First, an apology for the two-month break in August and September during which there have been no Chronicles. Alas, as sole author and editor for now, and mindful of my many other and varied duties as part-time secretary/receptionist/filler person and full time, newly-promoted-to, Coordinator of Human Resources, it has frankly been a little tough to find time enough for everything. Also, I am back to adjunct teaching at nights this fall (sociology and cultural anthropology, what else!) But the Chronicles are dear to my heart. In a funny way, by forcing me to reflect on the everyday practices and concerns of one subculture in which I spend a lot of time-the urban doctor’s office-they help me make sense of and integrate my own different social and cultural roles as both participant and observer in this fascinating world, and in the larger one of which it is a part.
The Chronicles were started eight months ago in the hope that they would serve as a loose kind of record of the story of one doctor’s office in New York City at the beginning of the new millennium. So far we have made no serious attempt to give shape to our story in the form of a chronological sequence. A puzzled reader might be forgiven for seeing them as periodic exercises in the expression of random thoughts, observations and opinions in whatever format seemed appropriate at the time of writing. For those who like their history straight, this approach is disconcerting to say the least. On the other hand, for those comfortable with the meanderings and sidetracking of a stream-of –consciousness approach to history, we hope our hodge-podge of offerings provides an occasional useful or interesting insight in to the familiar routines of that part of our every day reality that has to do with health and sickness, doctors’ offices and the people who work in them.
One of the people who work here is Dr. Sheila Cain, an Associate who has been with the practice for a little over a year now. I decided to interview Dr. Cain because of the many questions that occurred to me when I started thinking first in general about why people make the choices they do to be anything. Doctor, fireman, soldier or chef. Who or what are the deciding factors? Are there inner voices that compel people like Joan of Arc to seek their ultimate destinies, or is it just a matter of chance? Or is it a series of opportunities that present themselves at convenient intervals every time we face a turning point in our lives, and only at the end, when we look back at this road, full of bends and forks, do we see it was actually the only logical one that could be taken?
The more specific questions I had for Dr. Cain went somewhere along the following lines:
What is it like to be a young doctor in New York City starting out in private medical practice in the Age of Managed Care? What kind of training is necessary in Medical School these days that is adequate in terms of preparing the new M.D. for dealing with the morass of paper work, the endless and ever changing rules and regulations of HMOs and MBHOs, IPAs, PHOs and MSOs, PPOs, EPOs, POSes, PPMs or IDs? As one medic puts it, “any way you arrange these letters, they spell one thing: madness”! When little Molly Brown (or in our case, little Sheila Cain) decides one day at age six, that when she grows up she is going to become a doctor, does she realize that besides all that cool stuff of walking around in a crisp white lab coat, giving injections, sticking needles into people’s arms or cutting them up and putting them back together again, she will also have to learn about dull things like accounting? Possibly take some classes in jujitsu to protect herself against armies of enraged patients waving “referral” forms at her demanding they be filled out NOW? Memorize CPT Codes that might be harder to remember than the most mind-numbing chemistry formulas? Maybe she’ll decide, better stick to her original plan of becoming an astronaut.
Before Dr. Cain and I met to do the interview, I wrote out a series of 14 questions, which I present below. Under each question is a rough paraphrase of Dr. Cain’s response. (Unfortunately I did not have a tape-recorder to help me transcribe our interview verbatim (a practice I am always urging on my students when I send them out on their fieldwork projects!) So, such as it is, incomplete and imperfect, I hope it gives our readers a little bit of the flavor of one of the Yaffe/Ruden office’s favorite assets.
Question 1: When did you first decide you wanted to be a doctor?
SC: Between freshman and sophomore year in college. I spent one high school summer doing architecture at Cornell and first wanted to do that. So when I went to Stanford, I went into the engineering program because there was no separate department for architecture. I didn’t like the basics of engineering, especially physics! The next summer I applied for a research grant to the Worcester Foundation for Molecular Biology in their summer intern program. When I came back to Stanford, I had become very interested in neuro-biology research. That year I worked at the Howard Hughes Medical Institute at Stanford.
Question 2: What made you decide on medicine as a profession?
SC: The work experience at Howard Hughes. I applied to Medical School in my Junior year at Stanford. Initially I wanted to do ob/gyn. Then I wanted to do pediatrics but decided it was too hard to deal with the parents! Ultimately I decided on internal medicine. I wanted to come back to New York because it was closer to my family and because I wanted to experience a different pace.
Question 3: How much encouragement did you receive from family, teachers, peers etc. to go to medical school or follow a career in the “sciences”?
SC: Definitely from family. My parents were very supportive. So were my teachers in high school, especially my math/calculus teacher. Also, my older brother is a dentist. Another reason for my interest in medical research was that my younger brother had suffered a serious illness. I always had great academic advisors and very supportive research supervisors.
Question 4: At medical school, were you ever treated differently by your teachers because you were a woman?
SC: There were definitely biases when it came to things like clinical rotations. Nothing gross, but it always seemed like there were more male ‘attendings’ in surgery, and that in general, more men than women were being groomed for surgery (except for plastic surgery!) Women tended to be more encouraged to go into pediatrics or ob/gyn.
Question 5: In the course of your studies did you find that there were biases in favor of men as far as what kinds of research was funded or received the most attention?
SC: There probably were some, but I don’t really know enough about that in the sense that I don’t have any direct knowledge about it.
Question 6: Were you ever given any formal training either when you were a student or as a resident about what to expect as a physician in a Managed Care world?
SC: Managed Care came up only in a class called Introduction to Clinical Practice. But it was very much a textbook kind of understanding. I had no real idea what to expect until I started working.
Question 7:Did you find discrepancies/contradictions between what your teachers preached about ideal qualities in a physician and what you observed about the actual practice of senior physicians when you were a resident?
SC: There definitely were discrepancies between theory and practice. I did my residency at Mount Sinai and while I was there, I didn’t find any great role models at least in Internal Medicine.
Question 8: Do the rules and constraints under which you have to operate in Managed Care go against what you expected in terms of freedom of decision-making, treatment plans, time devoted to patients during office visits etc? If so, how do you deal with it?
SC: I find that Managed Care constrains who you can referpatients to, and also in terms of time. Any medical problem, which is complex, becomes very difficult to deal with on a practical level. In an academic setting, you don’t have the same type of time pressure placed upon you. When you go from there to a setting, which limits you to 15 minutes per patient…..
Question 9: How do you see patients handling it?
SC: I think patients’ reactions go from angry to resigned. For younger patients, they haven’t known anything else.
Question 10: Can you give your patients any pointers regarding how they can participate more effectively in their own care, be more “prepared” for a doctor’s visit so they can make the most effective use of their time while in the office?
SC: If they could prepare a list of any medications they’re on, give a background of their family medical history, make a list of their own questions that are of concern, that would be very helpful.
Question 11: What do you find the most rewarding thing so far about being a doctor?
SC: Definitely the interaction with patients and starting to develop a relationship with patients.
Question 12: What would be the single most useful piece of advice you would give the current batch of hopefuls graduating from medical schools around the country?
SC: Two things. a) You always need to listen to your patients, their outlook on what is going on, and b) Take some business classes.
Question 13: Now that you have worked in this office for more than a year, would you still choose working for a large practice in a “big city” environment versus working for a smaller practice in a suburban or “country” setting?
SC: I definitely see myself as a New York City person for the long term. Where else do you meet such interesting patients? There’s never a dull moment and sometimes it gets crazy. But it’s also very rewarding and the staff here works so well together.
Question 14: Would you make all the same choices if you had to start all over again from the beginning?
ONE FINAL FOOTNOTE:
In Chronicles to come, we hope to present more interesting profiles of people in the Yaffe/Ruden community of medical staff, administrative and clerical staff and of course patients. As much as possible we would like these profiles to be rendered from “the native’s point of view”.
Although it would be highly presumptuous to claim that from one interview I got to KNOW Dr. Cain, I did understand a little bit more about how she arrived at the point in her professional life where she is today. Being a doctor, especially in 21st Century America where the HMO is king, is not easy. It is not just about book knowledge and mastering technical skills. It is also about compassion and sensitivity to the patient as a whole human being, and keeping those ideals uppermost no matter how crazy the bureaucratic maelstrom surrounding the doctor-patient relationship.
In the short time that she has been here, Dr. Cain has earned the respect and confidence of her patients and of her fellow medical colleagues. She has also won the affection of those of us who work with her on the non-medical staff, by her modesty (she wears all those impressive academic credentials very lightly) and refusal to treat anyone as less than an equal no matter how humble the task they perform in the office. All I can say is that we here at 201East 65th Street are so glad she decided not to be an astronaut!