The Good Doctor (28 page)

Even more remarkable, in some ways, was my dad’s loss of enthusiasm for writing and scholarship. Even though he had rejected a traditional academic pathway when he left Boston, he had been remarkably productive in generating case studies, book chapters, and other manuscripts during his years in Cleveland—work that gave him “some cachet in the ID community.” I knew he was proud of these writings because he presented me with a collection of his reprints at some point during my medical school or residency training. I recall sharing them with my Columbia colleagues on several occasions when we had a relevant case.

By the mid-1990s, however, his output had slowed to a trickle. Some of this was natural, perhaps, as he had reached his sixties, and his responsibilities had, if anything, increased: “There is always another paper to write, a chapter to revise, a lecture to update, a seminar to organize.” But the same ennui that affected his clinical work and teaching had spread to his scholarship. For example, he turned in a review article on nocardiosis, a lung infection in which he was an expert, months late. He correctly predicted that it would be his last review article, as he had “lost [his] enthusiasm for such undertakings as well as the freedom to allocate my time to undertake such projects.” I now know that part of what he was doing, ironically, was compulsively writing in his journals about his inability to write.

As early as 1987, my father had begun musing about authoring a paper that summarized his “maverick viewpoints about antibiotic therapy.” Louis Weinstein, Max Finland, and many of the other founding fathers of infectious diseases had quickly realized that the new wonder drugs could be used improperly, leading to bacterial resistance and other unfortunate outcomes. My dad had been an apostle of this viewpoint throughout his career, insisting particularly that diagnostic imprecision had led to rampant misuse of antibiotics, even by specialists in the field. Over the years, he had developed other counterintuitive beliefs about antibiotics, which he had taught in the classroom and on the wards. One major point that my father consistently emphasized was that—counter to common opinion—antibiotics do not cure infections. Rather, they assist the body’s host defenses in doing so. Not appreciating this, clinicians often gave antibiotics for too long and at doses that were too high, which did more harm than good, including promoting the growth of resistant bacteria. “Why,” he liked to ask his colleagues, “do we not study precisely how much antibiotic is needed in a given situation and then give no more?” Sometimes only “very small doses” may be necessary to turn the tide. Another of my dad’s mottos was “Give a first-generation antibiotic for a first-generation infection,” again underscoring how doctors tended to overuse newer, more expensive antibiotics, assuming they were necessarily better. One of the forces encouraging this misguided approach was the pharmaceutical industry, which was engaged in what he called an “almost mindless, frantic search for and deluge of ever more potent agents,” rather than studying the advantages and pitfalls of existing antibiotics.

By ignoring what Louis Pasteur had termed the terrain and focusing too closely on the germ, medicine had missed an opportunity to study and improve how patients’ immunological systems responded to infections. “The Forgotten Host” was the title of an article by bacteriologist Ernest Jawetz from the May 1955 of the
Stanford Medical Bulletin
that my father had dug up on this topic. Physicians now placed too much focus on specific bacteria that grew from cultures of bodily fluids. Many of these were merely colonizers, present but not causing actual disease. Meanwhile, drug-resistant bacteria—reflexively termed
killer bugs
or
superbugs
—actually grew normally or sluggishly in patients with intact immune systems. My father even put forth the somewhat heretical opinion that nosocomial infections—infections that patients acquired in the hospital and that were the source of enormous consternation among administrators and regulatory agencies—often caused little actual harm.

My dad approached a friend, the editor of a major infectious diseases journal, who indicated interest in an article that made these points. The piece would be my father’s “main academic contribution to infectious diseases.” I recall him mentioning his proposed “antibiotic polemic” to me on many occasions. At some point, I began actively urging him to finish it. But, although he wrote several one- or two-page outlines in his journals, he never did.

His inability to finish this project, plus the continuing travails at the Mount Sinai, plus what was probably a degree of mental illness led him to muse frequently in his journals about his legacy. He often found himself wanting. At one meeting of the Infectious Diseases Society of America, he compared his “meager achievements” to those of several peers being given lifetime achievement awards. Due to his career choices, a lack of ego, and an unwillingness to seek recognition, he had chosen instead to be more of a “foot soldier.” On another occasion, a visit by a renowned infectious diseases specialist from Tufts, his former institution, reminded my father “what I might have become had I elected to remain in Boston, as Dr. Weinstein implored me to do.”

At some point, my dad began collecting quotations that reflected his mood. He approvingly cited the writer Mary McCarthy, who once said, “The belief in progress that animated my youth has vanished.” Elsewhere, he quoted an anonymous source as saying, “A man has only so many years of optimism.” He also increasingly contemplated his own mortality. In one’s forties and fifties, he wrote in 1994 at the age of sixty-one, “there’s lots of time left.” But in your sixties and early seventies, with contemporaries dying, “that means 5 or 10 or 15 years is what’s left.” On the fiftieth anniversary of D-day, June 6, 1994, he called himself “old enough to have experienced history.” On another occasion, when visiting his father’s and grandparents’ graves at the cemetery that housed members of my family’s old Jewish club, he ran into an acquaintance from the old Glenville neighborhood. “Seeing him there was a bit jarring,” my father wrote, “since he looks so much like his mother and he’s now an old man and, by some measures, I guess so am I.” In the summer of 1997, on the way to Cape Cod, we stopped to visit Louis Weinstein, my dad’s old mentor, at his home in Newton, Massachusetts. Weinstein was eighty-nine years old and in declining health, but my father was glad to see him and thanked him one last time for giving him such a great opportunity. By this point, my dad had begun to muse about an early retirement, something that would have seemed inconceivable a few years earlier.

Amid this profound negativity, my father experienced many happy events during these years, which he dutifully recorded in his journals as well. In 1990, he received a major teaching award from the medical school. As his own severest critic, he wrote that he did not need to hear from others that he was doing a good job, but he admitted that the award was “long overdue.” The next year, the editors of the prestigious
Harrison’s Principles of Internal Medicine
asked him to write a chapter on actinomycosis, a fungal infection on which he was a recognized expert. Writing for this particular textbook was something he had actually dreamed about doing since medical school. And, in September 1993, he finally hired an associate to help him cover the large number of infectious diseases consultations he received and ideally free up his time for teaching and research. The fact that the associate was a woman, Cindy Gustaferro, showed how much medicine had changed since my dad went to medical school. Her gender mattered little to him; he just wanted a partner who would be as obsessive as he was.

Gustaferro’s appearance was especially notable for another reason. “I’m not on call this weekend!” my father wrote on September 26. “The very first time in 20 years I don’t have to think about the hospital at all!” Being on call for twenty years did not mean that my father constantly got bothered every weeknight and weekend, but when there was a crisis, he surely did, and at times he headed back to the hospital. As someone whose sanity depends on patient-free vacations and catching up on sleep over the weekend, I can only shudder at the notion of being on call for over seven thousand straight days.

But my father’s greatest joys during the 1990s were surely my and my sister’s marriages, followed by the birth of his grandchildren. My wedding to Cathy was in Brooklyn in August 1990 and my father was especially happy that it—at least temporarily—reunited the family that had scattered within and beyond Cleveland. As usual, his emotions were less apparent in public than they were in his journals, where he wrote, “I was literally bursting with happiness, especially with all the family and friends around to share it with me.” Remarkably, four parents and four grandparents (Jessie, Pearl, and Cathy’s grandparents Teddy and Norma) plus Aunt Gertie were present. As usual, my father took note of who was not there, especially feeling the absence of his dad, Meyer.

Best of all, the wedding, at least transiently, distracted my father’s attention from the “turmoil” of the hospital. Anyone reading his description of the wedding, he wryly noted, would “notice a rather different mood in the writer.” The wedding gave him “new impetus to re-evaluate and carry on.”

Even more momentous, however, was the birth of Cathy’s and my first child, Ben, on January 20, 1993. At this point, we were living in Seattle and I was completing my fellowship. Within twelve hours of Ben’s birth, my father had begun another journal, inscribed “To my grandson, Ben Michael Lerner.” Ben was born on the day of Bill Clinton’s first inauguration but my father had no trouble terming his birth “the most eventful happening of the day,” especially because he was the first member of the next generation of his family. That Ben was named after Phil’s beloved grandfather Ben Lerner as well as his father and father-in-law (Michael was a tribute to Meyer and Mannie) ensured that there would be a family-history lesson in the inaugural entry of the new journal: the first Ben Lerner’s courageous decision to leave Poland, Meyer’s leaving school early and toiling as a furrier, and my father’s own fortunate pathway into medicine. Meyer and Mannie, he wrote, “would have savored this moment even more passionately than I.” Two years later, when Cathy and I were back in New York, our daughter, Nina, was born. “Welcome dear one to my heart and our family,” my father wrote, beginning a series of journal entries to Nina to accompany those that he continued to write to Ben.

Another source of joy for my dad was my evolving medical career. Yes, we disagreed about how to balance paternalism and autonomy, and the changes in medicine complicated my career path, but I had followed my father into academic medicine. Like him, I eschewed a traditional private practice, instead seeing clinic patients part of the time, teaching medical students and residents, and doing research. As with many, if not most, physicians I encountered, my father did not quite understand the idea of a research career in the history of medicine. Most researchers worked in laboratories or studied the medical outcomes of living patients, as he had. But he (and my mother) could not have been more enthusiastic, especially since I was doing what I loved. My dad had once known this same type of exhilaration.

I was amused, therefore, when I read what he had recorded in a journal entry in January 1996 when he was visiting us in New York. After having dinner on a Saturday night, I had apparently sat down to do work, looked at my father, and said good-naturedly, “It’s your fault.” “I suppose it is,” he wrote. Yes, the apple had not fallen far from the tree. But another journal entry, this one from November 1998, around the time of the publication of my first book, surprised me. “I think (in fact, I know),” my father wrote to me, “that you are more ambitious and far more disciplined than I ever was.” Having grown up thinking of my dad as the most disciplined person that I knew—and myself as insufficiently disciplined—it was hard to read these words. But it helped to explain his inability, at least later in life, to complete the projects that he knew he should.

I readily used my father’s expertise when I began to write articles on the history of medicine for both medical and historical journals. He was especially helpful when I researched infectious diseases, as he had personally encountered some of the events I described, but he was even more valuable as an editor, cutting down my expansive language into acceptable nuggets. He also relished inviting me to Cleveland to give talks, as my being there with my family had the added advantage of allowing him to see his grandchildren. I must admit that I loved these gigs, as I got to lecture in front of relatives, friends, and doctors I had known for years. It was also great seeing how proud these appearances made my father (and mother).

One particularly memorable visit was in October 1997, just before my dad’s sixty-fifth birthday, when I spoke on the history of breast cancer at the Allen Memorial Library. The night before, my father and I had suffered together as our cursed Cleveland Indians lost game seven of the World Series to the Florida Marlins after leading the game going into the bottom of the ninth inning.

During these years, my father and I worked hard on being more emotional with each other. He had never been one to display his emotions outwardly and I, his doctor son, was a chip off the old block. But now, when I left Cleveland to return home or when he departed from New York, we hugged and made sure to say “I love you.” Later on, when I read my father’s accounts of these episodes, I realized how hard it could be for him to display his profound feelings so openly. “It’s a bit difficult with a son, this hugging business,” he wrote in 1994, “to be careful and not overdo it with your grown man.”

During these visits, my dad’s discontent with medicine inevitably came up. I did my best to let him vent. In some ways, however, I disagreed with what he so passionately believed. Doctors of my generation entered the profession using different approaches. For example, I was much less willing to use my clinical judgment alone to make decisions for my patients. Among medical specialties, general internal medicine, which I practiced, had particularly embraced the notion of evidence-based medicine, which relied on sophisticated clinical trials and meta-analyses to ascertain the value of screening procedures and therapies. As a historian, I was well aware of how value laden and nonobjective the term
evidence-based
might be. And, when pushed, I did give my personal opinions to patients. But in general, I embraced the idea of providing patients with the best data that existed for interventions, such as mammography, colonoscopy, and prostate-specific antigen (PSA) testing, to help them make informed decisions. Similarly, I was much less likely than my father to recoil at the concept of guidelines, the algorithms provided by expert groups to help doctors manage complicated medical situations. In an era of rapidly expanding medical information and more sophisticated statistical analysis, it was wrong to assume that I knew best simply by dint of my personal experience.