The Good Doctor (4 page)

Among the small-town general practitioners who swore by the Osler text was John B. Beeson, who saw patients in Montana, Washington, Alaska, and Ohio between 1904 and 1957, when he retired at age eighty-five. One of Beeson’s two physician sons was Paul B. Beeson, and he kept Osler’s spirit alive through decades as a researcher, professor, and later dean of the Yale School of Medicine. Beeson did pathbreaking research on endocarditis, hepatitis, and fevers of unknown origin. He became a coeditor of the Cecil-Loeb textbook of medicine, which eventually supplanted the Osler volume, and later in his career moved to Oxford University, as had Osler. He trained large numbers of medical students and residents through his teaching rounds on the wards. But Beeson most resembled Osler in his humanism—his “quiet attention to each individual patient” and his “powerful sense of caring.”

In 1939 and 1940, Beeson had been chief medical resident at Harvard’s Peter Bent Brigham Hospital, serving under another famed physician-teacher, Soma Weiss. Weiss, in turn, had been a colleague of Chester Keefer, Louis Weinstein’s mentor. So when my father joined Weinstein as a fellow, he could trace his medical lineage back to Keefer, Weiss, Beeson, and finally Osler.

Although I did find a reprint of a 1980 article, “What’s So Special about Osler?,” in my dad’s papers, he would not have formally considered himself an Oslerian. But my father followed in the footsteps of those physicians who were comfortable with any type of medical problem, who taught young doctors with great passion, and who believed that connecting emotionally with patients was the greatest success they could have. And while they rarely took no for an answer from either colleagues or patients, these physicians viewed their decisions as being in the best interests of their patients. To complete the circle, when I did a fellowship in Seattle, I had lunch on a few occasions with the affable Paul Beeson, who had returned from England and become a distinguished professor at the University of Washington.

In recounting my father’s fellowship, I find it hard not to think of the excitement and optimism of the early 1960s. As the space program, the War on Poverty, and the civil rights movement unfolded, my father and his peers were expanding the study of antibiotics in the laboratory, publishing groundbreaking scientific research, bringing their findings to the bedsides of acutely ill patients, and saving lives that might have been lost just a decade before. And Weinstein was a great mentor. To be sure, Weinstein could be brusque and had a healthy ego; one of his trainees later wrote a satirical book,
Heartsblood
, that was quite critical of the revered professors of this era. But Weinstein saw things that others missed. His personal clinical knowledge—acquired through decades of hands-on experience with infected patients—was undeniable and inspiring. In 1962, for example, Weinstein diagnosed a case of typhoid fever in a man with a mass in his neck. The rest of the patient’s doctors believed the man had cancer. In another instance, when consulting on a physician’s child, Weinstein diagnosed whooping cough, which he had frequently seen at the Haynes; several other physicians had missed the distinctive
whoop
sound. Eventually, he instituted combined rounds, at which infectious diseases cases were presented at various hospitals in Boston in front of fellows, residents, students, and distinguished visitors.

In addition to teaching diagnostic skills to his fellows, Weinstein closely supervised them outside the hospital. At his Monday-evening journal club, an informal gathering of roughly fifteen physicians held in his West Newton home, Weinstein would lead discussions of the latest discoveries about infections and antibiotics as his fellows enjoyed brownies and, almost to a man, smoked cigarettes. This interaction—debating the scientific literature and how it might improve the treatment of patients—was the crux of the fellowship experience, the intellectual hook that had brought these young physicians together. When a fellow missed a meeting, Weinstein called him the next day for an explanation. “I do miss those old journal clubs on the ping pong table,” my father’s former colleague Kenneth Kaplan wrote to him in 1977, “with the paralyzing clouds of smoke, while Hardy nodded in the corner and the dog barked upstairs and the boss barked downstairs.”

This collegial atmosphere, with its emphasis on applied research, ultimately led to my father’s coauthoring nine peer-reviewed articles with Weinstein. The first, published in July 1964, looked at how well penicillin and a popular sulfa drug were absorbed in the intestines of diabetic patients. Another compared the effectiveness of penicillin versus a newer class of antibiotics, known as cephalosporins, in the treatment of certain bacterial infections. My dad was the first author on these papers; most mentors—including Weinstein—rarely permitted this, especially with a first paper.

But it was a four-part series by Lerner and Weinstein in the prestigious
New England Journal of Medicine
in early 1966 that suddenly accelerated my father’s career. Entitled “Infective Endocarditis in the Antibiotic Era,” the articles used one hundred cases of that disease treated at the New England Medical Center to summarize the dramatic changes that had occurred in the previous ten years. The choice of the word
infective
, as opposed to
bacterial
, was a conscious one, reminding readers that multiple types of organisms could infect heart valves. Other physicians readily embraced the new terminology. The phrase
antibiotic era
was also a conscious decision, meant to underscore how antimicrobial agents had transformed—almost magically—an incurable disease into a treatable one. While researching these papers, my father had spoken with the famous Harvard cardiologist Samuel A. Levine, who had told him that, prior to antibiotics, desperate doctors had actually injected dying endocarditis patients with even more dangerous bacteria, hoping to somehow increase the patients’ immune responses to their original infections.

Despite his own longtime interest in endocarditis and his senior position, Weinstein again let my father, who had done most of the legwork, be listed as first author on the four articles. This was quite a coup for a thirty-three-year-old assistant professor of medicine. Because there were four separate articles, the authors were able to cover nearly every topic related to endocarditis, including the organisms that caused it, the choice of antibiotics, the role of surgery, complications, prognosis, and prevention. The series became the definitive summary of endocarditis for years, perhaps even decades. Much later, when I was a medical resident and beginning to write my own articles, my dad told me with rare self-satisfaction that his series on endocarditis was among the one hundred most cited articles in the history of the
New England Journal
.

But my father was growing restless at Tufts, frustrated by the huge time commitment and the relatively low financial rewards of a career in academic medicine. Even as the
New England Journal
series was being published, he was looking for jobs elsewhere. Weinstein was upset, practically offering him his own job once he retired. But my dad did not see himself running a laboratory or administering a fellowship program. When the Veterans Administration hospital in his hometown of Cleveland offered him a position, he took it. Weinstein was sure he’d be back, telling him, “You’ll have my job someday.”

Another person dissatisfied with my father’s decision was my mother. Having grown up in Brooklyn and then the Boston suburbs, where her parents still lived, she had been unimpressed with Cleveland on her several visits there. But in those days, nonworking wives did not get a vote. My dad dispatched her to Cleveland to look for a house, and, in 1966, our branch of the Lerner family returned to Ohio. I was five years old and about to start first grade. My father’s Cleveland relatives were excited that the studious and earnest boy who had become the first physician in the family was returning home. But he would find that the close-knit group of cousins from his youth had dispersed around the suburbs.

My father adjusted quickly to his new position as chief of infectious diseases at the VA and assistant professor at what would soon be known as the Case Western University School of Medicine. He also offered his services as an infectious diseases consultant at other Cleveland hospitals. This arrangement not only supplemented his income but allowed him to see an ongoing stream of great cases, something that he had found so rewarding in Boston.

Working at a government hospital had its challenges. In his home office, my father hung a cartoon of a Civil War soldier with an arrow through his arm patiently sitting in a VA waiting room, still hoping to be seen by a doctor a hundred years after his injury. But as a child, I loved to visit the hospital, where my dad was always being paged on the overhead PA system, which thrilled me even more than the parking space with his name on it. I remember the floors with multiple-colored arrows directing visitors and staff members to the X-ray department, the cafeteria, and other parts of the hospital.

I spent much of every Saturday with my father. When I was still quite young, my mother enrolled me in music-theory classes and piano lessons at the Cleveland Music School Settlement, also located in University Circle. Typically, my dad would drop me off at my lessons and pick me up a couple of hours later. Sometimes, we went out to lunch. Other times, especially when I was younger, we went back to the hospital, where he would bring me onto the wards and plop me in the nurses’ station while he made rounds. Whether or not the legend of my wearing a white coat during such visits was true, the nurses and other staff members always made a big deal out of my being there. My father brought my sister to the hospital as well, but he was not nearly as focused on her becoming a doctor. Perhaps this was because she was a girl in an era in which most doctors were still men, but it also may have reflected the fact that she did not really enjoy math and science.

Another frequent stop was the microbiology laboratory. To this day, I can remember the distinctive sanitized odor of the lab. The technicians always greeted my father warmly, perhaps because he was one of the few doctors who knew them all by name and who looked for bacteria himself, putting infectious material on a slide and staining it—creating what is known as a Gram stain. This was a major issue for my dad, who feared that internists were becoming too reliant on technicians and specialists when it came to the diagnostic studies—not only slides but X-rays and biopsies—performed on their patients. Even so, he made a point of praising lab technicians who did a good job. And he showed me how to grow bacteria on agar plates and how to test them against various antibiotic agents—an early introduction to laboratory technique that fascinated me. “Plate your own cultures” was his chronic refrain to younger doctors.

No topic was more important to my father than hand-washing. Some men’s heroes are athletes, actors, or politicians. My dad’s was the heretical nineteenth-century physician Ignaz Semmelweis who was born in Budapest, Hungary, in 1818. As a young obstetrician in Vienna, Semmelweis made the initially counterintuitive observation that at his hospital, women whose babies were delivered by medical students or physicians died of puerperal (or childbed) fever at a far higher rate following childbirth than women whose babies were delivered by midwives. Noting that the students and doctors often performed autopsies prior to attending births, he deduced that they were inadvertently transmitting an unknown “cadaverous material” that caused puerperal fever in the healthy women. Semmelweis then set up an experiment in which he required those who performed autopsies to thoroughly wash their hands with a chlorinated lime solution prior to the performance of internal examinations. When the death rate fell to that found on the other ward, he believed that he had proven his case. Once the germ theory of disease was elucidated in the late nineteenth century, the rest of the world would agree.

It was easy to see why my father, as an infectious diseases specialist, was obsessed with hand-washing, which, in the 1960s and 1970s, occurred at a disturbingly low rate in hospitals. I was probably the only teenager of my era to read cover to cover
The Cry and the Covenant
, a fictionalized version of Semmelweis’s career. Sadly, things ended badly for him, as he became increasingly dogmatic and mentally ill in his later years. Little did I know at the time that these unfortunate aspects of Semmelweis’s life would to some degree mirror what would happen with my dad.

I was a smart kid, and by fourth grade, my parents had moved me out of public school and into Hawken School, an all-boys private institution. It was difficult for my father not to envision me as the next Dr. Lerner. When I was in my teens, he no longer took me to the nurses’ station while he made rounds but instead brought me to his Saturday medical school lectures. These occurred mostly in the late spring, when the infectious diseases committee, of which he was the de facto head, lectured the second-year medical students. I remember feeling proud, but also bored. I was a good science student but not one of those kids fascinated by how the human body works—or malfunctions. The medical students, however, paid close attention to my dad’s well-received lectures, which he never delivered from prepared notes. Instead, he showed slides, told stories, and shared cases. He cared deeply about his lectures and liked to reward the students who chose to attend these classes.

An annual highlight was the committee’s first lecture, when my father brought to class a rather disgusting but certainly vivid example of pus. What better way to introduce medical students to infections than by showing them what a really bad one could produce? Years before, instead of disposing of the contents of a large empyema (infected chest cavity), he had saved the material in a jar. Between its annual appearances, the jar stayed in our garage. Later in my life, when a former Case Western Reserve medical student realized that I was Phil Lerner’s son, his or her next words were often: “Jar of pus!”