A Wrinkle in Time

A final meditation on the historical record, the American dream and the forgiveness of sins.

I can agree this time with the bard when he says that “parting is such sweet sorrow.” I refuse to let the last Oh Henry degenerate into pure one-sided overly individualistic views of salvation and sentimentality. Such blathering is emotion in excess of objectivity, expressing a defect in one’s intellectual quality, trying to cover it by quantity.

I also refuse to violate the unwritten but fully understood relationship between writer and audience that requires me to detail the journey before the destination. For what is a homecoming without a struggle? If writing is to be art, it must be truthful in what it says about the subjective and objective worlds and our sojourn is really our thought.

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If you are glad to see this column go the way of all flesh, you are not alone. My wife hates it. Those conversations are not fit for public consumption. As fit punishment for my many strident but sincere critics I suggest an advance study course in reading St. Augustine’s Confessions. Here’s hoping that the scribbler who is to fill this space from now on will be your Paradise Found. Taking the advice of Dylan Thomas, I do not intend “to go gentle into that good night.”

I pen this missive on Election Day morning before knowing the result and quite frankly, I almost don’t care. A boorish, narcissistic crazy or a corrupt liar crook are caught in mortal combat. You decide which is which. The only problem is the mortality is not theirs; it is ours. This may be the death of civil government as we know it.

Hillary Clinton represents the focus group tested product of several decades of political sausage-making. Donald Trump represents someone who thinks there are no rules at all, who would make fun of a person with a mild dysplastic disease and criticize John McCain’s war record. Remember that man who refused to come home until all of his fellow airmen went with him? He is a genuine American hero and it broke my heart to see him criticized. I want Eisenhower back, damn it, and that’s that.

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The narcissism in the race is cowering. These contributions to the coarsening of our public life makes me ill. You will all remember that the Federalist Papers arguing for the establishment of the Constitution were written by three different people but were all published under the name Publius, so as to concentrate on the principles and not the personalities.

Under normal circumstances both of these people would be considered unfit to be dogcatcher, let alone President. But these times are not normal and we have only ourselves to blame. Our lack of balance, total abandonment of sound logic and rhetoric and our willingness to make every candidate’s life a prurient freak show is disgusting. How are we ever going to get anyone reasonable to run for the office?

I despise the crisis mentality that colors our news reporting. It’s always a crisis and a rush to the barricades instead of reasonableness and real dialogue in analyzing issues. The once expansive middleclass is eroding rapidly. It has lost the grounding of stable life forms such as family, pride in one’s trade and craft and God forbid, self-respect.

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The new poster boy against real intellectual discussion and champion of trite intellectual diversity is Harvard Law Professor Mark Tushnet. Tushnet feels that all religious people, or those who believe in a higher order, are mentally inferior and need “reorientation” to the politically correct forms of thought. In his mind, by raising probing questions, I am a racist, sexist, homophobic, Islamophobic or suspect Christian . . . and probably a Nazi. I actually don’t need him to determine my salutations or pronouns. I have no idea why he hates us so much.

I wish to extend my political metaphor to our emergency medicine situation. Again, the Chicken Littles of the world only seem to see brief moments and those moments are always in crisis. They cry out: How can we live with these injustices? Old age does give perspective. To those of you who feel there is a huge shortage of qualified ED doctors in the country, let’s deal with the facts. In 1968, at the founding of ACEP, nobody had done a residency in emergency medicine. People were born, lived and died at about the same rate they are doing it today. There are now 218 approved MD and DO residencies and about 32,000 residency graduates. This is progress like no other specialty has ever seen. We took the scraps and made it lunch. You were one vote from being a permanent part of family practice and it was stopped. Be happy. Things could be a whole lot worse.

Next. When I was president, you were about 16th on the list in overall income. Due to the hard work of people whose names you probably don’t know, you are now 7th or 8th (depending on how you look at it) of the 24 recognized specialties in what you get paid. Not a bad job done by people on the RUC working on your behalf. Just for those of you who feel you don’t get your dollars’ worth for your ACEP dues, deal with the fact that these victories at the RUC in the past two years will pay for your ACEP dues for the next 30 years. Go ahead, challenge the data. You are doing well because of the vision of excellent people who came before you and made it right.

Also in 1968, there were almost 7,000 “emergency rooms” in the United States; small (micro) hospitals were everywhere with staffing that would make grown men cry. With the Pontiac plans, most hospitals had all staff members take call. One night it may be the allergist, one night the orthopedic surgeon. Let’s just say there was a lot of luck involved in how you did. Things are much better today. Small hospitals closed or are closing. There are slightly less than 4,000 emergency departments remaining today and they are staffed to a lesser or greater degree by our people. New levels of service have been demanded and we have supplied them. In the past five years, I’ve spoken to more than 10,000 PAs and NPs, a group that 15 years ago didn’t even exist.

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So before you become Simpsonesque and “have a cow” over our current problems, step back and get out of crisis mode and look with some perspective at these issues. Are there still problems? Of course. But our 48-year vector is only in a positive direction. How many people in residencies today would want to swap their lot with pediatrics, internal medicine or surgery residents? Not many. [You notice I did not include dermatology.] I implore you in my leaving to be of good cheer. To say you have hooked your wagon to an ascending star is an understatement – ad astra per aspera (through adversity to the stars). But there should be no rose-colored glasses for us either. Maintaining our desirability with medical students and our white-hot image with the public (in no small part due to TV’s “ER”) will be the next great battle. The one place where national politics and the specialty of emergency medicine come together is over our new role in the evolving healthcare policy.

Twenty years ago I wrote about EDs as the center of all clinical decision-making. It has come true. We are the place where everyone goes to be sorted out and entered correctlyinto the system. We should be proud of this. There is no going back and healthcare policy wonks know it. Being at this policy table is not optional. It’s mandatory. At the community, state or national level not to play is to lose. If we don’t do it, it will be done to us: a consummation not to be wished. Ascension to leadership in medical trade organizations should be more than a popularity contest. Great leaders tell you what you need to hear, not what you want to hear.

Before I shuffle off this creative “mortal coil,” I wish to take a moment to thank some people who have allowed me this bully pulpit all these years. First, the father-son duo of Mark and Logan Plaster, who provided me this space each month and allowed me the freedom to create as I saw fit. My editor, Judy Tintinalli, who has been a friend for over 40 years, gave me unfettered license to expound. In September of 1976 I spoke at the residency program at Detroit Receiving Hospital with Ron Krome, Brooks Bock and Judy Tintinalli in attendance. It was the start of my academic career. A few days after my first residency visit, Judy called me and asked me if I would write a chapter for this book she had been planning. I said yes. She then asked if I would write nine chapters for this book. I said yes again and our warm relationship continues to this day.

Next, my wife, who as I pointed out earlier, is not enamored of my prose but understands I don’t have the talent or language to be a poet. She never said no, understanding my need to vent from my various frustrations – better it be through this column than to her. Thanks. After 52 years of knowing you, I realize we don’t always like each other but we do, I think, always love each other.

I was never much of a writer. So both my high school and college English and Latin instructors deserve credit for making a Naugahyde purse out of a sow’s ear. One man, Mr. Appleyard, opened the worlds of Shakespeare and poetry to me in the ninth drade and we were friends until his death. I will never have his skill as a teacher but I have the benefit of his example and his inspiration. I was blessed. He knew you never got any better performance out of a scruffy kid like me by making him feel bad about himself.

Lastly, let me fill in some biographical facts that may put my somewhat eclectic thoughts in context. Unlike most people in medicine, I was not of noble birth. My mother left high school in the tenth drade to travel 800 miles to get a job in a telephone exchange during the Depression. She was a half-Swede, half-Dane [such an intermarriage was frowned upon in those days]who always looked on the bright side. She was Little Orphan Annie on steroids. On her 18th birthday, she married my father, a British immigrant who was naturally brilliant. He finished high school, again, during the Depression and there was no money for college. So he ran a radio shop and taught himself electrical engineering from books at night.

Drafted for the Second World War, he was put on a troop train headed for St. Petersburg, Florida, where the U.S. Army Air Corp was training. This train, seemingly carrying soldiers, was actually carrying destiny. At a rest stop in Chattanooga, Tennessee, a federal judge was pulled on board to swear these immigrants in as citizens, so they could work on classified projects. During the War, my father, this high school grad, worked side-by-side with PhD physicists at the Bell Labs in New York and perfected AM radio sideband transmission. Few people know we were broadcasting on German radio stations to our own spies and the Nazis didn’t even know it.

Don’t be the son of someone that smart. Everything mechanical, electrical, plumbing, wiring, etc… was obvious to him and he didn’t understand why I should not have mastered Maxwell’s Equations in one sitting. He was excellent at all things mechanical. He was big – 6’3”, 220 lbs. I was small. He was athletic. I was not. I was the captain of the debate team, which he considered to be a waste of time. I was never smart enough for my father. In many ways, I was not my father’s son.

A post-war disappointment fell hard on my father and drowning his sorrows in alcohol and hitting my mother seemed like all he could do. Trying to protect my mother from this was my job and I didn’t do it very well. Let’s say we did not see eye-to-eye on many things.

So being as independent and belligerent as I am now, I left for college and started work on graduation night in the open hearth furnaces of the steel mills at Great Lakes Steel in Detroit. The open hearth was as you might imagine the pits of hell to be, but it paid well and I learned everything I needed to be a doctor working there. My strength and desire verged on the insane. I always knew my mother loved me and that was enough. So my wife and I worked hard. I graduated from medical school and life went on.

Now comes the hard part: admitting my failings. In the year before I became the president of the American College of Emergency Physicians, I was working at Beyer Hospital in Ypsilanti, Michigan. It was one of those Michigan days that happens in February – ice, snow – it was awful. A bus of school children had gone off the road and hit a pole. They were bringing about 20 children in to be examined. I went in, moving from room to room, fast as I could, doing the best that I could. The parents started to arrive. I walked into a room with a seven or eight-year-old boy and the mother was there. I started to ask questions: John, are you okay? Does anything hurt? etc… He sort of smiled, wouldn’t speak. And I said to the mother: Is there something the matter with him? I saw tears come to her eyes. I looked back at the child and it totally escaped me in my haste that he had Down Syndrome. It turned out that the bus in the accident had been carrying the “special” children to school.

That’s probably the cruelest thing I’ve ever done to another human in my entire life. That mother’s tears have never left me. I should have had the courage to go back into the room and apologize for what I did, but I didn’t. I just moved on. If you want to hate me for this, it’s okay. But I wouldn’t bother because I hate myself for it every day. A good day is when I do not envision a young boy with Down’s. A good night is when I do not feel that mother’s tears on my cheek. God forgive me my sins.

I let a lot of people down that day. The first group were the ancients of medicine. What I did would have made Hippocrates weep. I am ashamed. The next group were those people who had established the American College of Emergency Physicians and at that point the 25,000 members of the College. I openly apologize to you. I should have been the role model. I should have known what to do. I didn’t and I let you down. Forgive me. The last person was my mother. She was the hardest working, most decent person I ever met in my entire life. The day I graduated from medical school was to her the realization of the promise of America. I never told my mom while she was alive what I had done. Sorry, you deserved a better kid. God forgive me for my sins. Now I finish this column asking for your kindness and remembrance that I tried to do the best I could. It didn’t always happen.

“The time has come,” the Walrus said,
“To talk of many things:
Of shoes – and ships – and sealing-wax–
Of cabbages – and kings –
And why the sea is boiling hot –
And whether pigs have wings.”
-Lewis Carol
The Walrus and the Carpenter

Dear Dr. Henry…

Dear Dr. Henry:
I have always enjoyed reading your columns over the years, but none more than August’s suggestions how to deal with difficult patients. I’d like to add another type of difficult patient that we see in our suburban ED: the Entitled Patient. That’s the one who claims to be friends with either the CEO or other hospital big-wigs! Dealing with them presents an entirely different set of problems and perils! Anyway, best of luck in your retirement and thanks for all the insight over the years.
—Gary Glassman, MD
St. Mary Medical Center, Langhorne, PA

Dear Dr. Henry:
I have thoroughly enjoyed your EPM columns, your lectures at ACEP, your philosophical side, and especially your humor! Please reconsider discontinuing your column. Having just read about the six trigger patients I can shed some light on who invented the pain scale. It was the same guy who first imported Kudzu to Florida, brought in Starlings from England, invented political correctness, and started the disco craze. The dirty SOB!
—Neal Jacobson, DO
Baker City, Oregon

Dear Dr. Henry:
I enjoyed the “conversation” with Greg, Judy, Richard, and Earl. I know Richard from the early days in California, ACEP, and ABEM, Greg from many years at ACEP and ABEM, Judy mostly through her book, and Earl from his work at ABEM. I must admit I haven’t read all of the books, but I “saw the movie” by watching these folks over many years. Richard taught me tricks like wearing your name tag on your right lapel, so the other person can see it when you shake hands, over 40 years ago. I will never forget Greg’s lecture on power where he whips out a Montblanc pen.
—Bill Gotthold, MD

Dear Dr. Henry:
I have followed Dr. Henry’s musings for years. They have been thoughtful, provocative and often right on the money- I’ve enjoyed threm all.  Thanks Greg.
—Ric Larson

Dear Dr. Henry:
I for one have enjoyed your columns in EPM and will miss them after your retirement. Having retired myself 2 years ago I know the value of quitting while you’re still healthy. However, I’m working in a free clinic once a month and teaching nursing students pharmacology at a local university. I still enjoy the intellectualism of medicine while not missing the endless forms, opioid-seekers, and clueless administrators worried about the bottom line!
—Dr. Bill Ameen

Dear Dr. Henry:
I have been a fan of yours for forty years, thru lectures, circuit courses and your column in EPM. I will miss your periodic rants and raves. You have a lasting appeal to those of us who truly love what we do, do it for the right reasons, and still find satisfaction in patient care. Your brand of honesty and integrity will be missed. Thank you for your courage and contributions to emergency medicine for all these years.
—R. L. Peterson, M.D.