May 2014: Medicine - The Way it Was
Medicine - The Way it Was
Med School - Trial by Fire
Practice in Nebraska
Medical Costs of Long Ago
An Expert at Improvisation
A Note to the Reader
Commercial Drivers License Exams
In the 1930s, Doctor Hull Cook owned and ran a 20-bed hospital in the small town of Sydney, Nebraska. He recorded his 50-year practice in a memoir entitled "50 Years a Country Doctor", published in 1998.[1] Besides being a good read, his story provides a telling glimpse of the dramatic changes in medicine over the past seventy years; what has been lost - and what has been gained.
Hull entered medical school in Colorado in 1932. Examinations and tests were frequent and every few weeks someone would flunk out of the school. The original 90 students in his class were increased by 10 transfers, necessary to get a decent graduating class because a total of 50 students were failed out. By contrast, today upward of 80 percent of students graduate from med school.
By the last half of his junior year Cook was doing laboratory work at night, starting IVs, and taking care of people with life-threatening conditions such as diabetic ketoacidosis. In his senior year he delivered babies, assisted at major surgery, performed minor surgery, and was given far more responsibility than medical students are today.
Once, when he was assisting in surgery in his senior year, the patient's blood pressure fell precipitously. It was impossible to start an intravenous in the usual way. The surgeon was so busy trying to stop the bleeding that he asked Cook to make an incision in the patient's ankle, find a vein, and thread an intravenous catheter into it. The author notes that despite his anxiety he succeeded. He credited his success to the training he had been given using dogs.
In those days interns were on duty just about constantly. If they wanted time off they would have to pay a medical student to come in and take their place, a role Cook happily fulfilled.
In 1936 the author, now Doctor Cook, traveled to San Antonio for his internship. The attending doctors were not frequently in the hospital as they are today, but usually working at their office practices some distance away. When a person came in with an emergency such as appendicitis, Doctor Cook would call the patient's doctor, tell him the situation and ask what the doctor wished to do. The answer usually was "Can you handle it?" Doctor Cook usually responded in the affirmative and the patient's doctor would ring off with "Well, call me if you need help." I needn't tell you the training goes in a much more deliberate fashion today. In some the top programs surgical residents will not put scalpel to skin until much later in the program.
Doctor Cook was paid, as were the other interns, $10 a month.
After two years in San Antonio, Cook returned to Nebraska to begin practice in Sidney, a town of 3300 people. His employer, a much older physician, owned and operated a 20-bed hospital. Be it cancer or an acute surgical problem, few patients were referred out of town.
The hospital boasted an x-ray machine and a radiation therapy device to treat cancer. There were no lead aprons or lead gloves for the doctor, nor was there an x-ray technician. Doctor Cook developed some radiation burns on his hands and forearms before realizing the danger.
In today's hospitals, arguments rage over whether restraints should be used to prevent violent patients from leaving their bed and their room to wreak havoc on others in the hospital. No such arguments occurred in Sydney Nebraska in 1937. A man in delirium tremens posed a threat to the nurses; the police were called and loaned the hospital a set of handcuffs.
The hospital's methods, somewhat primitive by today's standards, were still the latest science compared to the local home cures. One farm woman, a strong believer in cow manure compresses, limped into the clinic with her nephew holding a bucket of cow manure under her broken ankle. She was mightily relieved when Doctor Cook pronounced that this remedy had produced all the benefit it was going to and they should move on to the second phase of treatment.
After Doctor Cook had been a year in Nebraska, the senior doctor died, and Doctor Cook started making payments to the widow in order to take over ownership of the hospital. He was now on call 24 hours a day, seven days a week.
To give you an idea of medical economics in those days, Doctor Cook had worked for the older physician at a salary of $125 a month, just above the average household income for those days.[2]
Billed rates for medical services in Sidney in the late 1930s were:
Obstetrical care and childbirth -- $35
Extra for complicated obstetrical care -- $10
House call base fee -- $3
Additional fee for every mile out of town he had to travel -- $1
Day rate for hospital stay (this included, if required, the operating room, the delivery room, all injections, and the nursery) -- $5
Gastro-jejunostomy for stomach ulcers -- $150
As an example, a woman requiring two days treatment for fulminant kidney failure, including all physician and hospital charges -- $62.50
Many of these fees, low as they seem today, ended up being reduced, forgiven, or just never remitted, as in the last example above. (The patient unavoidably died, and her husband decided a money-back guarantee was in order.) In the custom of the day, Hull cared for anyone who came in the door. In return, he had no concern about the legal or emotional drain of a malpractice suit. He was allowed to practice as he saw fit.
In the depression-era 1930s, Sydney Nebraska was not a particularly prosperous town. Hull's income from the hospital failed to cover his payments to the widow. He moved his offices from another building into the hospital to make ends meet.
Doctor Cook's medical career stretched some 50 years. In 1955 citizens of Sydney built a new and more elaborate community hospital to replace Doctor Cook's. But to the townspeople, farmers, and to Doctor Cook change came slowly. Here is just one example.
You may have seen pictures of people lying in bed with the cast on a broken leg, and ropes from the cast going to a pulley at the end of the bed with weights to keep the bones aligned while the leg healed.[3]
Of course, to do this Doctor Cook had to place a pin through the tibia.[4]
Usually setting the pin requires a doctor, at least one nurse, a small mountain of supplies and equipment in an operating suite, and, in Doctor Cook's mid-career, cost some $1000. The good doctor, in his never-ending quest to solve his patient's problems at a cost they could pay, realized he could insert the blunt end of the orthopedic pin into his electric drill, douse the pin with alcohol, light the alcohol to sterilize the pin, cool the pin in a surgical antiseptic, inject a local anesthetic into the skin and area around the bone, and drill the pin through the bone in the patient's room. He reports that he always succeeded with this and never caused an infection.[5] These days, any hospital attorney would suffer a cardiac arrest at the mere suggestion.
Today we can relieve many kinds of suffering much more effectively than could Doctor Cook, and in those situations, you wouldn't wish to go back in time. But if you sense we have also lost something vital, you'll want to read this book.
Doctor Cook's stories cover Sidney, life on the surrounding farms, on the wintry roads to the farms, the local house of ill-repute, people with all their embarrassments, foibles, faults, and yes, heroism from both genders. I promise that you'll laugh and you'll smile.
Some readers may find Doctor Cook's stories and attitudes somewhat disturbing, especially regarding the use of handcuffs as restraints or dogs for practicing surgical skills. If you do read this book, you deserve a warning that your reading journey will carry you into quite a different time than you may be used to.
Commercial Driver's License Exams
The Federal Motor Carrier Safety Administration has begun to apply standards for commercial truck drivers that approach those of the Federal Aviation Administration. As a result, only physicians certified by the National Registry of Certified Medical Examiners may complete drivers' physical examinations. We now carry this certification.
Many of our patients are working individuals; we do take care of work-related injuries under Washington State's industrial insurance law. You do not need to pay for work-related injuries at the time of the visit. We process all claims directly through Washington State's Department of Labor and Industries and the private insurers, and are paid directly by these companies.
You do not need to be an established patient of our clinic for such care.
[1] http://www.amazon.com/Fifty-Years-Country-Doctor-Hull/dp/0803263899/
[2] About $1000 per year according to US government records. http://www.bls.gov/opub/uscs/1934-36.pdf
[3] https://www2.aofoundation.org/wps/portal/!ut/p/c0/04_SB8K8xLLM9MSSzPy8xBz9CP0os3hng7BARydDRwN3QwMDA08zTzdvvxBjIwN_I_2CbEdFADiM_QM!/?basicTechnique=Femur%20shaft%20fracture%20management%20with%20minimal%20resources&segment=Shaft&bone=Femur&showPage=redfix
[4] http://roentgenrayreader.blogspot.com/2012/01/lower-limb-skeletal-traction-proximal.html
[5] 50 Years a Country Doctor by Hull Cook page 186