Most of the friends who graduated with me from Louisville’s Ballard High School were headed to one of Kentucky’s state universities, or maybe to Indiana University two hours away. I wanted to go somewhere I could enjoy a little more distance and anonymity, as well as get a good education—meaning that I could have fun without having instant reports filed with my folks via hometown friends. Armed with my 8mm movie camera and the earnings from my summer jobs, I headed for New Orleans and Tulane University, which took me in as a would-be chemistry major and premed student.
I was grateful: Tulane exceeded my criteria for excellence and distance. My mother was giddy; this fulfilled step two in the three-step tribute as “he wants to be a doctor” slid into “my son’s studying to be a doctor” (which would ultimately morph into “My Son, The Doctor”).
During my sophomore year, I became friends with a slender, shapely, dark-haired Tulane freshman with a stunning smile and incredible mind. Amy Weil was dating her hometown sweetheart, who had decided to go to the University of Florida. This left her going out at Tulane with several guys just casually; I loved watching her roll her eyes, giving each of them grief for their lame attempts to woo her. I elbowed my way into her social circle, where I worked, hard, to become her confidante and friend. When trouble brewed in her long-distance relationship with the Florida Gator, she sought my advice; when he wanted more, I was clearly opposed. By the time I started my junior year, I was in love.
In fact, Amy and I had much in common. We both were born into spirited Jewish clans. Our families owned remarkably similar businesses: Hers ran an electrical supply company in Birmingham, and my dad purchased a lighting distribution company with proceeds he made from the sale of the movie theaters. Both Amy and I enjoyed socializing, thought having a sense of humor mattered, studied hard, and wanted eventually to have a family. We also both felt strongly about making a contribution in the world. While I hoped to do that as a doctor, Amy was studying to be a teacher. We were and have remained idealists and in love.
Among the sweet gifts Amy brought to me was this: She laughed at my jokes. When I sang songs, instead of suggesting an improved key—say, the one in which the music might have originally been cast—she tapped out the rhythm on the table top. If I tried a dance routine, she’d giggle and dance next to me. When I recited long passages from classic Marx Brothers movies, she was the perfect audience of one, applauding when I delivered (however lamely) the punch line. And when I told her I was making a movie, she cared.
With my acceptance into medical school and Amy a year away from graduating from Tulane, it was time to talk about marriage. From my college philosophy class, I remembered Aristotle’s contention that true friendship presents the option of viewing the world through two sets of eyes. I asked myself, “Is this the person whose eyes I want to see the world with, for the rest of my days?” My answer was an unqualified yes. I didn’t see any advantage to waiting a year or two to marry; if this was the right person, waiting meant missing out.
Amy and I were married in Birmingham on a stormy summer night in July 1977, under a chuppah we shared with Rabbi Henry Bamberger. Temple Emanu-El’s rabbi at the time, Rabbi Bamberger made the night memorable by somehow relating marriage to Atlanta Braves baseball. I’ve never been able to reconnect the two, or explain how he did it, but he pulled it off to everyone’s delight.
After a brief honeymoon, we moved to my hometown, Louisville, where Amy finished her degree in elementary education while I started medical school. I’ve never regretted the decision to return home and attend the University of Louisville, although I’d been accepted at other medical schools with more prestigious names and bigger reputations. Maybe it was the lessons I’d learned while riding a jackhammer or digging postholes, but I couldn’t help noticing that the cost of one semester at any of the fancy schools was about equal to all four years at U of L. The thought of explaining such lofty costs to my father made me itch: I couldn’t think of a single good reason to tax my savings, my parents, and my government in order to have a famous name on my diploma. (As it turned out, the choice was not only prudent but hugely beneficial. I received gifts of faculty interest and personal attention at Louisville that I would never have enjoyed in one of America’s more famous “doctor factories.”)
The next decision was a tougher one: What kind of doctor did I want to be, and why? I spent most of medical school going over the options. Because my mother greatly admired a hometown surgeon, Norton Waterman, she had always hoped that surgery would be my specialty. But I had at best marginal interest in cutting bodies open and having people’s lives so literally in my two hands. I wasn’t keen on having to report to work every day at 5:00 a.m. And I didn’t like the brevity of the surgeon-patient relationship: Surgeons were forever saying good-bye to patients, even those they cured.
I also ruled out oncology for fear that I would feel useless and hopeless treating so many terminal patients. And I steered away from pediatrics because I did not think I could stand kids dying and feeling the pain of the bereaved parents, especially the moms. (I could not have imagined, at that time, the reality that I and so many other HIV docs would confront in the eighties and nineties: so many terminal patients, so many of them little more than children, and so many bereaved moms and dads.)
By the start of my senior year, I’d decided to do internal medicine with the ultimate goal of being a cardiologist. In the vast and complex medical universe of thirty years ago, cardiology was a discipline that made sense to me: There was a pump, there was blood flow, there was resistance and pressure. But even as I made that choice, running through my head was the siren song of the classmates who chose radiology: C’mon, Mike, join us! Civilized hours, fantastic pay …
The fall of my senior year I snagged a role I’d coveted for four years: co-chair of the Skit Night show that the medical school staged every December. The show gave would-be doctors a chance to flaunt our nonmedical talents in wicked parodies that we wrote and performed. By tradition, after all the silly skits, the finale would be a sentimental slide show of pictures taken over the previous four years, usually set to sappy music (think: The Way We Were).
If I hate anything more than sappy music, it’s a photo-montage slide show set to sappy music. So I proposed we do what I considered a much more suitable finale: a movie-quality music video set to The Beatles’ classic “A Day in the Life” from their 1967 album Sgt. Pepper’s Lonely Hearts Club Band. I wound up being the chief cinematographer, director, producer, film editor, and projectionist. From the start, I could see each scene of the 4-minute-48-second movie in my mind:
I read the news today oh, boy
About a lucky man who made the grade …
A student—played by my classmate Bruce Tasch, now a psychiatrist in Louisville—is seen opening his acceptance letter to medical school. That’s how it starts, I thought. You take these incredibly creative, diverse, interesting people, and then you put them on a conveyor belt of endless, mindless classes out of which they all tumble, at the far end, stamped into precisely the same form.
And though the news was rather sad
Well, I just had to laugh …
In the second year, the medical student faces more courses, more pressures. At the end of that year—when he’s supposed to be ready to go on the wards and see patients—the film shows him flipping out while observing a grisly procedure in the ER, reeling down the hospital halls, and winding up spinning dizzily in a graveyard. And then he’s in his third year:
Woke up, fell out of bed
Dragged a comb across my head
Found my way downstairs and drank a cup
And looking up, I noticed I was late
Found my coat and grabbed my hat …
But instead of making the bus, he’s at the hospital making rounds
… in seconds flat.
Found my way upstairs and had a smoke
And somebody spoke and I went into a dream …
In the fourth year, and the movie’s final scenes, the medical student dreams that he’s lying on the lawn of a big mansion, wearing his white coat and wondering how he got there. Patient-like wraiths appear out of the mist, and they do to the student doctor what he’s been doing to patients—inserting tubes and catheters and worse. “Hold that position, please.” “This will sting a little.” “Cough.” He awakens from the dream as the soundtrack moans,
I’d love to turn … you … on …
Against a montage of LIFE magazine photos of major events in my generation’s life from 1955 to 1981, the music crescendos and builds. After four years, we medical students finally are coming off the conveyor belt, molded into what we are supposed to be. The last chord resonates as the newly minted doctor, wearing his white coat and carrying his black bag, walks into the sunset.
I wasn’t trying to be outrageous or shocking. I was just following my gut instinct about what would make a good movie. But sometimes, as my fellow director Frank Capra once said, “A hunch is creativity trying to tell you something.”
The Monday evening before Skit Night, I completed the final edits. I threaded the film onto the reels of the projector to watch the newly completed movie for the first time. As I turned the projector on, the bulb blew, and when I reached in to remove it, the metal spring that held the bulb in place sliced my left index finger. “Is there a doctor in the house?” The humor wasn’t that keen, and my finger hurt like sin. I grabbed a gauze pad, wrapped the wound as best I could, and hoped the bleeding would stop before I needed to actually get stitches. While waiting for the blood to stop splashing on the floor, I turned on the television.
At the moment the bulb had popped in Louisville—December 8, 1980—John Lennon was being fatally shot by a deranged fan on the Upper West Side of New York City. I had always felt psychically or spiritually connected to Lennon. I was injured, and he wounded fatally, as I finished my cautionary tale mocking the choice for a life of conformity. As I tried to screen the film for the first time, the brilliant nonconformist on its soundtrack was silenced.
Parallel and perhaps paranormal things like this have happened throughout my life. My great-aunt Florence (Flohoney, the family’s benevolent witch) called such incidents beshert. Loosely translated, beshert means something that is fated, preordained, destined for the one who experiences it. Sort of a Yiddish cousin of magical thinking.
Beshert experiences aren’t the sort of thing I include in conference presentations or scholarly journals. I’m not embarrassed by them, exactly, but neither do I know quite what to say or do about them. They leave me feeling there’s something special going on. It’s not being charmed or invincible; if there’s one thing medicine shakes out of you early, it’s the youthful sense of indestructibility. But a beshert experience leaves me a little silent, vaguely feeling that something uncommon is expected of me, or maybe that I’m called to a special duty or role. If this is delusional, fine; it’s been a useful delusion.
Skit Night went on as scheduled the weekend after John Lennon’s death, and we dedicated the movie (“A Day in the Life”) to his memory. Sappy as it may sound now, I was not the only one who wept while watching and listening.
Leaving med school for residency, I wanted both a specialty and an institution full of possibility, a place where I could do uncommon things. I interviewed at six internal medicine residency programs, but the one that stood out above the rest was the program at the University of Alabama at Birmingham Hospitals and Clinics. Though barely forty years old, UAB had one of the most respected training programs in internal medicine anywhere in the United States, competing well with Duke, Vanderbilt, Emory, and other southern medical-program powerhouses.
At UAB, I was instantly impressed with the charming, bespectacled Alabama native who interviewed me. Bill (William E.) Dismukes was the newly appointed director of UAB’s house staff training program. He’d been educated in the finest programs in the East, then returned to build research capacity at UAB. There he came to be recognized as one of the world’s experts in the treatment of fungal infections, particularly cryptococcal meningitis, a type of fungal meningitis that would later loom large in the world of AIDS and, therefore, my career. Magic.
UAB had a great cardiology program, inspiring leaders, and a wonderful house staff. On “Match Day,” when I opened the envelope to learn which of the schools I wanted had also wanted me, I was elated to see that I had matched in UAB’s internal medicine program. I was on the road to becoming another bald, Jewish cardiologist—precisely what the world needed.
Birmingham offered me an education and brought Amy back to her hometown and her parents, sister, and two brothers. Amy had a native’s knowing love of the city. My first glimpse of Birmingham had been in news photographs from the desegregation battles of the 1950s and ’60s: snarling dogs, brutal sheriffs, and fire hoses unleashed on schoolchildren asking to be treated as human beings. Before we headed to Birmingham, I had to make peace with that history.
I’m not black and did not suffer those dogs, those police clubs, or those fire hoses. Blacks in America have always had the harder road to travel, forced to pay the cost of slavery, Jim Crow lynchings, and segregated institutions. But I am Jewish, and I know something about discrimination and socially sanctioned evil. From childhood, I remember my grandparents explaining to me in whispers why some people we knew had hidden their lineage, and why others wore tattooed numbers on their forearms.
Silently renewing my opposition to all forms of enslavement, hatred, and inequality, I moved with Amy to Birmingham. I embraced as if it were my own “Letter from Birmingham Jail,” in which the Rev. Dr. Martin Luther King explained that “I am in Birmingham because injustice is here.” I began the journey from my own self-righteousness over Birmingham’s history to the discovery of my own ignorant biases and prejudices.
Just a few days after we landed in Birmingham, on June 5, 1981, the US Centers for Disease Control reported eight cases of unusual opportunistic infections that were occurring in gay men in Los Angeles and New York City. If I read or heard the news report on that day, I scarcely noticed it in the excitement of moving and my anxiety about surviving my internship year.
During my first six months at UAB, I rotated through three facilities: the University Hospital, the Veterans Administration (VA) hospital associated with it, and the Cooper Green Hospital, which served the indigent population of Jefferson County. Like most cocksure new docs, I thought I was prepared to practice. But I was completely unprepared for how differently medicine was practiced at these three locations. And so began my earliest education in just how separate-and-unequal American healthcare could be.
The VA rotation was first. Patients there were mostly middle-aged to elderly men with chronic medical conditions, and I’ll never forget one who greeted me on the sweltering day I started. He was sitting in his wheelchair in a shady spot by the hospital entrance, wearing a brown seersucker robe. For a brief moment, perhaps because of the heat of the day and the memory it evoked, I thought the patient was my old construction boss, Pitt. His skin was as leathery, his eyes were the same squinting blue, and in his right hand was a smoking, unfiltered Camel cigarette.
It wasn’t Pitt, but it could have been. Just beneath his Adam’s apple was a permanent tracheostomy, a metal plate with a hole in the center, held in place by a green nylon ribbon. There were deep purple ink lines on his neck, roughly box shaped, to help the oncology technician aim the radiation equipment being used to treat his throat cancer. As I approached him, he lifted the Camel to his “trach” opening with tobacco-stained fingers. Feeding the monster that’s killing him, I thought. He took a deep drag through the tiny metal opening in his throat, and as he exhaled a gust of blue-gray smoke, his eyes met mine and he nodded. I swear it felt like Pitt saying, “Hey, Mike, welcome to your new job.”
At the VA, the government paid the bills as thanks for the veterans’ service to country. The place wasn’t luxurious, but we could mostly get the patients what they needed, if only by slogging through a lot of paperwork. During each of my early rotations, partly to keep my sanity and partly just to have fun, I wrote parody songs with a new set of lyrics for what I experienced each week. The song from the VA was set to the tune of “In the Navy” by Village People, and its opening verse featured that memorable patient:
At the VA
You can get an even break
At the VA
You can smoke right through your trach
At the VA
Everybody cleans their plate, at the VA
Next rotation: University Hospital, so new and well appointed compared to the VA that it felt like moving from Dogpatch to Beverly Hills. Providers from around the region sent patients with unusual diseases to University for evaluation, and fewer than 10 percent of them arrived without health insurance. Thanks to an abundance of resources and staff, the patients there generally received timely, top-notch care.
Then came Cooper Green, a hospital established to serve Jefferson County’s uninsured patients. The same residents and many of the same attending (senior) physicians who worked at University and VA also saw patients at Cooper Green, so there was little difference in medical providers. There was a big difference, however, in ancillary support services and the overall patient experience. Most everything at Cooper Green happened in slow motion: The lab work came back slower, the X-rays took longer. And the patients—on average, lower income and less well educated—showed up for care much later in the course of their illnesses. Because these folks had avoided seeking medical care for as long as they could, the severity of their condition was striking, especially compared to what I saw at University. Ulcers were bigger, heart failure more severe, tumors more advanced.
Patients came late to Cooper Green for all kinds of reasons: the hassle of getting off work or finding transportation, no primary care physician to refer them, no habit within their family of seeking early or preventive care. But I quickly learned that the chief reason patients arrived at Cooper Green long after they had first begun battling symptoms, months after they’d first felt the lump or spotted the blood, was dollars and cents. They saw doctors, hospitals, and clinics as just another source of bills that they had no money to pay. Many of them came from generations of families who might have valued hard work more than education, who had limited finances but a strong sense of decency, for whom incurring a debt you could not pay was shameful. It wasn’t that they were cheap or that they “didn’t know any better.” The truth is that they often knew the risks they were taking with their own lives, but they did not want to suffer the shame of unpaid bills.
The staff at Cooper Green did its best to explain to them that they could seek care and then hope that the slow-moving state benefits system would declare them “medically indigent” and not required to pay. But the sound of it, “medically indigent,” was insulting. And what if the bills arrived before that ruling, or if they somehow weren’t eligible for free care? Rather than risking it, they stayed away, using home remedies that included heavy doses of prayer and blind hope. When it became clear that the symptoms were not reversing, they came reluctantly (and usually at night) to our emergency room. By then, for so many, the time when we might have arrested their disease was long past.
For most of my residency, I divided my time between the three different worlds of these hospitals. When I was at University Hospital, the faces and lessons of the Cooper Green and VA rotations never quite left me. To this day, I remember the fifty-six-year-old black grandmother who collapsed at home and was brought to the Cooper Green ER on a Friday night. The woman’s head CT showed a massive bleed in her brain, the result of years of untreated high blood pressure. There was nothing that could be done. We put her in a private room with the head of the bed elevated.
I had been up the whole night before, and I looked it in my bloodstained scrubs and vomit-smeared sneakers. When I went in to check on the woman before going home, it was just the two of us in the room. She looked peaceful, almost dead. I leaned in to see if she was breathing. As I positioned my head above hers, her jaw suddenly snapped, forcing her teeth together in a loud “whack.” I leaped backward, shaking.
After about twenty seconds, I cautiously eased back to the bedside. She hadn’t awakened. That jarring jaw snap was some sort of reflex—that was the medical explanation, I told myself. But in spiritual terms, I felt like she was telling me, “Back off, Sonny. I’m here because your system failed. And it’s far too late for you to do anything about it.” She was dead the next morning.
The man outside the VA, the apparition of Pitt? He has become, for me, the face of medical need, the patient who has only the US healthcare system standing between him and disaster. He took up residence in my cerebral cortex where, as it turned out, he never left. Decades later, he’s still shoving that Camel through the slot in his shiny metal plate directly into my brain stem.