MEMOIRS
A Medical Odyssey
by Franklin Friedman, MD
We arrived at Ellis Island in 1947. It was
two years after the end of the Second
World War. It was three years after the
destruction of our families in Hungary
and five years after evading the Germans
in Vichy, France. We were sponsored by
a relative in Ohio to come to America, a
small nuclear family. Life in America was
not easy. We spoke Hungarian and French.
We moved around quite a bit. One of our
homes was in Colchester, Connecticut. The big city was Norwich,
my first encounter with the “Rose City.” We ended up settling in
Hartford, CT. My mother worked as an LPN at Hartford Hospital.
Sixteen years after arriving at Ellis Island, in September of 1963, I
started my medical education at Albert Einstein Medical College in
the Bronx. Medical school in 1963 was a special, almost magical
place. It was a combination of Parris Island and a most rigorous
university. The prevailing theme was that medicine was a calling,
not a job. And the calling entailed responsibility.
November 22nd 1963, John F. Kennedy was assassinated. Calls
were made for cancellation of first semester exams. Answer:
Medicine is a calling and responsibility. You will face adversity all
your life. Suck it up. Get back to work. Final exams were not to be
canceled.
Medical school was tough, but you slogged through. Most people
made it. What direction to take from here? You thought you had
plenty of time to decide. The best students went into internal
medicine.
Almost everybody’s future was decided by the government and the
Vietnam War. Medicine was a calling and responsibility and you
complied with the draft.
We were the gap generation, too old to fight the war, but too young
a physician to avoid the war. We had to go into “the service”, no
matter your personal handicap was. You could avoid war for two or
five years depending on the lottery decision of the Berry Plan in your
second year of medical school. Some of us were lucky. I enlisted
in the Air Force as a flight surgeon, actually a general practitioner
to pilots stationed in US. Other physicians were not so lucky, such
as the William W. Backus radiologist who served in Vietnam and
was exposed to Agent Orange and died a few years later from lung
cancer.
32 THE OPEN JOURNAL
Residency training after military service was a unique experience,
especially with a wife and kids. The urology department was not
unlike the military. Your chief was “the Boss” with life or death
power over your life. Your family was secondary. Training was an
apprenticeship. At every level you had a resident below you and
above you. In the Chief year you were in complete charge, working
with attendings but only if you needed the help. No time off to
spend with the kids, no time off to be at their deliveries, you had a
calling and a responsibility. And that attitude was deeply ingrained.
I was on call when my fifth kid was born at Backus, and I had just
enough time to sneak in and out the delivery room.
The great change occurred in 1998 when Medicare mandated that
an attending had to be physically with you. This act fundamentally
produced future generations of docs who had never practiced
independently. In the Chief year you were totally independent. Some
thrived, others folded or stayed in academics.
The transition to practice was similarly unstructured. Medicine was
a calling. Money was not the “raison d’etre”. Making a living would
happen. You either went into a group or started an independent
private practice. If you wanted to delay things for a year, you could
get an academic job, a level just above the Chief year. You did not
know anything about the business of medicine. When looking for
a job you had to beware of physicians that would employ you and
never grant you a partnership.
These concerns were not paranoia, but very real. The first group I
worked with in Florida, two urologists, decided that they were not
busy enough to offer me a buy-in after a year. A guy I had interned
with in Jackson Memorial Hospital in Miami, Jeff Goldblatt, told
me they needed a urologist in Norwich, CT. There were already two
urologist in town. With four kids and one on the way, I briefly left
my family and moved 1500 miles to Norwich. I started a practice.
No business consultant. No hospital guarantee. They could not
care less. On April Fool’s Day 1976 at 12 Case Street with the help
of Jeff Goldblatt’s nurse, and one week’s help from a nurse from
the Florida practice who flew in, I was up and running. The family
moved two months later on June 1st, and our fifth kid was born in
November. My income the first months was $26,000, mostly from
assisting the wonderful neurosurgeon, Dr. Mario Sculco. I had no
cases booked from Thanksgiving to New Year.
Continued on page 33

These beginnings were not unique in the world of private practice.
I built a business like an small business entrepreneur, just like
the guy who builds a bodega, butcher shop, or a restaurant. I
moonlighted in the ER at Lawrence & Memorial two 16 hour shifts
a month and at Seaside Clinic for handicapped kids, two mornings
a month.
The business of medicine was viciously competitive. You had to
visit all the doctor’s offices to curry their favor, to obtain referrals.
Some people used golf and social events to foster business
relationships. I did not have the time and did not play golf. In the
beginning, you were expected to use referral docs as OR assistants
for the 20% assistant fee. There were very few tight knit groups.
The competition among the surgeons reflected the various ethnic
groups in town; Wasps, French, Irish, Italian, Polish, Jewish, and
Greek.
The competition did not deter the arrival and successful practices of
Asian MD Sully Ahamed, and the Texan, Tom Bell MD.
With time and perseverance, I came to realize that patient care
superseded other life commitments. The community embraced
me and others like me. Ethnicity was celebrated in families, but
ultimately professional and social friendships trumped any religious
and cultural differences.
The relationship between the hospital, the community, and the
physicians was a special one. When we arrived in 1976, the docs
had to live in town to properly take call for emergencies. Living
in Norwich created a bond between patients and physicians, and
among physicians themselves. Your kids went to school here, your
kids played in the church league at St. Peter Paul. You knew the
neighborhoods, you read the local paper, and you knew the issues.
When you went to Stop and Shop people said hello, and your kids
noticed.
Then when the emergency department was developed and the
local coverage rules were changed, docs could live in the suburbs.
The docs never intimately learned the Norwich neighborhood.
Professional relationships and friendships frayed, mirrored on a
national scale with the balkanization of our society.
Doctors were an integral part of the administration and board. The
relationship between docs and the administration has always been
contentious. However, it reflected physician involvement in quality
of care, strategic planning, and financial affairs. Most docs rotated
MEMOIRS
through the medical executive committee, the hospital board, and
department chiefships in two or three-year stints.
Then the fundamental changes in medicine occurred and private
practice began to die. The Medicaid population in my practice rose
from 10% to 50%. Government regulations increased the cost to
practice, while reimbursements were cut.
The sale of Backus Hospital to Hartford HealthCare sped up the
demise of private practice. Independent hospitals, fearful of
financial collapse, joined mega corporations. Hartford HealthCare
and Backus Hospital expanded and controlled primary care, the
hospitalist service, and specialists, killing most private practices
in Norwich. The few docs who avoided being swallowed up were
in practices that had a good payer mix, or in a field of medicine
largely independent of hospitals such as ophthalmology, ENT,
or orthopedics. Some doctors were bold enough to open their
own outpatient surgical centers to avoid financial collapse and
integration into Hartford HealthCare.
Today we live a world of mega corporations. The goal is a valuation
of 10 billion dollars, large enough to be capitated and self-insured.
Docs running small businesses have vanished. We are now
employed by corporations and reimbursed by RVUs.
When I arrived here from Europe in 1947, the local environment
was replete with small factories whose modus operandi was the
piece work system of manufacturing. Paying factory workers by
the number of widgets they produce, with bonuses that were less
and less attainable, as the workers were in effect burned out and
replaced by new workers.
Medicine is now dictated by RVUs and bonuses, incentives to bring
in more business, downstream income derived from facility fees
and lab testing and procedures. What a change! We were taught
that medicine was a calling and a responsibility, and you sucked
it up and did the right thing, and worked hard to care for the sick.
What you did was immeasurable, but immeasurably valuable. You
would make a reasonable living from your hands on care. Debt from
schooling and business upstart were easily paid off in 5-10 years.
Nowadays, docs are $250,000 in debt after medical and training,
they worry about RVUs and the sweatshop work environment and
the financial viability of mega hospital corporations. This structure
dissuades you from establishing roots in the town in which you
practice. Today’s generations of employees, you are always looking
Continued on page 34
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 MEMOIRS
for your next job, the next hike in pay. Medical school has to be
more affordable so that young doctors are not paralyzed financially
from the beginning. So that severe financial decisions do not
deter them from their calling and responsibilities, and establishing
community bonds.
There are bright spots to build on. The new organizational structure
will be more able to meet the expanding population and their
medical needs. In the hospital, the hospitalist service is much more
efficient in hospital care. The role of mid-levels is evolving to fill the
void of primary care. The educational training and preparation of
PAs and APRNs should be more rigorous. Oversight by physicians is
essential. In time PAs and APRNs will be better integrated into the
treatment team.
Unlike a generation ago, the work force is increasingly diverse with
more women and minorities and foreign educated doctors. This
change is good, since it more accurately reflect our diverse Norwich
population.
34 THE OPEN JOURNAL
Finally, I think that we will inevitably transition to a single payor
Canadian type health system. The emphasis will shift from
reimbursement on the basis of volume of work and testing and
procedures, to a capitation type of system which will entail different
stresses of delivering less care, for greater profit.
The interim step now currently thrust upon us is a valued based
system rewarding lower costs and incurring new stresses for
doctors. Hopefully this will allow physicians and allied healthcare
workers to focus on their calling rather than paperwork.
I have the good fortune of working with a scribe to help me navigate
the trials and tribulations of EPIC, the Byzantine electronic medical
record system. This bright young man is an enthusiastic pre-
medical college student, a native born Pakistani–American, with a
complex family history of his own to tell. He is the new face and
the old face of the medical odyssey, tomorrow’s physician who feels
a call and responsibility in the learning and practice of medicine. n