A Medical Economics Web Exclusive

"All of your patients are going to die"

Tired of this sad truth, the author made an unexpected midcareer switch.

By Gregory G. McKenzie, MD
Internist/Kerrville, TX

It was on the second day of my practice in early February of 1982 that I got a hint of one of the most difficult challenges facing a small-town doctor.

Standing in the corridor of the hospital, I felt a massive hand clamp onto my shoulder. I turned face-to-chest with Dr. Morris, a 6 foot 4 inch member of the internal medicine staff.

"How old are you?" he asked.

"Twenty-seven," I squeaked.

"Well, let me tell you something," he said. "No matter how smart you are, or how much you care, or how much you keep up with the medical literature, or how good a doctor you are, all of your patients are going to die!" Then he wheeled around and lumbered away, leaving me convinced that he was just a cynical, old, burned-out doctor.

Nearly 20 years later, as I sit in my hunting blind awaiting first light, I reflect on my years of solo private practice in Kerrville, a quiet community of 18,000 nestled among the cedar- and oak-studded hills of the Texas hill country. I ponder the reasons that led me to close my successful and lucrative internal medicine practice last year, at the age of 46, to become a hospitalist. In the process, I’d left hundreds of patients scurrying to find a doctor in an area already underserved by primary care physicians.

Was it a midlife crisis? Stress and burnout? I don't think so. I try to rationalize that government, insurance companies, managed care, malpractice attorneys, and other external forces are to blame. But I know the need to change was internal–I was tired of burying my friends.

Dr. Morris wasn't cynical at all. This wise man was trying to prepare me for something that couldn’t be learned in medical school or residency, where one- or two-month rotations offer little opportunity to develop more than cursory relationships with patients.

Once I was in practice, the transformation from patient to patient-friend to friend-patient was inevitable after decades of caring for people who are like me and who share my small-town ideals. We hunted and fished together, attended church and studied the Bible together, shared life crises as I attended their medical problems, laughed and cried together, until finally I cried alone at their bedsides.

The emotional relief of closing my office doors was huge: no more long-term relationships with patients, just brief encounters with the hunters, RV'ers, and retirees who are drawn to the hill country by its mild climate and pristine beauty. I relished the idea of meeting new people with new problems, diagnosing and treating their conditions, and then sending them on their merry way.

That seemed to be the case during the first week of my new position. But yet . . .

Arriving home shortly after midnight, exhausted from a hectic day of admissions, consultations, and medical emergencies, I fell asleep quickly. Then the phone rang at 1 am. "Greg, you've got to come quickly, there's something wrong with Louie!" It was Louie’s wife, Chrissie.

Louie, 41, was the youngest son of Charlie Schreiner III, heir to the famous YO Ranch, a 40,000-acre spread legendary for its Texas Longhorn cattle drives and exotic game animals. He and Chrissie were longtime friends of my wife’s and mine; we’d met through our sons.

I threw on some clothes and arrived in their driveway minutes later. Louie was lying on his back in the hallway in full cardiorespiratory arrest, having suffered a massive anterior MI and ventricular fibrillation. Yelling to Chrissie to call 911, I started CPR. It was familiar territory, but not on a good friend five years younger than I.

The few minutes before the EMS unit arrived were surreal and unforgettable. My mind was flooded with thoughts. This can't be happening to Louie! God, don't let him die and leave three young sons without a father the way my two brothers and I were left. Who will coach Griffin's baseball team?

"Dad!" I was startled back to reality by my son's voice. There peering over the back of the couch were the two blond-headed, blue-eyed best friends, often mistaken for twins, one watching his dad work, the other watching his dad die. I had forgotten that my 9-year-old son Michael was spending the night with his friend, Bobby Lee Schreiner.

Fourteen hours later in the ICU, I once again cried at the bedside of a friend.

Now the glow in the east is unmistakable through the window of my hunting blind, and reveals the silhouettes of two bucks moving through the clumps of cedar. I am overwhelmed with my love of this area and all of God's creation and of all of the relationships I am privileged to have as a small-town doctor. Sure, there are heartbreaks, but the good far outweighs the bad.

I tousle the blond locks of the head resting on my right leg. Michael sits up, mutters unintelligibly and falls back to sleep. I reach for the head on my left leg but the boy is staring out the left window of the hunting blind at a magnificent 10-point buck strolling through an oak cluster 80 yards to our left. Grinning with excitement, he asks, "Do you think my dad would have liked this one?" Yeah, I do," I answer. "He's a real good one, Bobby Lee."

Gregory McKenzie. "All of your patients are going to die".

Medical Economics

2002;3.