college, okay. So you said you went to college in Albany? And can you tell me again what was the name of the? Yeah, it was the State University of New York at Albany campus. I think it's called the University at Albany now. And what did you study? What was your major there? Biology. Biology. And I'm assuming at that point, you were thinking about premed? Yes, they didn't have a premed major. I considered being a music minor but in college-level music, I found it very difficult and I didn't quite make the grade so I dropped out as a minor. Any experiences in college that kind of stands out of mind that you really maybe wanna share? You mean about medicine or? Medical or in general, anything, something that just sticks out and you think it's worthwhile sharing. I mean for me I guess I was lucky enough to have a set of roommates that we stuck together for four years. There were five of us. And we lived together in the dorm and then we all got a house together and we were very close and it was very strong support for me but I was the only biology major and I think I had to work harder than they did and so we played a lot of cards in college, played Bridge and which I liked to do very much but it

6 6 became our social thing and I always had to be have the conflict between sitting there with the boys playing cards and going to study and going to lab. That's definitely a difficult decision, having fun or studying, yeah. It's an age-old question. We all struggled with it. I agree. And where did you go to medical school? Albert Einstein College of Medicine in New York City. And similar question again, did you go directly after college or did you take time off in between college and medical school? Well, I should say that I made a little roundabout route although I went right to medical school, but I started medical school in Italy. Oh, okay. University of Bologna and I was there for four years and then transferred and got my medical diploma from Albert Einstein. Oh, wow. So it was a total of actually six years but the Italian medical schools, I don't know how they are in India, but they're six years and so I took four years in Bologna but I wasn't finished so I took two more years in the U.S. I see. I think it's similar in India but you get a MBBS degree rather than an MD. You still had to do further qualifications to get a MD degree. I think MBBS, it's MBBS, what is it? I think it's I know the last one is Bachelor of Surgery and I think the first two letters stand for Bachelor of Medicine, but I am not sure. This gives you the right to be a general practitioner and then I think over there the classification is that if you go further on, you can get an MD and be a specialist. I see.

7 7 So that's how it works, but MBBS would probably be primary care doctor classification. Probably similar in Italy. It's a six-year program and you can get MD when you're finished but I didn't stay, I transferred back. I see. Can you tell me a little bit about your thought process on why you decided to go to Italy? Well, at the time, I didn't get accepted to medical school in the U.S. so I chose I was shopping around, trying to figure it out. My parents encouraged me to drop the whole idea actually and I didn't want to, and I'm happy I went to Italy. It was a life experience. I learned Italian and living in another culture as you know it has advantages and learning part of it and I think it was good for me. But it was also good for me to wind up with the American diploma so I feel I had the best of both worlds. Absolutely. That's good that you were able to come back here. I guess after you finished medical school, did you go straight into a particular training or did you have to take time off for exams and things like that? Is it kinda like what we do now, take your Board exams in medical school and then start residency right after? Pretty much. Yeah so what we did then I don't know if it's the same now, but I took the Family Practice Boards in July right after I finished residency so I had already started my job. Oh, nice. I took the job as a Board Eligible Physician and then but there was no gap. I took the job right away. Okay, I see. And just going back to choosing Albert Einstein, is there a reason why you chose that when you came back to the U.S. just because you have family in New York or? Yeah, it was local to me. Got you, good. How did you? I should say I'm sorry. They were accepting transfers. Not every medical school will accept a transfer.

8 8 I see. They accepted transfers and so that was opportunistic for me. And once again, kind of going back and forth between college and medical school, how did you prepare for medical school? Did you have to worry about the MCAT or was there? Yes, took the MCAT. Like I said for me, I was sure all along that I wanted to do it and had strength in math. I don't know if it's the same now, but emphasized Math and English pretty much and I was always a good test taker. Okay, that's good. And now we're going back to the medical school part, you are a teacher yourself now and can you compare and contrast a little bit of the education that you received yourself as opposed to what we are getting now? What do you see as the main differences or? Well, obviously the information age. I was just talking earlier today, if we're on rounds with our faculty and they said we need to get an answer, they would send the medical student to the library to look it up and we'd come back later that day done a literature search in the library. When I was a resident it would be in this library. Back in New York, it would be the library there. Now, if we ask the medical student to look something up, you just go to your iphone. Phone, so speed is different. As a medical student, my training at Einstein, there were a lot of New York's a lot of my training was in New York City hospitals. And the poverty there was overwhelming. I think having been here, there's poverty here, but there's also a mix. I felt there that part of the education was the poverty and the hospitals were poor. The hospital did not have resources and so there were times a patient didn't have a blanket and as a student, I'd run around trying to find a blanket for a patient. Wow. And so that I think affected me in terms of people's needs and how hard it is to meet all those needs and the hospitals and one in particular huge city hospital that I did a lot of my major clerkships

9 9 there were, you know, the patients were poor and the hospital was also struggling with just the regular amenities and medical students did a lot. We did stuff that nowadays that's probably done by, you know, drawing blood, taking patients to the bathroom, doing stuff with patients that probably students do not have to do now. I see. And can you just give me a timeframe of like what year did you graduate from college and what year did you graduate med school? Yeah, graduated college in I graduated medical school in '78. '78, okay. That's good. Any faculties or any teacher that stand out in medical school, similar question that I asked you about earlier, but as far as directive mentorship. There should be. Oh, yes, several, I have to sort of think through about who I want to mention. Take your time. Yeah, yeah. There was an OBGYN in medical school that I took the clerkship from that was very important to me as a teacher, but he was not the kindest teacher, he was fairly harsh and strict and expected a lot and I didn't like him at the time but I realize now that I learned a lot from him. I see. That's one. I also remember a hematologist, a woman; she helped me learn about social issues. Even though she was a specialist, she was very much into sort of talking with patients about their families and using that information to help them even though like I said, you would not always expect a hematologist to be like that and I was interested in primary care, but she affected me in that sense. But I knew at the time that I liked her influence whereas this other person, the OBGYN person, I did not like him at all but I realize now I can still remember some quotes and things that have stuck with me many years later that he taught me. That's definitely good. You can correct me on this one if I'm wrong. The understanding I was under that in those times there

10 10 weren't as many female physicians, you know, and you at least mentioned two right away, one your pediatrician and your hematology professor. So do you see that trend has changed quite a bit? Now we have a lot more female physicians, but how was your experience working in that environment? Yes, I hadn't thought of it until you mentioned it, definitely true, definitely mostly males. And my answer to that may come, well, I guess as a resident, I remember that there's more interesting job sharing or the idea of working part time would never have occurred to me back then, but as the years went by, and I think women for all the reasons women tend to be more interested in part time work, they want to do their parenting. Although there are men that are like that also but not at the same level so that's one change I think has occurred, a big change. I think it's carried through to my practice, was less true in medical school, little bit more in residency and growing even in practice now in working with women. And you're definitely helping me segue a lot of things, you brought up residency, so the next question is you did your residency at UNC here, correct? Right. What made you come down to North Carolina? Yeah, I mentioned I was one of the only people in my family to move away. I was interested in primary care. I originally wanted to do pediatrics and then I actually did an elective out on the Navajo reservation with Native Americans as a medical student and I got interested in family practice there. I saw some role models that I liked in family medicine, and when I realized I wanted to do family practice, the choices of residencies in the city were not that great. And so I knew at that point that I wanted to go away from New York. I actually looked in the northeast and I also looked in the southeast. I thought I would wind up in the northeast. I looked at some programs in Maine that I liked. But it turned out I had a friend down here so it's like that sometimes who invited me down and I came down here and I did an elective year. I did an ambulatory care selective here in medicine clinics at UNC. That would have been, I guess it was '77.

11 11 And it was like September or October and the weather was beautiful in Chapel Hill and as you know, Chapel Hill's hard to beat certain times of the year and it was right like that in October and I used to walk the campus and I said this is so beautiful here and I had a faculty member who mentored me here who was very important to me as a resident and he took on the project of trying to convince me to come to Chapel Hill. Oh, nice. And he said you're a New Yorker but I'm gonna show you how it is and took me under his wing and all and he was not totally responsible, but he was to a large extent responsible for sort of showing me. I mean, he obviously didn't make the decision for me, but showed me the beauty of North Carolina and he said overtly, he said my project's gonna be to try to talk you into getting out of New York and coming here for a residency. And he wound up doing that. Looks like he was very successful in that. So he was and I stayed, yes. That's good. Since you brought up the clerkship you had done with the Indian reservation with the Navajo community, can you tell me how that was different from your regular clerkship rotation, anything? Well, of course, culturally, I had stayed with another roommate in a little trailer in this incredibly isolated place, a rural place, and we used to walk to the clinic and the clinic was across a cow pasture, right, I mean it was very rural. It would probably resemble more of India than it would of lots of parts of the U.S. I can imagine. And it was very depressed and culturally very different from anything I had done and we would take call and come in. I had a lot of, I think, and I haven't thought about this in a while, so thank you for that I had a lot of experiences that could not have happened. For example, I rode in an ambulance to someone's home that was very far away and she was in labor and I was by myself with the ambulance driver and I wound up delivering her

12 12 baby in the ambulance as a medical student. And it was actually frightening at the time. I can imagine. And luckily it worked out well. It was no harm done. I know now, as you do, many things could have gone wrong and I mean, I wasn't at risk because I was put in that situation, but that will stand out as one of those things that would not have probably happened no matter where I was, North Carolina, New York, maybe some places in North Carolina, but they wouldn t have let the medical student do that. The fact that I was out there and the providers were so spread thin that there were not enough providers and so I was the closest thing to a provider. I had not done any OBGYN yet. And so it was impressive and so that was an example of something that could not have happened so the rural setting, walking to work between the cows, it was obviously not a New York experience. Definitely not. And then having things like that. I remember I did some suturing. We worked we would take call at night and so if there was somebody that came in I remember would have to do suturing and I was allowed to do stuff as a student, and the other thing I'll say about that experience besides the culture, I remember very clearly, I don't remember the people's names, but I remember faces and how it affected me, was the alcoholism. It was a terrible, terrible problem there and I remember seeing my first drunk driver who was raging drunk, blind drunk and was driving. And then he cracked up his car and came in and I remember interviewing him. The state trooper came and was talking to him while I was sewing him up. And he said well, how fast do you think you were going and the guy says oh, you know, probably 55. And then afterwards the trooper told me that he was going like 90 or something, he was drunk. And so I began to understand alcoholism in a way that I did not before so that was a strong learning experience for me. I can imagine. And did that kinda maybe help you make a decision going into primary care or was it your residency that kind of help make that decision?

13 13 No, I knew I wanted to do before most people know before residency what you want to do. I was set on family practice. I went in there thinking I wanted to be a pediatrician so I always liked children, I thought pediatrics was good. I have a family of teachers and I had this role model as a pediatrician. I saw myself as a pediatrician. I've always been sort of good with kids, let's say but I saw family physicians there doing a lot of stuff that I do like, obstetrics, and I like doing suturing that you could do and I saw the last thing I'll say about this and you can cut me off if I No, please no, I was just making sure everything's going well here. Yeah, no problem. No, you're fine, really, we're good there. When you take care of children and I was just talking to my students this morning, when you take care of children, most of the counseling is really to the parent. When they're older, they're adolescent, you can counsel the child, but when they're young, most of the counseling and teaching and intervention is with parents, and so I said well, I'm taking care of the child, but I'm really counseling the parent and I didn't mind that, but I began to see the family as a unit, the unit of care is really the family and if you want to intervene with a person, part of that intervention includes their family members whether it's diet or lifestyle or medication compliance or all the things we say, you know this. And so this family practice flag was waving, I began to see that. Well, I can still take care of children but really the unit of care is the family and I felt that suited me. And so that happened while I was out on the Navajo reservation, I remember. And plus the role models. I saw role models that I really liked. I said, well, I could be like one of the things you see some I could be like that person. That's very powerful. And I see a lot of the sameness in me and so I saw that and I liked the variety a lot and I saw, like I said, the unit of care, the family, not just the individual so that's how I sort of ended up in family practice. And once I saw that, my own medical school, Albert Einstein, did not have a department of family practice and so I'm swimming upstream a little bit. In fact, I had several of my faculty members advice me against it. I see, wow.

14 14 Including that pediatrician that I really admired. She said well, you're probably not gonna be happy, which was wrong. Even though she was a role model to me, and sometimes you know that the role models may not, they're not always right. That's true. And so that plus a couple of my faculty members, I did well in several clerkships and the ones, I said, well, you'd write me a letter of recommendation, say well, yeah, but you're not gonna do family practice are you? I said well, yes I am. It's a waste. You shouldn't do that. You could do better. And so that was some obstacles to get over but I did. It was a core of us at Albert Einstein that wanted to do family practice that overcame that. So anyway, without having the advisement, that was a long way of saying I decided I wanted to go away from New York and I had this friend in Chapel Hill and I spent time in Chapel Hill and so That's definitely a big contrast from what we see at Chapel Hill, I agree because it's such a strong push of going into primary care, family medicine and that and so You get a lot of exposure. Absolutely. Yeah, so maybe I wonder if it backfired. You wouldn't think it'd be too much. Sometimes you see it so close, and go I don't really like it. You're right. Just a quick question, going back to Albert Einstein, is Albert Einstein a research-based school? Is that why you think they probably weren't focused? Yes, it was strongly research based. I mean, they're a very strong internal medicine school and they have several teaching hospitals, very well thought of in New York but it was mostly research based and I believe they now have a department of family medicine. Okay, got you. But back then, they didn't, in the '70s they did not.

15 15 I see. So bringing you back to the '70s how was it like working at Memorial Hospital and doing your residencies instead of these? Well, I thought that's why I was here. Yeah, that's why It's still okay. Yeah, we're still I had to get to that point, right, some way or the other. Gotta get to that point, very nice job building up to that point. Thank you. Well, it's funny, I said it was a cultural difference out in Arizona, but it was a cultural difference for me to be here. I was the only New Yorker in my residency class. There were a couple from the Midwest and there were several from North Carolina. I don't know. Ask me more questions about it. What about it? Sure, sure, I can ask you. All right, so at that time, why did people choose to come to Memorial Hospital? What was what were the key? You mean patients or you mean residents? The residents first and then the second part is I'm gonna go to patients. Well, yeah, it had the strong reputation of obviously the highquality care. I mean I interviewed at Duke also, family practice. They had a very strong residency program and I wound up ranking UNC higher, Memorial Hospital higher, and the biggest reason I did was because I saw family practice as having a stronger position here, not getting swallowed up by the medical center which I still think is true and also there's one of the things which was very political for me was and I don't know if it's the same now, patients had the same ward team regardless if they were private pay or if they had Medicaid whereas if you go to other teaching hospitals, there's a stratification.

16 16 People who don't have money go on a teaching service and people who have either private pay or they have insurance they went on the private attending service. And UNC did not have that and that was important to me that the patients were treated the same, the care was very high-quality care but they didn't have a private service separated from an indigent service. I don't know. Do you know if it's the same now? I don't know, but I think it's probably not as much and maybe even in private setting but I don't know. I can't speak for it. I don't have the experience here to say yeah. Well, I guess it was, like I said, strongly at that time, it was, I think it may still be the same now. Although I think if you come in here and if you're Roy Williams, the basketball coach Of course. You get attention from the attendings but you know and that's sort of an exception. It's a VIP or celebrity really but other than that, I felt, and I think it's probably still the case, that services are the same if you're private pay or not and that was a political thing for me. That meant a lot to me. Yes, I've heard something but once again, this is more of a hearsay than anything else, that if you go do a residency at a public hospital or a university, academic center, you get the attending, the residents, medical students, everybody's taking care of each single patient, everybody, as opposed to if you go to a private one, sometimes you may be taking care of the patient alone while the attendings are off at night and he'll come back in the morning. You're in charge a little bit more so than anything, but these are things I've heard. I don't know if it's true or not. Yeah, you have to choose which is better, find out which is better. Exactly. I remember something as a resident. I remember that we had a decision in family practice about the difference between a community hospital and a teaching hospital, community hospital and a university hospital. And this was a university hospital. I looked at some programs that were at community hospitals where they did not have all the fellows and layers of trainees and I chose the layers of trainees because I kind of wanted the exposure. I felt

17 17 the community hospital, although I did rank some community hospitals in my match, but I felt the university hospital had more strength I would agree. In that sense, but you have more learners. You may do more. If you go to a community hospital residency in primary care, you may learn more, you may do I'm sorry, you may do more because there's no cardiac fellow who's gonna put in the central line or something like that whereas here, and if you're at a community hospital, you may be the only resident. There aren't surgery residents and OB residents and all that, so you may get to do more so you could argue that that may be better to train. That's true, yeah. So what was your daily routine like as a resident at Memorial, whatever you can remember? It would vary according to the service. That's really important. The different services had different routines and in family medicine, we would rotate through a lot of different specialties and so we often would be off-balance. We would show up at the next service and we didn't know the attendings and so that was a little bit of a disadvantage being in family practice. It would start early in the morning and we would make work rounds. We would meet our senior resident and meet the team, usually a senior resident, a couple of junior residents, interns, maybe a couple of students and we'd start early and make all the rounds and find out what happened the night before and scurry around to check on lab results or write orders before we would have attending rounds. And attending rounds was different from work rounds. The attending would be present and the attending would sort of ask questions about the cases and then give input and tell us what to do. And usually go in then and see the patient and then come out and the residents would get more assignments. We usually have a lunchtime conference which is where I learned to eat my lunch while I was doing something else. And then the afternoon we would do work with patients, whatever they needed, taking care of them or if we needed to discharge them, write the discharge summary. Most of that happened in the afternoon. And then the big thing about being a resident was trying to get out at the end of the day.

18 18 And the basic, the culture was you get out when you're work is done. And that was hard at times, especially if you hadn't slept. If you were sleep deprived and it's 4:00 or 5:00 in the afternoon, just dying to get out of there and I'll say this stronger, needing to get out of there for your own personal health, very, very important. But yet you had to finish the work and I can still feel the weariness of trying to finish that. The only time that was different, it was different in two settings. It was different if you worked in ICU. That was different because there you would really punch a time clock and get out whereas on the wards, the general wards taking care of patients. I can distinctly remember if I was slow or if I had a harder patient, I couldn't get out until later and that was hard, knowing you had to come back the next morning. I was gonna say something else about my daily routine. So work rounds, do the work, attending rounds, lunchtime conference, work in the afternoon, try to get out. Other than if you're on call, you'd be admitting patients and so you'd be in the hospital and you'd be expecting to stay and sleep over if you could get sleep or not. And we would sleep, and it's probably different now, we would sleep in a call room that was joint, call room for a couple different specialties, sometimes five or six or seven people and I remember sometimes there would be women in there also, it was different. I don't know if they allow that now. They probably don't. But we'd be in bunk beds. We didn't care. It was like male, female, who cares, just try to sleep and then people's beepers would be going off through the night. Even if it was not my own beeper, the person above me getting beeped and they would climb down to go answer the phone. We didn't have cellphones then and so it was a stress at night and then again the next day, I found tiring. Tiring, I can imagine, yeah. But the learning was very concentrated and the joy of learning was, I think there still, so maybe I gave you more than you wanted. No, no, I think you gave me a lot of good things so that's great there. That's good. I think so just to I ask you a question on your training, you worked closely with the person directly above you so whether it'd be senior resident or attending, is that correct? Yes.

19 19 And then did you do teaching as well while you were a resident to medical students? Yes, part of the culture was teaching. Everybody teaches the level below. The level below. And even to a degree, and you guys do this now, instead of teaching each other, if you have a group of six or eight people and the student is presenting, the other students try to pay attention because it's your peer. And so teaching peers yes, but especially teaching a level below you and not too far below you so that an attending teaching students is very nice but that didn't even happen as much as residents teaching a student or a senior resident teaching a junior resident, teaching an intern, intern teaching a student. I see. And I think that model still holds up to a degree. I think it's a very strong model. I still believe in it. And you get to a certain point where you realize your attendings don't know everything and I call senior residents like adolescents where they get to a point just like a teenager when you're parents all of a sudden seems dumber. When you become a senior resident and you learn which attendings have different strengths, you then sort of realize their faults and you get sometimes I think not quite disrespectful but you challenge. And I remember that I had a classmate who was very challenging to the attendings. Sometimes I would cringe when I would hear him speak, but not that they were afraid of him, but they began to not like him because he was very challenging to them and I was more I would do that to a degree but not like he did. And he was I think at times was abrasive and that was probably not good. Absolutely not. Even though he was very smart and very competent, but you know, you have to play the politics. We all know that. And you had to respect your peers and question them in a certain way.

20 20 Question them in a certain way. I think he didn't have that knack. I agree. And that kind of goes along with my next question, is there somebody you got along particularly well or didn't get along with, anything that caused friction, any story that you wanna tell me or something that happened that comes to the mind? Well, sure. I mean you talking about my fellow residents or my teachers or my attendings? Either or, whichever one you want to share. Too many stories. I'll have to screen them out. I had a couple of attendings that were fantastic role models for me here. One of them was the one who I met who was not a family practice person but a internist who remains one of my heroes, the one who recruited me when I was in the ambulatory care selective and I'll just say it was Jim Bryan who is I think still a teacher here although he's semi-retired. But he was an internist and hematologist and he remained for me a close friend and an advocate for me, someone I would go to when I made a decision to go into practice, I would ask him. But I had two family physicians who were on faculty here who were very strong role models, two or three really that I really admired that I couldn't soak up enough of their pearls of wisdom. Among residents, in family medicine, we were lucky because we rotated around the hospital and we kind of really were exposed to a lot of different people and there were several in other specialties that I was close with that I remember well. There were also several that I remember not as well, not as kindly, that were not collegial or were not fun to be with and were not good to patients in my view. So you can always learn. You can learn from negative role models also. We used to go over to Wake Hospital to do you know if the residents still go over to Wake? I do not know, but I know we get placed in different sites during our clerkships so I think that it is still one of the sites, yeah. We did a lot of time at Wake and we'd ride the bus over there. We'd have to catch the bus. It was either right in front of the health sciences library, it may have been in the front of the hospital

21 21 and we would hop on the bus in the morning and it was very it was kinda like riding a school bus. It was very sharing and stuff and we'd be over there and we would take night call and so we'd be over there all night and it was very strong bonds between residents and that was the example where the attendings were not necessarily there at all and we were there alone and you forge friendships and colleagues very strongly. I remember several of those. One guy we used to call Wild Bill so I won't mention his last name, but he was a senior resident above me, a great guy, a good teacher, but a little bit of a sarcastic attitude and so. It's good to have those experiences. Like you say, you grow from it; learn from it so that's wonderful. Can you maybe speak a little bit about other workers that you worked with, like nurses and the staff, any I guess the bonding going on there and how was the teamwork, and things like that in those days? My view of it was very strong. I guess you'd have to ask them. I've remained friends with several people who were nurses. I have a few nurses that I knew as an intern which was in the '70s who see me as patients now which is 30, 35 years later and so that represents a strong relationship. Absolutely. And it's a compliment to me of course, but it also represents a friendship with them and people that worked here that followed me when I left as a when you finish residency, I went into practice, they followed me. I have two or three that I like very much who it was a woman who was a ward secretary on pediatrics and turns out she lives in Hillsborough which is where I live and she's on a first-name basis with me because she always jokes what I was like as an intern. I looked very differently because I had long hair and a beard. And more beard, yeah. Yeah, a lot of beard and bushy, hippie looking. I bet she gives you a hard time for those days, that's lovely. She still does. And this one guy who's my friend who was an ER clerk, a receptionist in the ER and I think he might still be there

22 22 and I ran into him recently and we just had a great old time, memories. Wow, that's good. I felt that there was a team. Certainly I mentioned first-name basis, I mean, the interns and residents would be called by first name, at least I was, and I liked that. I felt this is part of a team. I was one who would not sort of wanna play that high doctor role. I remember in particular my very first rotation as an intern was in the NICU, the newborn ICU which handled the preemies and I learned a lot from the nurses there and felt that the nurses there were good or better teachers than a lot of my attendings. While the attendings were very good, they were also the the day-to-day, one-on-one teaching with nurses, to watch them with these very small babies, it's a high specialty thing and that rotation for me stands out as of course, it was the first rotation as an intern, so it sticks with you, but even so, the types of nurses that were there, it was very powerful learning. Respecting them and being a colleague with a nurse. And I guess now going a little bit to the patient direction oriented interview I guess I should say, I think Memorial Hospital used to be a racially segregated hospital back in the day. When you came, I guess that wasn't the case. It was not. But did you experience any residual? Not that I can recall. Not that I recall, no, as far as I know, it was integrated. We took care of blacks and whites. I see. And was there certain disorders or problems that stand out that were more prevalent then? I mean I know currently it is obesity and hypertension and was still the big thing then in those days? Not as much obesity. Hypertension and strokes very much. Tobacco use maybe? Yes, and people smoked in the hospital.

23 23 Oh, wow. Okay. People smoked in the hospital. And you could have someone come in and be in their room and they would wanna smoke in their room and it was not unusual. You'd have to it depends with their roommate. If their roommate didn't smoke, you would try to do that, but sometimes you couldn't do it and so they would have to either not smoke which made them irritated or smoke anyway which was very inconsiderate to the nonsmoker and let's see what else. Diseases, I think a lot of that, at least my memory is it's fairly similar. We didn't have the HIV. HIV was not heard of. Although who knows we may have been seeing it and we didn't know we were seeing it. That's true. Lots of diabetes and renal disease still. I think strokes was the biggest thing that I remember a lot of. I mentioned substance abuse, alcoholism, less other drugs. During my career, IV drug abuse became more common and with that I think came the blood borne diseases. And since you brought up HIV and AIDS and stuff, that started going up early '80s and then from that onwards when we found out more about the causes and things like that, how did that change? Were you still at Memorial Hospital at that time? I was not. I was in practice then although I was precepting and teaching residents then. In primary care, it affected our differential diagnosis so when a patient came in, it was a big part of the differential diagnosis, before it was not. And then in my career, I cared for some patients. I did primary care for HIV patients that were still seen at the HIV clinic. That didn't last. I think it was hard to do well and most HIV patients get their primary care at their HIV clinic. But about Memorial Hospital, I don't recall other things that strike me as far as the diseases that were different. I mean all the things about hospitals were patients could not have their families there. Visiting hours were very strict and it was much less common for a family to stay overnight with the patient. They would leave where now a lot of times, you have family members staying which I think is a good thing. I think so. It's a good support system.

24 24 Good support system. And it helps with the healing so I agree. Helps the healing and it helps the providers if you know how to make use of them, it can help you. I totally agree. So as you went further on as a physician, you said you got into training a little bit and as you became a more astute clinician, what did your? More experienced anyway, whether it was astute or not How did your responsibilities change would you say? Did you see yourself taking on more teaching responsibilities as well or? Well, now just speak to myself personally; I've always been interested in teaching. I took medical students in my office, all years, took a physical diagnosis. They didn't have CSD then. We taught physical diagnosis in the first and second year and I took clerkship students in my office and I took fourth year ambulatory care selective students. But then I was offered the chance to become a clerkship director and so I came out of my practice 50 percent of the time and I carved out 50 percent of the time to be back in Chapel Hill. My practice is in Hillsborough, maybe you knew that. You know where that is? I know where Hillsborough is. I don't know where your practice is. Yeah, Hillsborough's close enough and so I worked 50 percent as a clerkship director here on campus. I did that for ten years. And I liked that but then I began to feel I was being pulled in too many different directions and I didn't think I was doing it justice and also I felt my practice needed me and so I did it for ten years and then I resigned from the clerkship. And so I went back to my practice full time, but then about five years ago, I came back to teach Med- Soc which I think is a good class for me. And so I do not take students in my office very much anymore. I mostly just come here once a week. I see. And when did you start your practice?

25 25 Well, I came there in '81, but I wasn't the owner. I came as an employee. I became the medical director in '84 and I bought the practice in '89. Okay, I see. So it was that first decade out of practice, I was an employed physician and then we became a private practice in the late '80s. And just to ask you a little bit about your work and life balance in those days so if I'm not intruding, you can tell me a little bit about if you got married around that time or when you had kids and how did you balance your residency and those kinds of things? Sure. Again, I wish you would just raise your hand if you want me to stop. No, but I do want us to keep track of time. I know you have to be somewhere. Okay, yeah, that's okay. I'm a little loose. I don't wanna keep you either. You have your class meeting. That's fine. They're recording it so I can watch it so not a big deal. Well, it's an issue. My current wife was my girlfriend then and she remained in New York when I first came here as a resident. I mentioned I was a rarity. I did not I was the only one who left New York. She's from Connecticut and she was in school in New York in the late '70s and so we had a long-distance relationship my whole first year as an intern which was challenging because if we could see each other on the weekends, I was sleep deprived. And so she would say can I come down for the weekend. About every third weekend, I would have a day and a half off. We didn't even have a full weekend off and so I think I would say in general, the work burden was fairly extreme as an intern, being on call every third night and then when I would see her, when Suzie would come down, she'd fly down, I'd meet her at the airport and I was exhausted. And so we would have sort of a night or two and I would sleep a lot of it away. And once I remember when she was here, I was on call and she came to bring me dinner. We both remember this night really well.

26 26 She brought me dinner, takeout food or something that I couldn't get in the hospital cafeteria, and I said well, that'd be great if you can come up at suppertime, I'll meet you for dinner. And she waited for me in the cafeteria and I never showed up because I couldn't get off the ward. Of course, we didn't have cellphones so I couldn't even call her to tell her and she it was I think about an hour and I felt horrible but I could not leave. There was a patient that was coding or whatever it was and she sort of sat there and when I finally came out later, she was sitting there forlornly with this takeout dinner. It was the saddest thing. It was very powerful for both of us, but she understood it was not my fault but yet her feelings were really hurt that she had gone and it became a teachable point for both of us that this is what it's like in medicine, but it also became like don't promise me you can meet me if you can't be there. And that was very hard for me because I meant every part of my body I meant to do that and I just could not pull away. And so we both still remember that time. But anyway, that was internship. In the second year of residency, she moved down here and enrolled in public health school at UNC and we lived in Carrboro and that was better so that we could see each other each night and then we got married shortly after that, bought a house and decided to stay. And we have two kids. They're in their twenties and ironically they both grew up in Hillsborough but they moved. One is in Boston and one is in Los Angeles. Oh, wow. They're your age. My son is 25 and my daughter is 29. And so that's always interesting that I came from a city and moved here and they lived here and they both moved to cities. Moved to the cities. My wife says they'll be back. It's the circle of life that's going by you. Balancing life is a challenge. It remains a challenge for me. I see. And if you don't mind me asking, did either of your kids end up going into a health profession?

27 27 I don't mind you're asking, strong no. Did you have any or was that decision on their own or did you have any input on that? No, I had no influence. I never encouraged it or not. They both I think respected my work. I used to bring my daughter with me to the office on weekends at times and she liked that. The patients liked to see that, but neither one of my kids wanted to do medicine although both my kids tell me that they are the expert, they're the local expert for their friends. If their friends have a problem, they go to them as an expert. Hey, they learned something from you right? Must have learned something from me, yeah. And just to talk about your activities outside of medicine now like church activities or sports that you are currently involved with? I play soccer although I'm currently injured, but I play soccer for fun. I'm not very good, but I enjoy it, enjoy it very much. And I like to run. I'm active in our local synagogue. I've been on the board of directors for years on and off and what else, I like to do environmental community activities, clean up the highway, clean up the riverbed. Got you, good. And like I said, I don't want to keep you too much, but anything you wanna share with me that I probably have not asked you about that has changed drastically in medicine in your opinion? I know we have the other issues, health reform and insurance and all that, but like maybe in patient care in general or anything? Yeah, I'm just thinking. I appreciate you guiding me, yeah. Well, I have plenty to say about either one. I mentioned the growth of the information age. I think that that's the biggest thing. Also I think what I call consumerism is bigger now. People get on the Internet for themselves and search and I have some old habits that maybe are not as suited now. For example, I typically run late in the office. I think I learned that kind of bad behavior over the years and I think people do not tolerate it as much now and I think it creates a stress for me and unfortunately, I think I learned some bad habits. Maybe some