Friends and Family

Our Plague Year with Heschel

photo by Bertie Bregman

Should doctors treat their family and friends? 

The experts say no, citing personal bias, conflict of interest, professionalism, and other concerns. Our own experience suggests otherwise.

In the early days of the Covid pandemic, Westside Family Medicine partnered with The Heschel School around testing and treating for Covid. The arrangement grew out of a conversation with the Head of School and two doctor-parents, who also functioned as medical advisors to the school.

The Heschel/WFM partnership made practical sense. Rachel and I are also parents at the school - our five children are all current or former students - and we knew and understood the community inside and out. 

We also knew Covid, at least what there was to know at the time. We had diagnosed and treated scores of patients; had a testing infrastructure in place; and were in the trenches, alert to the twists and turns of the pandemic before they hit the news, let alone evolved into CDC recommendations or revisions.

In those early days, before vaccines and home tests, it was difficult to get tested or treated for Covid - unless of course you were sick enough to be admitted to the hospital. Most doctors had locked their office doors; lines at Urgent Care centers snaked around the block; and the labs had turn-around times of up to a week, sometimes longer, making the tests essentially useless.

Most of our doctors quit when Covid hit the city - moving to the hinterlands or choosing to quarantine at home out of fear for their own and their family’s health. We understood but chose to stay.

The NYC DOH directive at the time - advertised on street kiosks and elsewhere - was simple(minded): quarantine at home unless you feel sick, in which case go to the ER.

This was idiotic advice. 

Covid had overwhelmed the ERs, which teemed with the virus - if you didn’t already have it, the ER was the perfect place to get it. Furthermore just because you were sick, even with Covid pre-vaccine, didn’t mean you needed emergency department level care - most of the time you did not.

If the ER was the only choice, patients would be forced to go there who could have been treated in the office, which is precisely what ended up happening, making a public health disaster even worse. We wanted our patients to have a better option.

Besides, I wrote my senior thesis on Albert Camus, the French writer and Existentialist philosopher. He wrote The Plague, a classic novel about an outbreak of Yersenia Pestis, the bubonic plague, in colonial Algeria. The main character, Dr. Bernard Rieux, is a hero of mine. “I have no idea what’s awaiting me,” he says, “ or what will happen when this all ends. For the moment I know this: there are sick people and they need curing.”

The great lesson of The Plague is that at a time like that, it is neither required nor important to make grand moral gestures. It is only necessary to show up for work and do your job.

That’s the problem with the liberal arts. Camus made it tough to flee when we were called upon to be the plague doctors. I felt him judging, looking down on us from above, wearing a trench coat and smoking a cigarette (Camus styled himself after Humphrey Bogart).

So we stayed, and I went in every day, except for the week I got Covid myself. In those early days, as those of you who were also here will remember, the streets of New York were deserted, quiet, eerily peaceful. Was that a tumbleweed that just blew across Broadway? It felt uncanny, post-apocalyptic. I was often the only one on the city bus, sitting alone in the back, the driver sealed off from the passenger area by sheets of cellophane and tape. 

Sometimes I drove to work. Thanks to my MD plates I never got a ticket, no matter where I parked. Everyone has a story about the moment when they realized that Covid was “over” (usually it involves some potential Superspreader event where no one even bothered to bring a mask). For me it happened earlier on, when I started getting parking tickets again.

Over the course of that first year we saw everyone - teachers, students, parents, and siblings. We saw grandparents and babysitters, roommates and friends. We took care of our own families - siblings, parents, cousins. We swabbed thousands of patients - including back-to-school days where we set up testing stations in the waiting room of our office or the lobby of the school.

This was all in addition to our regular patients, some of whom had stayed in New York and some of whom had scattered across the country and the world, but were able to connect with us via telemedicine.

We took care of sick patients over the full spectrum of disease. We did telemedicine visits for students at school, the children peering balefully at us through the iPad in the nurse’s office. We spent hours on the phone, explaining guidelines, giving advice, often functioning as impromptu therapists. 

It was a hard time, often a dark time, but a time I don’t regret.

Family Medicine is a specialty that likes to break down the barriers that Medicine throws up - between organ systems, age, sex, and social groups. Internal Medicine doctors specialize in the heart, the kidney, the liver, the lungs; Psychiatrists specialize in the mind; Gynecologists in women; Pediatricians in children.

Family doctors, for their part, specialize in the person, which may include some or all of the above. It sounds like an oxymoron, but we are an integrative specialty. We call our approach the ‘biopsychosocial model.”

And Family Medicine doesn't stop there, but rather attempts to situate the individual within a family, community, culture and history that invariably and often profoundly contribute to their illness and health. This idea comes across nicely in the academic name of our field: Family and Community Medicine. 

If our work with Heschel is not an example of Family and Community Medicine, I don’t know what is.

Here are two more examples, one real one fictional.

Back in 1998, when we were still residents, Rachel and I spent a month working on the Zuni reservation in New Mexico. We lived in a trailer twice the size of our New York City apartment that looked out onto an enormous mesa rising out of the flat desert landscape. 

The doctors who worked there were inspirational and very Family Medicine. A typical day could involve treating patients in the diabetes clinic, setting a broken bone, delivering a baby, and admitting a patient with ketoacidosis for intensive care. All in the same shift. A month-long rotation is not a lot of time, but I quickly learned two things.

One, there were places where if you weren’t as broadly trained as a Family Medicine doc, you were basically useless. And two, if you didn’t get to know the Zuni as more than just patients, you wouldn’t get very far as their doctor.

The second example is another hero of mine, perhaps less exalted than Albert Camus but no less of an influence: Joel Fleischman, from Northern Exposure.

For those who have never heard of it, Northern Exposure was a TV series from 1990-1995. The main character, Joel, a newly graduated, nebbishy New York Jewish doctor, discovers to his shock and dismay that he is required to work for four years in a remote Alaskan town of 214 people, thanks to the small print in his scholarship contract.  

I won’t go on about this legendary show - don’t get me started unless you don’t want me to stop - except to say if the line between Joel’s patients and friends was not very blurred, there would not have been much of a show and he would not have been much of a doctor. 

Northern Exposure, in other words, is very Family Medicine.

But why resort to the fictional town of Cicely, Alaska, when the real town of Salem, NY, is right at hand? One of my Family Medicine attendings and mentors, Daniel Garfinkle, MD,  moved up there a few years after Rachel and I finished residency. He was the only doctor in town and saw everyone for everything. True, if a patient needed emergency or specialty care there was Glens Falls, about an hour south, but they always came to see him first.

This kind of arrangement is actually more the rule than the exception. Although Family Medicine may be relatively uncommon in the urban Northeast, there are more visits nationwide to Family Medicine than to any other specialty. In rural areas, where access to health care is always a challenge, if you are lucky enough to have a local doctor they will likely be trained in Family Medicine.

Dan is back in the city now, and I called to ask him about his Salem experience. He regaled me with stories that had one common theme: for a doctor in a town like Salem, the dividing line between patients and friends is highly porous.

And not just friends. One of his funniest stories is about a man with whom he was involved in a personal dispute. One day the man, who refused to say hello to him in the street, showed up at his office with a medical complaint. Dan expressed surprise to see him there. “Well, you may be an asshole,” the man said, “but you're also a damn good doctor so here I am.”

Very Family Medicine.

Maybe it was just that the man had no choice. But my theory is that sometimes, choice is overrated. Family Medicine docs like Dan see the question of whether to treat friends and family as kind of a joke. After all, if you live in Salem, who else is there? 

The question is, a joke on whom? Maybe what rural patients have by necessity and urban patients lack by design, is actually the better model. Maybe everyone should have a family doc who treats you like a patient but knows you like a friend. Our experience with Heschel seems to bear this out.

I floated my theory past Dan, who heartily agreed. 

“So then, why did you leave Salem?” I asked.

“I burned out.” He said. “That’s the downside. Anyway, see you next week!”

Next week? 

Oh right, I neglected to mention: Dan is not only my mentor, colleague, and friend - he is also my patient.