Table of Contents
Preface 1

Boston City Hospital, July 1, 1961

The Brigham, 1964-1975
The Beginning of Heart Surgery
Dr. Harken Up Close
The Dexter Fellowship
The Emergence of Technology
Some Boston Politics
Center Stage — The Emergency Room (ER)
Who Gets Sick?
Medicare and Medicaid
Coronary Care Units
The Incredible Operation

U Mass, 1975–1988
Opening a New Medical School
Medical School Politics: Departments and Divisions
Search Committees and Promotion Committees
Research Grants and Research Space
The Role of Departments of Medicine
My Very Favorite Patient
The Massachusetts Legislature
The Mail
The Overdose
The Bishop Has Collapsed!
Malpractice Is in the Eye of the Beholder
A Christmas Story
The Chancellor

The University of Arizona, 1988—
Arizona: People and Politics
Admissions: Choosing the Best Students
Outreach Programs
Cardiology Trips to the Reservation
The Best Part—The Patients
The Arizona Cancer Center: Star of the Show!
The Price Tag of Success
Paying the Price: The Advent of Managed Care
A New Approach: Integrative Medicine

Addendum

Chapter 1:  Boston City Hospital, July 1, 1961

Dr. Franz J. Ingelfinger, Chief of the Boston University Medical Service at Boston City Hospital and the Wesselhoeft Chair of Medicine at Boston University Medical School, glanced at his watch: 6:30 a.m.  Morning Report at 7:00.  A brand-new group of interns.  He always loved the first of July, the day that each teaching hospital in the United States got an infusion of youth.  Bright young men (and a few women!) fresh out of medical school, eager but tense.  Could they cut it?

There was so much to learn in medical school.  After the first week, even the most compulsive medical students knew that they would be lucky if they remembered half of the material.  Had they learned the right half?  Did they forget the half that they would need as interns to take care of critically ill patients?  As the year progressed, their confidence gradually increased.  By the end of three years of internship and residency, they had become well-trained clinicians, ready to go into practice as general internists (or, as they are also called, primary care physicians), or they went on for another two to three years of training to become specialists in cardiology, hematology, pulmonary disease, or other specialties.

To see each group of new interns blossom into mature physicians was a process that kept Dr. Ingelfinger feeling young.

I was told to report to the sixth-floor conference room at City Hospital at 7:00 a.m. on Saturday, July 1, for orientation.  Our group of sixteen interns was to meet with Dr. Ingelfinger and the chief resident. I thought that the orientation would last for most of the day.

The orientation began promptly at 7:00 a.m. We quickly learned that Dr. Ingelfinger was exceptionally punctual and he expected similar punctuality from the house staff (interns and residents) and faculty.  Dr. Ingelfinger was a near legend. He was tall, with a rim of white hair, and he was almost always smiling—even when he was angry!  He had the look of a former athlete—he had played football at Yale. He was extremely competitive and he expected the interns to compete. The three medical schools in Boston (Boston University, Harvard and Tufts) shared responsibility for patient care and teaching at Boston City Hospital. Dr. Inglefinger expected the Boston University (BU) medical service to be the best of the three medical services at Boston City Hospital.  He liked intellectual confrontations, as long as he won!

Dr. Ingelfinger’s remarks to us lasted a total of about ten minutes.  The essence was that we must do everything perfectly, make no mistakes, get a post (autopsy) on every patient who dies, and get as many family members to donate blood to the blood bank as possible.  He pointed to two posters that showed the current percentage of patients dying on the medical service who had autopsies (55 percent) and the current number of units of blood for medical patients in the blood bank (71).  "I want these numbers to go up, not down!"  Furthermore, it was essential that we would have a higher percent of autopsies and more blood in the blood bank than the other two medical services, Harvard and Tufts.

Then he said, “We have new name tags for you.”  House staff on the BU and Tufts medical services had very narrow plastic name tags, just wide enough for one’s name. The Harvard service, on the other hand, had wide name tags with a crimson border.  Our new name tags were wide, with a green border. Dr. Ingelfinger (who had been chief resident on the Harvard service as a young man) said, “If you measure these new BU name tags, you will find that they are one-eighth of an inch wider than the Harvard name tags.”

At the end of these stirring remarks, he turned the meeting over to the chief resident, Barouk Kodsi, who was also quite remarkable.  He was about forty-three and had been on the faculty at the University of Cairo until he emigrated to the United States.  In order to be licensed in the United States, he had to start over as an intern.  By the time he finished his second three-year residency and became chief resident, he had an extraordinary breadth of knowledge.

"Everyone has a room in the House Officers' (old name for interns and residents) Building,” Barouk explained.  “Two to a room.  You can pick up your keys when we finish.  You'll find three sets of uniforms on your bed."  Most of the interns were single, and so they had a very small new home.  The married interns used their rooms when they were on call: every other night and every other weekend.  Today, interns are on one night in four or even less.  Most are married, and no one lives in the hospital. Everyone now wears scrub suits—the white uniforms are gone.

“Since today is Saturday, half of you are off until Monday at seven in the morning.  The rest of you are on until Monday night.  There are two interns and one second-year resident on each team.  One third-year resident is responsible for two teams.  On the weekend, there's one intern for each ward and one resident for every two wards.  Okay?" 

Barouk continued, "When you get to your ward, start looking over the charts (each patient's record).  The resident will be there if you need help."

I looked around the room. Fifteen of the interns were men; there was one woman.  Ten of the new interns were from Boston; they seemed so confident.  Many of them had taken rotations through City Hospital when they were third- and fourth-year medical students.  They seemed to know everything.  The other five were from five different medical schools around the country.  Boston City was a very competitive internship, so I knew that the interns who were from other medical schools must have been near the top of their class.

I wasn't sure how I got here.  I wasn’t at the top of my class. Like the other interns, I had just graduated from medical school several weeks earlier. At age thirty, I was the oldest intern.

I had decided that I wanted to be a doctor when I was about ten.  I had an aunt and uncle who had a subscription to Time magazine. Whenever we would visit them, I would read the section on medicine. My aunt would save the medicine sections for me. I told my mother that I wanted to be a doctor. She said you can be a doctor, or you can be anything that you want to be if you work hard enough. That was the most important advice that I ever got! I didn’t come from a medical family; in fact, no one in my family had gone to college. My father was born in Norway and was a commercial fisherman.  Each spring, he would leave our home in Seattle and travel in a fishing boat to Alaska to fish for halibut.  Our family income depended on whether the fish were running and how much he could make with part-time jobs in the winter. The total wasn’t much and we were quite poor.

I was always a good student until my mother died in an accident when I was twelve.  I stopped studying, didn’t do homework and stopped paying attention in class. One day, my science teacher asked me to stay after class. I thought that I was going to get a lecture. Instead, she asked me if I would like to visit the University of Washington with her.  That Saturday, we took a bus to the university. She introduced me to one of her professors and told him that I was one of the very best students that she had ever had. I almost fell over—I was one of her worst students!  Her professor said, “Well, I hope that you come to the University of Washington.” (I did, many years later!)  That Saturday changed my life. I began studying again and did very well in school. When I think of teachers and the incredible impact that they may have on their students’ lives, it is shocking how little we pay them.

I began college as a pre-med and did everything that the pre-med advisor told me to do. He picked the courses and I took them like all the other pre-meds. My grades were very good, and it looked like I would make it to medical school.

The summer before I started college, I had joined the Navy Reserve to make a little extra money.  When the Korean War started at the end of my freshman year, I was called to active duty. I was a hospital corpsman assigned to the Marine Corps for two years.

When I returned to college, I had the GI Bill behind me and didn't have to worry about money.  I met with the same pre-med advisor and he again told me what courses I should take. In addition to the required courses for medical school, he said that I should take additional chemistry or biology courses as “electives.” I told him that I would rather like to take a history course and a psychology course as electives.  He said, “Are you sure that you want to be a doctor?” I said, “I guess not,” and I changed my major to psychology.

After graduation from college, I got a fellowship to go to graduate school at the University of Michigan. After I received my master’s degree in psychology, I realized that what I really wanted to study was medicine. I applied and was accepted at the University of Washington, and I headed back to Seattle.When I got to medical school, I was one of the oldest students in my class and one of a very few non-science majors. Now our medical students tend to be older, and a few even start medical school in their forties. All medical students have to take certain science courses in college, but they can major in anything that interests them. It makes for a much more interesting group!

 After going to graduate school, I had a very difficult time accepting that in order to be a physician, one must memorize all of the minutiae in the first-year medical school curriculum. (I still do!)  I began to think that I had made the wrong choice. Maybe I should drop out of medical school.

One afternoon in my first year, I was so miserable that I decided to take the afternoon off.  As I headed toward the exit, I saw a poster announcing a guest lecture.  A Dr. Lewis Dexter from Harvard was going to talk about a particular form of congenital heart disease—atrial septal defect.  In embryology, I had thought that the early development of the heart and how various congenital defects might occur was fairly interesting.  I decided to go to the lecture.

Dr. Dexter began the lecture by presenting a case of a thirty-five-year-old woman with a heart murmur and shortness of breath. Then he showed what he had found at cardiac catheterization.  He explained how the findings of catheterization showed that, if someone were born with a hole in the septum (wall) between the right and left atrium, some of the blood coming from the lungs would go the correct way, to the left atrium, and then to the left ventricle.  However, some of the blood from the left atrium would cross the atrial septal defect and enter the right atrium.  As a result, more blood entered the right ventricle from the right atrium than normal.  The amount of blood going out the pulmonary artery would increase as a consequence.  Dr. Dexter called this a left-to-right shunt.  He was the first to figure this out. 

Because the right ventricle was doing twice as much work as normal, it became enlarged.  He showed an x-ray that showed the large right ventricle.  On physical examination, one could feel the enlarged right ventricle push against the chest wall.  The murmur that was heard was due to increased blood flow through the pulmonary artery.  The patient’s shortness of breath was due to the increased blood flow to her lungs.  It all made sense! There was nothing to memorize.  If you understood anatomy and physiology, you could figure it out.

Dr. Dexter went on to say that it was now possible to repair these defects using the heart-lung machine.  The cardiac surgeon could examine the defect while the heart was open and not beating and then close the defect with sutures.  This patient had the operation two years before.  He showed her recent chest x-ray. Her heart size was normal, and she no longer was short of breath.

Some patients do well despite having an atrial septal defect, while others develop a marked increase in the pressure in the pulmonary artery, sometime in their thirties or forties, and die prematurely.

If the physician can suspect an atrial septal defect on the basis of the patient's history and physical examination, cardiac catheterization can determine if there is an atrial septal defect and whether it should be repaired.  Once the surgeon has the right diagnosis, the patient can be cured and have a normal life expectancy.
I was overwhelmed, and I decided three things: One, I would stay in medical school; two, I would be a cardiologist; and, three, I would work with Dr. Dexter.

I struggled through the rest of the first year—hour after hour of lectures. The second year was a little better, especially pathology. On the third year, when we started to see real patients, everything changed. I loved working with patients, trying to figure what was wrong and how it could be fixed.

In the fourth year, one of my advisors encouraged me to apply for an internship in a teaching hospital. He suggested Boston City Hospital. Boston seemed a long way off! I remembered that Dr. Dexter was in Boston and that I might increase my chances of working with him if I interned in Boston.
Well, here I was at Boston City Hospital.

Barouk said, “Okay.  Bass, you've got Medical Four; Lester, Medical Six; and Dalen, you've got Medical Three, but your old patients are in the Dowling Building, sixth floor.  We're moving your patients from Dowling to the Medical Building.  Admit your new patients to Medical Three, but take care of your old patients on Dowling Six."

I thought, Good God  Where the hell is Dowling?

"Okay, let's go.  Those of you on call, go change, and then hit the wards." I headed for the House Officers’ Building, which was a very old brick building in the middle of a series of very old brick buildings that together constituted City Hospital. Boston City began with four buildings with 208 beds in 1864. It is one of the oldest teaching hospitals in the U.S. Thousands of physicians, many of whom became professors in medical schools across the country, received their training there. Twice, its distinguished faculty had won the Nobel Prize for Medicine.

City Hospital was designed to care for Boston’s poor without charge. At its peak, Boston City could handle 2,000 inpatients.  With the decrease in infectious diseases associated with better living conditions after World War II, it was down to about 800 inpatients.  But it saw more than 200,000 patients per year in the clinics and in the ER.

I found my room on the sixth floor of the House Officers’ Building.  It was pretty small, with two beds, one chest of drawers, two lockers, and no bath.  The communal bathroom with showers was down the hall.  One small window overlooked the backside of the surgical building.  I tried on the white pants and white top with buttons but no collar.  No one wore scrub suits then unless they were in the operating room. I put on the name tag—James Dalen, M.D./Intern.  Not bad.  I was ready; I felt like a real doctor!

After asking directions, I found the elevator in the Dowling Building. Even though all the elevators were self-operating, each had an elevator operator during the day, all appointed by the former mayor, Michael J. Curley.  As is the case in many large city hospitals, Boston City was a haven of patronage. Most of the political appointees had their jobs for life (better than tenure for professors), and they tended to be hostile towards the house officers who were very transient in their view.

On my way up to Dowling 6, I thought about which conditions I felt most comfortable in treating and which I knew less about.  Somehow, I felt most comfortable with GI bleeders, because I had a good experience with them as a student.  I knew less about chronic lungers (patients with chronic lung disease).  I found the nurses' station on Dowling 6, and I found the nurse.  She was about fifty, steel gray hair, white uniform, and a white cap with the two black ribbons that indicated she was a City Hospital graduate.

She didn't look up as I approached her desk. I said, "I'm Jim Dalen, the new intern."

She glanced up.  "You'd better go check bed seventeen." 

It was clear that no further information was forthcoming.

I looked to the right and saw a large open ward with twenty beds.  Nineteen patients looked up at me as I entered.  I went to bed 17, the one bed where a patient didn't look up at me. An elderly man was lying on his back, looking at the ceiling. As I got closer, I saw that he wasn't moving and didn’t seem to be breathing.  I looked around; no one seemed to be interested in what I was doing.  What is this?  I wondered if it was a test of some kind.

I got out my brand new stethoscope and listened to the lungs of the patient in bed 17.  No breath sounds.  I listened to the heart.  No heart sounds.  I assumed that my main job was to pronounce the man in bed 17 to be dead, if he was indeed dead.  What if he wasn't dead?  Maybe he had bad lung disease that made it hard to hear his heart.  I'd look like a fool if I pronounced him dead.  Then it hit me!  Get an EKG.  If it was flat, with no evidence of heart activity, I could pronounce him.  Because the patient in bed 16 was sitting on the side of his bed and seemed alert, I asked, "Would you ask the nurse if she would bring me an EKG machine?"  Bed 16 got up and left the ward.  A few minutes later, the nurse appeared in the entrance to the ward and pushed an ancient EKG machine in—then left.  When I plugged it in, there was a puff of smoke, and nothing on the EKG machine seemed to work. 

At that moment, Dr. Ingelfinger appeared.  "Look what you have done. You plugged it into DC  You've ruined the only EKG machine on the medical service."  Then he stalked away.

The last time that I had heard of DC power was in high school physics lab.  It turned out that City Hospital still kept DC power for some of its ancient equipment (not including EKG machines).  I found the charting room, where patient charts were kept on mobile carts. I sat down to think.  Suddenly a resident, Dr. Levin, appeared.  I looked at him eagerly, as if he were the only other survivor on earth, and told him what had happened. 

Levin warned, “Make sure you get the post." 

"Post?  I don't even know his name.

“Well, find out and get the post." 

I found the chart of the man in bed 17.  I found the relative's name and called.  "Hello, I'm Doctor Dalen from City Hospital.  I'm very sorry to have to tell you that your grandfather just passed away.  We're not sure why he died.  It would be best if we did an autopsy.  Do we have your permission?"  I got the post of the man in bed 17.
The head nurse came over to the table where I was recording my triumph at obtaining the post.  I thought she was going to congratulate me, but, instead, she said,

“You’ve got a D/L on the accident floor.”

I had no idea what she was saying.  “What does that mean?”

“It means that you have a new admission who is critically ill. That’s why he is on the D/L (danger list).  You have to go down to the accident floor (emergency room) to bring him up to the ward.  He’s too sick for the orderly to transport.”

“What’s wrong with him?”

“They said pneumothorax.  You’d better get moving.  Better take the stairs down.  The elevator’s too slow.  And, remember, take him to Medical Three, not here.  We’re taking all new patients over there.”

I headed for the stairs.  While rushing down the six flights to the accident floor, I tried to remember what I knew about pneumothorax.  Very little.  Usually a patient had a bleb (cyst) in the lung and it burst.  Air got outside of the lung, between the chest wall and the lung.  The result was that the patient could not bring air into the affected lung.  Good God!  What was the treatment?

I got to the accident floor and wished that I had never come.  Patients were everywhere, far outnumbering the three nurses, two interns and one resident.  I approached one of the interns who seemed to be in a state of shock.  “I’m Dalen from Dowling Six and Medical Three. Is this my admission?”  I looked at the patient.  He was obese, around fifty, and he was very blue.

“Yes.  The priest has already seen him.”  It turned out that the most important thing to do when a patient was put on the D/L was to call a priest to give the sacraments of the sick if the patient was Catholic. 

I listened to his lungs, but it was hard to hear anything in either lung.  “Why do you think it is pneumothorax?”

“What else could it be?” the other intern said as he hurried over to an elderly patient who was vomiting blood.

I got directions to Medical 3 and began to push the metal gurney (ancient stretcher) bearing the patient down a tunnel that I was told led to Medical 3. All the ancient buildings at City Hospital were connected by a series of tunnels.  As I moved the gurney, we passed a number of derelicts who apparently lived in the tunnel.  I kept wondering if this really is a pneumothorax.  If it is not a pneumothorax, what is it and what do I do?

I found the elevator to the Medical Building.  The elevator operator, who appeared to be a dwarf (Mayor Curley was especially supportive of the handicapped), reluctantly took us to the third floor.  As soon as the elevator door opened, the head nurse of Medical 3 was there.  She took one look at the patient and said, “It’s Ralph.  I’ll go get the aminophylline.”  As soon as I had wheeled the patient into the small treatment room on Medical 3, the nurse handed me a tourniquet and a syringe.

“Ralph’s a chronic lunger,” she said.  “He’s here all the time.  Give him this aminophylline IV.”  I did, and Ralph turned pink.  In medical school, I had been advised to always listen to the nurses!

In those days, it was common to take a medical internship at one hospital and then take the next two years of residency at another hospital. Now, nearly everyone takes his or her internship (now called first year residency) and subsequent residency at the same hospital. I didn't think that I wanted to spend more than one year at City.  It was old and gloomy.  The equipment was terrible.  Everyone knew that if you wanted to stay on at City as a resident, you could as long as you weren’t a bad intern.

My roommate, George, went to see Dr. Ingelfinger at the beginning of August to tell him he wanted to stay on as a resident.  Dr. Inglefinger replied, "Well, we'll see.  I'm only going to keep four of you interns—the best four."  From that point on, all sixteen interns wanted to be one of the Chosen Four.

The rules of combat were quickly established.  Each day on attending rounds, Dr. Ingelfinger would point to an intern, staring directly at his nametag, and ask a penetrating question.  It soon became apparent that on a given day all the questions related to a single disease or topic.  Everyone figured out that Dr. Ingelfinger reviewed a chapter in one of the classic textbooks of internal medicine each night.  However, he seemed to pick the chapters in random order, so that there was no way to be ready for him.

When he asked a question, there were only two possible replies.  The most frequent was “I don't know.”  The only other reply was the exact, precise answer.  In other words, you didn't try to bluff Dr. Ingelfinger.  On very rare occasions, someone would tell him something that he didn't know.  He would ask, "Is that a fact?"  It had better be, because he would never put anything into his brain that wasn't verified.

Over the next six weeks, I did not fare well with Dr. Ingelfinger's questions.  I was 0 for 20.  On one occasion, he told me, "You might be right, but if you are right, you're right for the wrong reason, and that's even worse than being wrong."  With my track record, I knew that I wouldn't be one of the Chosen Four.  I began to inquire about other residencies in the Boston area.

One morning on rounds, Dr. Ingelfinger examined one of my patients, Mrs. Minneka, who had had a series of devastating strokes.  Dr. Ingelfinger spent a long time checking her reflexes.  He seemed especially focused on the Achilles reflex.  What had he been reading the night before?  Then it came, “What's her PBI?” (PBI was a blood test that measured thyroid function at that time.)

I was standing at the back of the group in accord with my perception of having become a nonplayer.  "Why do you want a PBI?"  I was shocked that I had spoken.

"Who said that?"

"I did. I'm her intern." 

Dr. Ingelfinger moved toward me, his gaze intent on my nametag.  "I want a PBI because this woman is hypothyroid.”

I said, “Why do you think she is hypothyroid?"  The rest of the house staff stepped back as Dr. I moved even closer to me.  He sensed a battle coming on that he would surely win. 

"I can tell she is hypothyroid just by looking at her.  She has the classic face of hypothyroidism." 

I looked at her face and replied, "She is a normal-looking Eskimo." 

"What? Are you telling me that this woman is an Eskimo?" 

"Yes."

"How do you know she is an Eskimo?"

"Just by looking at her." 

"Are you telling me that you can just look at someone and say that she is an Eskimo?"  By now Dr. Ingelfinger and I were a few inches apart.  "How can you do that?" 

"Because I spent a summer in Alaska and worked with Eskimos every day."

Dr. Ingelfinger was taken aback.  He had never been to Alaska and had never met an Eskimo.  Was it possible that this intern was right and that he was wrong?  He went over to the patient and asked, "Mrs. Minneka, where were you born?" 

As far as I knew, Mrs. Minneka had not spoken for years.  But she opened her eyes to speak, "East Boston."  Dr. Ingelfinger gave his victory smile.  From then on, I was one of the Chosen Four.  I had gone head to head with Dr. Ingelfinger and lost! As far as I know, Mrs. Minneka never spoke again.

I did win one battle with Dr. I. One day, I found a note in my mailbox: “See me—FJI.” This was not a good sign; in fact, it was an extremely bad sign. To be summoned to Dr. I’s office meant that you had been two minutes late for rounds or had committed some other equally heinous crime. When I got to the office, I told Dr. I’s secretary that I had received a note that Dr. I wanted to see me. She asked my name.  I replied, “Jim Dalen (Doll-en).”

Suddenly, Dr. I emerged from his office.  “That’s DAY-len.” 

I said, “No.  It is DOLL-en. That’s how my father and my grandfather always pronounce it.”

Dr. I responded, “Okay.  It is DOLL-en whenever you do something right around here. All the rest of the time, it will remain DAY-len.”

Years later, Dr. I was the editor of the New England Journal of Medicine, and I was a cardiologist at Harvard’s Peter Bent Brigham Hospital.  About two or three times a year, I would get a call from Dr. I.  The conversations were always the same.

"How are you, Jim.  This is Franz."  Before I could reply, Dr. I would say, "I have a paper here (a manuscript submitted for publication in the New England Journal) and something doesn't look right. It says...,” and then he would read something about cardiac catheterization.  I was head of a catheterization lab at the Brigham, so the questions were not like the old days: I knew the answer immediately.  But I knew the game.  I would hesitate and then say, "Would you ask me that again?"  Then I would pause. "Yes, that's correct."  Dr. I would ask, "Are you sure?"  I would say, "Yes, I'm sure."  Dr. I would then say, "Okay, thanks."  Click.

No one knew how many calls Dr. I made every day.  But, under his editorship, the New England Journal of Medicine's reputation for accuracy was well deserved.
Several pictures on the walls in the House Officers’ Building were of James Michael Curley, former Boston mayor, former governor, former congressman and patron saint of City Hospital. One of the Curley pictures was a giant Mayor Curley hovering over a picture of City Hospital.  Another was a picture taken the day that Curley left the federal penitentiary after serving a term for extortion.  Another showed him tipping his hat on the day that he had lost his last election, his last hurrah.

Mayor Curley died at City Hospital two years before I started my internship.  But Curley left his legacy.  I began to hear about Mayor Curley from my patients.  Older patients, who had been coming to City since they were born there, talked about James Michael in near-reverent tones.  I designed a survey, which I presented to a select group: patients who had lived in Boston for at least seventy-five years and were in full possession of their faculties.  Most of those meeting these criteria were little old Irish ladies.  The first question was this: “Who in the past seventy-five years was the best mayor Boston ever had?”  Ninety percent said, “James Michael.”  Five percent said, “Honey-Fitz” (John F. Kennedy's grandfather) and five percent named others.

The next question: “If you met the mayor on the street, would he call you by name?”  Fifty percent said, "Yes."

The last question was this: “Did the good mayor ever do anything for you personally or for your family?”  An incredible one-third said "Yes."  They said that he “got my brother a job” at City Hospital or on the police force, or “got my husband out of trouble when he got arrested for fighting.”  One said that on Thanksgiving the mayor had a turkey delivered to her apartment (probably from City Hospital).  The list went on.  No wonder he usually got elected and reelected—even when he ran for Congress while he was in prison!

Before Medicare passed in 1966, when poor patients and patients without private insurance were admitted to hospitals, they were “ward” patients. In city and county hospitals, their beds were in wards: large rooms with fifteen to thirty beds. They had very little privacy, although men and women did have separate wards.  The house officers at Boston City used to call the largest men's ward “life under the big tent.”  

Patients with insurance were usually taken care of in private hospitals where there were private rooms or double rooms and a few four-bed rooms for the ward patients.  It clearly was a two-class system.  The private patients had a private doctor who was responsible for their care.  In private hospitals that were teaching hospitals, the residents also took care of them, but they had much less authority than with the ward patients.

At Boston City, virtually all the patients were ward patients and they were the responsibility of the interns and residents.  There was an attending physician, a faculty member from one of the three medical schools (Boston University, Harvard and Tufts) who made rounds with the house staff three to five times a week.  The house staff only presented the most “interesting” patients to the attending physician.  They would often spend an hour discussing the proper laboratory workup of an exotic disease. Faculty members were available as consultants for patients with special problems.  Although it was a two-class system, it worked fairly well.  The house officers were convinced that ward patients got the best care in the world. The price was certainly right; ward patients never received a bill for their hospital stay.
When a ward patient became critically ill, the intern called the resident, not the attending. In the early ’60s, there were no ICUs (Intensive Care Units), no CCUs (Coronary Care Units) or monitoring equipment. If a patient was critically ill, the patient remained in his bed in the ward and the house officer stayed at the bedside.  Most wards had one or at the most two nurses on the evening shift to care for the twenty to thirty patients. If one were fortunate, an additional special nurse might be available to take care of one or two critically ill patients. Each of the wards had one or occasionally two small private rooms that were designed for the very rare private patient—that is someone with health insurance. Usually vacant, these rooms could also be used to treat critically ill ward patients.

The care of patients with heart attacks (myocardial infarction) was not very complicated. They were placed on the danger list—this meant that if they were Catholic, the priest was called to give the sacrament of the sick. They were at bed rest for six long weeks. The treatment was entirely reactive. The mortality was 20 to 30 percent. An EKG was done daily to see if they had arrhythmias that required treatment. If congestive heart failure occurred, it was treated. If the patient developed shock, they were treated with a medication named Levophed—which was rarely successful. Patients who survived rarely returned to work. Some studies from England at that time indicated that the outcome for patients with myocardial infarction was better if they were kept at home.

We did see some very unusual cases at City Hospital. When we had a new admission, someone from the Accident Floor (ER) would call to the ward clerk and announce the patient’s name and the admitting diagnosis. The ward clerk would then pass this information on to the intern who was “up” for admissions. The interchange between the clerk in the Accident Floor and the ward clerk often resulted in some garbled diagnoses.  I was quite taken aback when the ward clerk told me that the next admission had a diagnosis of Hansen’s Disease. I said, “Are you sure they said Hansen’s Disease?” (This is another name for leprosy.)
She said, “Absolutely!” 

We all anxiously awaited his arrival. All anyone could remember from medical school was that patients with leprosy had “leonine facies,” which presumably meant that they looked like a lion. When he arrived, we decided that he did look something like a lion. Even though leprosy is minimally contagious, the nurses put him in a bed at the very end of the ward, and they put room dividers around his bed. Within a very short time, all the patients on the ward knew that one of their roommates had leprosy. None of the other patients would venture near him; he was treated as pariah. The next morning when we made rounds, his bed was empty. We never did find out if he really was a leper!

Another memorable admission came when the ward clerk said the patient coming up from the Accident Floor had a diagnosis of Rule-out Rabies! When the new patient—a middle-aged man—arrived, he said that his cat was sick, so he had put him in a cardboard box and took him to a veterinarian. While he was in the waiting room, the cat got out of the box, bit our patient on the arm, had a seizure, and then fell to the floor, dead. Our patient said that there was no one else in the waiting room, so he put his dead cat back in the box and left it in the waiting room. Then he came to the ER to have the bite treated. The shots to prevent rabies were quite toxic at that time, so we needed to find out how great the risk of rabies was. We got an infectious disease consultant who told us that we had to bring the cat to the state health department. They would examine the cat’s brain and determine if the cat had rabies. If the exam turned out negative, our patient would not require the shots.  We called the veterinarian and he remembered finding a dead cat in a box in his office. We asked where the cat was now and he told us that he had a service come in that picked up all dead animals from his office. We called the service and they confirmed that they had picked up the cat and had taken it to a pig farm thirty miles north of Boston and buried it with other dead animals. How could we retrieve the cat? We called the Boston police for help. They said that they would send an officer right over to pick up our patient and take him to the pig farm so that he could identify his cat. I was then a resident and decided that he should be accompanied by his intern.  A few minutes later, the police officer arrived and the patient and intern traveled to the pig farm by police car at great speed with the siren blaring.  When they got to the pig farm, they found that the cat had been buried in a huge pit containing hundreds of animals. The patient was asked to identify his cat—a very unpleasant task!  He quickly pointed to one of the dead cats and said, “That’s the one!” The cat was retrieved, and then they sped to the state laboratory to deliver the cat where they were told that we wouldn’t have the results of the exam for several weeks. Further discussion with another consultant revealed that dying cats frequently have seizures and rabies is very rare in cats! The patient decided to go home without the rabies shots. He did well, and we never did receive the results of the cat’s exam.

Health care costs were not a concern in the ’60s and ’70s.  The health cost per year per capita in 1960 was $141; in 2005, it was $6,400.  One night in a private hospital cost less than $100.  Now, one day in the hospital costs more than $6,000. Patients stayed on the wards for weeks, getting tests that could have been done as an outpatient. Each intern had more patients than today's intern, but the pace was slower because the patients were not as sick. It was very common to admit patients for a GI workup, which meant an upper GI series and a barium enema.  With scheduling problems or “poor preparation,” that is, when the enemas used to clean out the GI tract prior to the upper GI series and barium enemas were less than successful, a GI workup in the hospital could take up to a week.

City Hospital had a very large parking lot, but it was reserved for the administrators and favored employees—especially those who had been hired by Mayor Curley. House officers were not allowed in the lot; they had to park on the streets surrounding the hospital. However, there were large signs that said no overnight parking. Since interns were on duty at the hospital every other night, the only place that we could park was against the law. The law was only sporadically enforced, except when it snowed one was sure to get a ticket. I parked on the street with the other house staff and would pay $10 for the occasional ticket. Unfortunately, I neglected to pay some of them on time and I received a summons directing me to pay $120 or to appear in court. Since my monthly salary was $128, I had no choice; I had to go to court.  I went to see one of the hospital administrators to inform him that I might not be able to come to work for a while. He asked why. I told him, “Since you don’t allow the house staff to park in the hospital parking lot, we have to risk getting tickets when we are on duty all night, and I can’t afford the tickets so I am going to jail.”

He said, “Thanks for the information,” and I left. The morale of the house staff at City Hospital was very high. The one thing that tied us all together was our universal dislike and mistrust of the administration!

I did have fifty dollars that I had been saving, so I took the fifty dollars, wore my intern’s uniform, and I took a large textbook of medicine to read while in jail. When I got to the court, I found a seat in the waiting room. 

Soon a Boston police officer saw me and came over. “Are you an intern at City?”

I said, “Yes.”

He then said, “You shouldn’t be here (he didn’t inquire as to my crime), come with me.” 

I followed him into the crowded courtroom and sat in a vacant seat in the front row that he pointed to. He then approached the judge in the middle of the proceedings and leaned over and spoke into his ear. He then pointed at me and the judge looked over at me. I didn’t know if I should wave or smile. 

The judge then called my name, and I approached the bench. He said, ”Guilty or not guilty?”

I said, “Guilty.”

Then he said, “One hundred twenty dollars, file.”

I replied, “I don’t have one hundred twenty dollars.” 

He said, “File, file, go, go!”  And he pointed toward the door. I finally got the message that “file” meant that you didn’t have to pay a fine, and I left as quickly as I could!

The cafeteria in the House Officer’s building served breakfast, lunch, dinner, and a midnight meal. The price was right (free for house officers), but the cuisine was less than inspiring. Liver with onions and boiled potatoes was one of the staples. Rumor had it that if one took all one’s meals there they could expect to develop a variety of vitamin deficiencies as well as anemia.

One of the reasons I chose Boston to do my residency in internal medicine was because I knew that Dr. Dexter was at the Peter Bent Brigham Hospital in Boston.  When I finished my residency at City Hospital, I asked Dr. Ingelfinger to write a letter of recommendation for a fellowship in cardiology with Dr. Dexter.  He said, "Lew Dexter and I were classmates at Harvard Medical School.  I'll write a letter for you."  Dr. Ingelfinger was famous for his terse, brutally honest recommendations. 

Years later, I came across the letter of recommendation from Dr. Inglefinger in my personnel file: "Dear Lew:  Jim Dalen tells me he wants to take a fellowship with you.  First of all, Dalen is no genius.  However, he would be good enough to be a GI fellow with me.  Therefore, he certainly is good enough to be a cardiology fellow with you."  The one letter from Dr. Ingelfinger got me the job.