Bureaucracy

Medical School: The VA Hospital

A Few More Humiliations 

One of my first rotations in general medicine was at the VA Hospital in Jamaica Plain, Massachusetts. In the 1970s the VA hospital system was more like an extended care facility or a hotel than an acute care institution. Hospital stays for a simple seizure evaluation could last for weeks or months.

The patients were required to wear green and white striped sear-sucker pajama robes, could smoke on the open wards, despite having emphysema, lung or throat cancer, while the ones who were not bed ridden would even take the elevators down to the cafeteria at mealtime.

One ridiculous scenario of note was the man who still smoked through his tracheotomy after having had his larynx removed for cigarette induced throat cancer; making him a true veteran of the cigarette wars as well as any other he may have fought.

Another one was the typical Irish drunk in alcohol withdrawal DTs, tied to the bed, with a bead sweated forehead, while swatting away at imaginary flies he had named after long lost friends.

  • Get offa me O’Donnell. Go to hell O’Doule. Go fuck yerself in the arse Father Ryan. Give us a little kiss there Mary Rose, ya trollop, ya whore

The place operated like any typical Federally subsidized bureaucratic waste project. Nothing could get done without excess paper work, repetitive requisitions, delays in responses, and the litany of more reasons not to do something that had to eventually be done anyway, than to just go ahead and do it. This was coupled with an endless shortage of even the most rudimentary medical supplies making it a good thing that no one was really that sick or they would have all been dead by the time their tests and consultations were done. 

The Resident I worked with was an exceptionally bright Indian at a time when there was considerable bias in the United States medical system against Foreign Medical Graduates (FMGs), as well as against women.

There was additional bias even against Americans who could not get into U.S. medical schools, who instead went to foreign schools; because these students never had the same credibility as those graduating from the U.S. schools.

FMGs also had to go through extra layers of testing called the Fifth Pathway, to be licensed, which were nothing more than creative barriers set up specifically to discourage these people from emigrating and working in the U.S. The paradox was that because our own schools were not graduating enough doctors to fill the needed residency programs, or because there were shortages in certain disciplines, we still needed FMGs. Usually they gravitated to non-teaching community hospitals, where they essentially functioned as warm bodies, but did not get the same level of vitally important training offered in academic hospitals.

Women were not treated any better. They were deemed as being weak, soft, unable to stand the rigors of training, too emotional and doubtful to ultimately make a career out of it because of their known susceptibility to want children and then to stay  home with their kids. Training female physicians was felt to be a waste of resources, and even after passing the initial hurdles, once entering their training programs, they would be singled out for abuse or treated like second-class citizens.

One particularly nasty physician in the Harvard system, who interviewed medical school candidates or applicants for internship, had a uniquely cruel way of sizing up the candidate.

He would turn up the heat in his office, no matter the season, then first ask the candidate to open a window he had previously nailed shut.

Any candidate who tried but failed, then either asked for a tool or told him he should get a maintenance man, would then qualify for being interviewed a second time. This poor person then of course sweated bullets throughout the ensuing inquisition while not even knowing he had already garnered a preliminary pass by his first response.

Anyone who lost his temper at failing to get the window open would not be interviewed and asked to leave, while anyone who cried, to which the women candidates were particularly prone, would be told they should leave medicine altogether and look for another career.

Anyone who immediately went to another window and opened it was accepted without further interviews.

This technique reminded me of one used by a premarital counselor who would take the affianced couple out to the woods, where she then asked them to cut down a small tree with a band saw. The way they worked together was all she needed to know to predict the long-term success of the marriage; then advise them whether or not to take their vows.

She related one improbable scenario in which the female partner sat down and demanded that the man work the two-person saw by himself. I think that was my ex-wife; being evaluated for her second marriage.

However, this Indian resident was neither soft, nor weak, nor emotional, nor lazy, nor stupid, nor poorly trained, nor any other bigoted epithet one could conger.  He was bright, industrious, a hard taskmaster who took the time to get me through some rudimentary skill sets as well as a jump start on the road to developing sound fundamental work habits.

Even writing orders was an embarrassment when on my first try he read them while scornfully deriding:

  • And so. Vill your patient starve to death? You did not even write an order for his diet. Or do you think he cannot eat and needs some IV fluids instead; and if so what vill that be?
  • Oh. You have to take care of that, too? Patients need food and water?

We were expected to arrive early and to stay late, whereas on other rotations we worked banker’s hours. We also learned in short order that there was no excuse for not knowing our patients in intimate detail and to be immediately up to date on their current test results. In addition, we also had to do a tremendous amount of scut-work, which included the likes of making, staining, and microscopically looking at blood slides as well as collecting, spinning and analyzing urine samples or other unmentionable body fluids, solids and semi-solids

It was quicker to do it on the floor than in the VA lab, often being information we needed to know on a timely basis to expedite therapies. In today’s modern hospital labs these results are accurately turned around in minutes by a technician.

One day on rounds, when I was not up to speed on some test results or a specialty consult had not been done, my Resident taught me the hard lesson that I was ultimately in charge of the case, that the patient’s life and destiny was in my hands, and that if I did not know something or if something had not been done that I only had myself to blame.

Knowing how inefficiently slow the system operated, he told me from that day on if I needed a result or if I needed a specialist that I should go to the department in question, to make such a pest of myself that anyone involved would hate the very sight of me. After that, my charts were complete and consultants saw my patients as a priority.

Still being a shy, standoffish person, I gradually came to learn that face to face or direct personal contact is the most efficient as well as the most courteous way to communicate, that it not only helped future networking, but after all was also not even the least bit painful.

This Resident also expected me to know anything and everything about the primary or secondary disease entities of all my patients.

On one occasion when I failed to answer a question about cirrhosis he told me I was “refractory to education” and should consider becoming a plumber.

  • You vill fail as a doctor. All your patients vill die. You vill be a curse on the house of medicine and a blight vhich anyvere you may go.

I wanted to cry.

He then told me to read the text section on any disease I was involved in treating, tested me on it the next day and did not stop there by adding the afterthought that texts are out of date the day they go to print; such that the only way to really keep up was to read the journals.

He gave me a pile of that year’s American Journal of Medicine and told me get a subscription after I was done reading them.

  • Only that vay vill you always be on the cutting edge. 

Interestingly, in the hallowed halls of academia there was a permeating bias against Indians. They were never seen in the upscale training programs.

At Columbia Presbyterian, the Cardiology director at one time privately admitted that he made two piles of applications for Fellowship: One pile for the Indians; and one pile for “all the others.” The Indian’s applications were then swept into the trash bin.

Some people also sniggered at the Indian custom of wearing a small Avatar dot in the middle of the forehead by parroting a possible socially acceptable answer to the query:

  • So, what does that little dot in the middle of your forehead mean anyway?
  • Oh, sir. In my religion, it means that every day is Ash Vednesday

I felt otherwise, because it was early in my career as a third-year medical student that the inspirational foundation for my future work ethic was laid down by one of those Indian pariahs, who while making the best of his lot in life, was making mine miserable in his role as the medical Master Sergeant in a second-rate VA hospital in Jamaica Plain.

When I eventually sold my practice, it was to a mixed cultural group, half of whom were Indians that were individuals I had worked with side by side for years and whom I always held in the highest regard.

Subscribing to the Hindu faith, it was somewhat of a shock for me to discover that they did not drink alcohol, they did not go to parties, they shunned bars, usually did not ever dance, were extremely family oriented and were very devoted to their children as well as to their patients. Education of the next generation was a number one priority.

They were also equally if not more knowledgeable than I was and generally worked their butts off with very few, if any, complaints about their workloads.

It was also an insight into my own indifferent bias to not even know anything in general about the Hindu religion, even though I had learned about its history and tenets in college. I thought it was simply a polytheistic concept hinged upon reincarnation, cosmic cycles, and portrayed by strange looking multi-armed gods who looked more like an octopus than a real person.

I did not know, for example that Hindus have a litany of holidays that include the following:

  • A celebration of the triumph of good over evil
  • A festival of lights
  • A celebration of renewing family ties
  • A celebration of exchanging personal gifts
  • A habit of giving excess bounty to the poor
  • A celebration of sweeping out the old and bringing in the new

 

Odd thing is it not, how it sounds vaguely like Christianity or Judaism.

 

Hindu greeting card

 

Source: Hindu Cards for Holidays

 

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Bureaucracy 1: The Bicycle License

The Bicycle License

Rules and models destroy genius and art.

(William Hazlitt) 

In second grade all the kids on my block got around on bicycles. You had to have one to be in the secret club that had a private hailing signal, which we yelled out across the streets. If there was an echoing answer, it meant another club member was outside somewhere and we would be able to find each other by following the ever increasing Doppler intensity of our squawks.

There was also a law in White Plains (NY) that all children had to have a bicycle license. It was a small metal disc that was attached to the front wheel under the tire bolt. Bicycles had to have a safety inspection and children had to pass a safety course, both of which took place once a year at the elementary school.

Since my birthday was in December, my physical development was, at a maximum, one year behind the January students in my class. As a result I needed a shorter and smaller bicycle than the standard one. I got a beautiful shiny red two-wheeled bike for Christmas and could not wait until spring when it would be inspected so that I could ride in the pack with my friends.

When the eagerly anticipated day came, I took my bicycle to the inspection stand, but the person in charge told my mother that the bike was not officially tall enough and therefore did not qualify to be licensed. The man was stoically inflexible about not bending any Rules of Local Cycling even though it would help a little boy who desperately needed his official wheels.

My mother angrily argued with him, but to no avail. She said it could not possibly make that much difference since a bicycle was after all, a bicycle. Then when she asked him where I was supposed to ride it, he said he didn’t know as long as it was not out in public. Now there was a truly enlightened response. I guess I was supposed to ride it in my bedroom.

All the other kids laughed and made fun of my mini-bike as we packed it in the car and I went home crying at having been both rejected for a license as well as being disgraced in public. But worst of all, now I had lost my wheels.

For a short time I was devastated, but managed to bounce back fairly quickly. Because there wasn’t any logic to the rule anyway, I decided to furtively ride my unlicensed bike around the nearby blocks, sometimes hiding behind trees or bushes, always on the lookout for the police who never seemed to show up or to even to care very much as they whizzed past in their patrol cars.

Probably having bigger fish to fry than a seven year old unregistered bicycling scofflaw, I never did get busted and rode around for the next year on my two-wheeled ‘not really a bicycle’ until I grew big enough and tall enough to fit into a standard sized officially legal velocipede which then had an officially proper license.

Aside from being a public embarrassment, this encounter was also my first frustrating experience with a bureaucracy of any kind along with its typical immutable characteristics: inflexible, insensitive, lacking compassion, uncompromising, rule bound and rigid. Unfortunately, it would not be the last such encounter for me, as later in life I was obliged to add many more to the list: Usually all laced with incompetence and definitively lacking initiative.

Although I do not usually advocate breaking rules, I repeatedly discovered over a long period of time that there exist a significant number of ridiculous prohibitions that completely defy common logic. Beginning in my childhood and continuously escalating over decades, it seems that America has become a nation, which feels compelled to legislate for every social flaw or every social conflict; otherwise known as the phenomenon of creeping paralytic Socialism.

What I did come to realize was that for every inane rule, which is designed to legislate behavior, regulate our environs, or to protect some special interest, there exists an equal number of individuals who employ these rules specifically so that they do not have think for themselves. Like the rules they represent, these entities are completely incapable of acting by utilizing or applying any simple principles of ordinary common sense. In fact there must be a disclaimer on any bureaucratic job application, which states that: ‘Anyone blessed with common sense need not apply for this position.’

No explanation needed then for why the Hell’s Angels went completely around the bend. Big men on big bikes flipping their middle fingers at the norms and values of over restrained regimentation.

Bicycle

I don’t want a pickle.

I just want to ride my motorcycle.

And I don’t want to die.

I just want to ride my motor-cye.

(Arlo Guthrie)

Bicycles © Paul F. Gabriel