The Good Doctor (2 page)

But reading my father’s copious and detailed journal entries brought to life a seminal era in the history of medicine. Much has been gained during my time as a doctor, but much has also been lost. I came to admire many of the practices and assumptions of my dad’s generation, including some that shocked me when I first learned of them. And even as the Affordable Care Act marshals scientific and economic information to reform health care in the United States, this earlier brand of medicine reminds us how the expertise and professionalism of physicians remain central to this effort.

Dr. Phillip Lerner, of course, was my parent, trying to raise me with the values that he and my mother believed in. And he was also, in a sense, in loco parentis for his sick patients, who followed his advice so they could be healed. But halfway through my father’s career, those same patients—and those of his peers—began to question the doctor-as-parent model, rejecting their physicians’ paternalism in favor of gaining a degree of autonomy. Meanwhile, I chose a path that honored my father’s profession but also criticized it. And, at the end of his life, as my dad’s Parkinson’s disease worsened and therapeutic decisions needed to be made, I reluctantly took on the roles of both his doctor and his parent. In some sense, therefore, this book is about skills that are crucial for both health professionals and parents: knowing when to insist on something and knowing when to let go.

CHAPTER ONE

The First Dr. Lerner

My father’s decision to become a physician stemmed from his upbringing in a close-knit, working-class Jewish community during World War II. Although he was largely unaware of the mass murder of Jews as it was occurring, what he learned later would affect many aspects of his medical world. His career trajectory was also greatly influenced by his attending a medical school that was in the forefront of efforts to train humanistic physicians. And he had an inspiring mentor who practiced a particular type of patient-centered, case-based medicine that hearkened back to the practices of some of America’s greatest early doctors and reached its apogee in the mid-twentieth century.

As a historian, I was not surprised by what I read in my father’s journals. After all, everyone is, to some degree, a product of his or her times. Yet as a doctor, I was amazed by much of what I read. Indeed, my dad’s medical school training and early career would probably be unrecognizable to most modern physicians.

My father’s story is typical for an American Jew of Ashkenazi descent whose family left Poland in the early twentieth century. Fortunately, my paternal great-grandfather, Ben Lerner, chose to immigrate to the United States as the century began. Realizing that the Jews of Poland would never belong and would never be able to live in peace, he left shortly before World War I, escaping the fate of most of the Jews of his village, Yanova: they died in the Holocaust. As was common then, he left his wife and children behind, hoping to get a foothold before sending for them. Over the years, first in Pittsburgh and then in Cleveland, Ben would work in a series of jobs, eventually running gas stations from dawn to dusk—“in good spirits,” my father wrote, “because he knew what he had escaped.” He was, my dad went on, a simple man with “basic values and resolve”; his favorite expression was “Hope for the best.” The second-oldest child of Ben and his wife, Dora, was Meyer, my grandfather, who was born in Poland in 1907. Meyer’s wife, my grandmother Pearl, was also born in Poland. Her family arrived in Cleveland in 1920. They met there in 1927 and married three years later.

Being Jewish in Cleveland at this time was all about religious commitment and unity. Both of my great-grandfathers on my father’s side of the family, Ben and Chaim, belonged to the Mezricher Society, a Jewish club (or
landsmanshaft
, in Yiddish) that sponsored social events, helped welcome newcomers, and supplied cemetery plots. Chaim and his wife, Dina, were Orthodox Jews, following all the customs, such as not mixing milk and meat, not using electricity on the Sabbath, praying with phylacteries every day, and regularly going to synagogue. Ben and Dora Lerner were not as strict as Chaim and Dina, in part due to an incident in which Ben, a struggling peddler at the time, was turned away from High Holiday services at a temple because he could not afford a ticket. Thanks to Dora, however, they still observed most of the religious rituals. Yiddish was the mother tongue in both homes, although the families spoke more and more English over time.

By the 1920s, Cleveland’s Jewish community had mostly congregated on the city’s east side, in an area known as Glenville. The main thoroughfare was East 105th Street, which, one historian wrote, was “lined with Jewish bakeries, pharmacies, shops and important charitable and religious institutions.” There were still peddlers with horse-drawn wagons. Life centered on the family. My father had eighteen first cousins, several of whom lived in a two-family house on Eddy Road that the Lerners shared with one of Pearl’s sisters and her family. His cousins were his best friends, and with so many relatives living within a few blocks, informal socializing on the stoops of houses or in local playgrounds was the rule.

My grandfather Meyer worked steadily as a furrier during the 1930s and 1940s, despite the Great Depression and the deprivations of World War II. Although I always knew that these events had shaped my father’s life, his journals revealed just how directly his family, class, and religion affected his eventual career choice. His parents expected him to earn money during high school, and he did. They also expected him to succeed in ways that they, as first-generation immigrants from the working class, could not. College was an absolute certainty. During college, my dad worked in his father’s fur shop as well as in the local butcher shop. In medical school, he drove a creaky electric trolley bus with straw mesh seats for the old Cleveland Transit System in some of the most dangerous parts of town. “Love of family, honesty and hard work,” he wrote many years later, were the “common values of strong families in those days.”

The fact that my dad was a diligent and enthusiastic student surely helped him achieve his goals. In later years, he would characterize his youth as mundane and his view of the world beyond Cleveland as completely naïve. Before visiting St. Louis, New York, Boston and other cities in 1958 at age twenty-five to interview for a medical residency, he had never been so far from home. The only real vacations that the family had taken were trips to Pittsburgh to see relatives. But his experiences in Cleveland, working hard to help support his family while also excelling in school, prepared him to move beyond the confines of his provincial upbringing.

He chose medicine as a career not only because it was a path to the middle class but also because of his experiences growing up Jewish in the 1930s and 1940s. He attended Glenville High School, a predominantly Jewish public school filled with second-generation-immigrant teenagers from working-class families with lofty aspirations. The informal name for Glenville students, the Tarblooders, came from a local tar company and reflected how hard these children were willing to work at school and sports in order to succeed. Brooklyn and the Grand Concourse in the Bronx are the repositories for memories of New York Jewish children coming of age in the mid-twentieth century, and Glenville and its high school serve the same role for Clevelanders. Still, after his Orthodox bar mitzvah, my father concluded that religion meant little to him. Mild-mannered Meyer, who took enormous pride in his sons’ accomplishments, often let my dad and his younger brother, Allan, know that he was nonetheless disappointed that they had turned their backs on their faith.

But they really had not. Even though my father would resist going to temple for decades, his identity as a Jew and the moral teachings he encountered in Hebrew school stuck with him. As the writer Abigail Pogrebin has detailed, this generation of Jews “absorbed a sense of peril, the need to prove themselves [and the need] to stay connected to the Jewish community.” Learning about that existential peril, the Holocaust, affected my dad’s outlook profoundly. When World War II ended, media reports—and the arrival in America of distant cousins of his who had survived concentration camps—brought home the full scale of the horror. “Growing up in this magic country and peacefully going to school, smothered and protected by my family and the circumstances of the times,” my father wrote, he had not known of any of the atrocities that were going on in Europe. He realized, as he later put it, that he had been “spared by one generation” from almost certain death. “It was your great-great-grandfather Ben Lerner,” he wrote in a journal entry addressed to my son, also named Ben Lerner, on the day of his birth in 1993, whose “adventurous spirit and gutsy determination” had “made our lives possible” by sparing the family from the deprivation, danger, and doom experienced by Jews in Europe during the 1930s and 1940s.

More subtly, surviving the Holocaust in the safety of the United States helped forge my father’s career path. It stood to reason that with such an acute sense of survivor’s guilt and an appreciation for his good luck, my dad would choose a profession that first and foremost enabled him to help others. And he would become a physician who was fiercely devoted to his patients, more than a few of whom were themselves Holocaust survivors.

As with many teenagers who aspire to be physicians, my father had a role model. In the era of the house call, a dedicated Cleveland general practitioner named Clarence Weidenthal was a regular visitor at all hours to the house on Eddy Road. In his journals, my dad recalled an incident when—in his late teens—he ran into Weidenthal somewhere in Cleveland. It had been at least five years since they had seen each other but, according to my father, “after a few minutes of mental gymnastics, [he] offered not only my family name, but the address, and the street, and that I had lived in one of the two suites in a 2-family home on Eddy Road.” That sort of intimate knowledge of one’s patients made a lasting impression.

There was little doubt that my father would attend Adelbert, the undergraduate college of Western Reserve University, located in downtown Cleveland’s University Circle, home to many of the city’s cultural institutions. He received a partial scholarship and offset the remaining tuition costs by living at home and continuing to work. He remained in Cleveland for medical school, enrolling in 1954 at the Western Reserve University School of Medicine (the merger of Western Reserve University and the Case Institute of Technology would occur in 1967).

It was an exciting and dynamic time to be at Western Reserve. The vast majority of medical schools in this era taught in a very traditional manner. The first two years consisted of classroom lectures and laboratories. Students spent years three and four on the wards, essentially as clinical clerks, learning from residents and attending physicians and caring for patients for the first time. By and large, a mid-twentieth-century medical school education was rote and dull.

But in 1952, three of Western Reserve’s faculty members banded together to revolutionize and humanize the curriculum: Dean Joseph T. Wearn, Director of Admissions John L. “Cactus Jack” Caughey Jr., and a dapper hematologist with the memorable name of T. Hale Ham. Their idea was to turn students into “colleagues,” inspiring them to do independent research and introducing them to patient care in their first year. In addition, rather than requiring separate courses in traditional subjects like biochemistry, pathology, and physiology, the Western Reserve educators reconfigured instruction to focus on specific organ systems. Professors from multiple departments worked together to integrate their information into a more dynamic whole. At the beginning of medical school, each first-year student was assigned a pregnant woman to follow, and the student was expected to care for her through and after the birthing process, even making home visits. Focus on the patient as a person was key, as was getting to know one’s patients’ families. (Western Reserve was farsighted, but only to a point. Only nine of the seventy-eight students in my father’s class were women. And both professors and students smoked during lectures, even those lectures about cancer.)

The gruff, “bullet-shaped” Caughey prided himself on accepting nontraditional medical students, such as those who were older and had had other careers, if he believed they were especially interesting or focused on the humanistic aspects of medicine. My father’s classmates included H. Jack Geiger, who would later help found both Physicians for Human Rights and Physicians for Social Responsibility; Abraham B. Bergman, a pediatrician and public health pioneer who championed the use of bicycle helmets for children; and Sadja Stokowski, daughter of conductor Leopold Stokowski, who became an early advocate for abortion rights. And my dad’s faculty preceptor, who supervised his first-year clinical work, was Benjamin Spock, the legendary pediatrician and author of the best-selling 1946 book
Baby and Child Care
.

A star student, my father quickly realized that he’d made the right decision in attending medical school. He was endlessly fascinated with both the scientific explanations of diseases and the personal stories of people who were sick. He graduated near the top of his class, and Western Reserve would have been happy to have him remain in Cleveland for his internship and residency in internal medicine. But my dad knew that his academic performance placed him in high demand everywhere, and he decided it was time to look beyond Cleveland.

So the young man who had traveled so little took the train to St. Louis to interview at the renowned Barnes Hospital of Washington University. The University of Rochester and the Yale–New Haven Hospital were also on his list. In New York, he interviewed at Bellevue Hospital, New York Hospital, and Columbia-Presbyterian Medical Center. At Columbia he met with Robert Loeb, the chairman of the Department of Medicine and the coeditor of the famous Cecil-Loeb
Textbook of Medicine
. My father’s most vivid memory of his interviews is jarring but says a lot about the enormous egos of medical school professors of the era. During one interview, held in a laboratory, the physician calmly stood up and urinated into a sink, continuing to speak the whole time. My dad assumed it was some sort of test, but he was not impressed.