Constance E. Putnam, PhD

Concord, Massachusetts, United States

Schoolyard taunts generally convey an obvious message to all who hear them: "Fatso," "Four Eyes," "Slowpoke," "Dumbo." One directed at me when I was a child, however, baffled me: "You think you're so smart, just 'cause your dad's a doctor!"


To be sure, my dad was a doctor, which I knew set my siblings and me apart. The fathers of most of our classmates and friends were stay-at-home subsistence farmers; their children understood each other. A couple of dads were on the staff of a nearby college. Other kids' fathers included a store keeper, a janitor, and a cook. Except for the store keeper, they worked out of town and were relatively invisible. My dad, on the other hand, was very visible, not only in the village but traversing every back road of our town and some two dozen nearby communities. Most families in this far-flung territory had reason, at some point, to make use of his assistance. Old and young alike knew him.


Dad believed that the life of his own family had to be integrated into his work if the practice was to be viable. I think parts of my story about the close connections between my father's practice and our family life can shed light on the classic picture of the rural general practitioner (GP). The image of a heroic doctor crisscrossing his fiefdom at all hours of the day and night—to heal and comfort and sometimes save lives—has much verisimilitude. Many such tales have been told. Certainly the country GP was for generations a hero of small-town and rural America; my father fit the pattern. The doctor's family, however, has generally been left out of the picture. No one has really examined how a rural doctor might need or want to have his family pitch in, turning his medical practice into a very personal kind of family business. But the logic of this made sense to a doctor and his wife who were liberal arts graduates in the humanities and saw the practice of medicine as more than a strictly scientific or medical endeavor.

 

The most obvious indicator that a rural medical practice is a family business appears when the doctor's office is located in the family home. A second sign, frequent at least in those instances where physical proximity made it convenient, is the active assistance of the doctor's wife in the practice. She might be a nurse, work as a bookkeeper, or manage the office.

In such cases, the parallel to the family-run store—often in the front of the house or on the ground floor of the family's home—is easy to see. On a busy day, the shopkeeper might call over his shoulder to the back room for his wife, or even one of the older children, to lend a hand. Just so, the doctor might stick his head through the doorway that separated "office" from "home" to ask his wife to answer the phone, make appointments, or hold something for him when he needed a third hand.

A rural GP's children might also see themselves as part of a family business, being counted on to use a wide variety of skills to help out. Certainly that was true in our family. For one thing, we all knew a lot about what kind of work Dad did; he was not employed in some distant office we had never visited. We saw a good deal of him, more than children whose fathers worked away from home all day ever saw of their dads. We knew medicine was more than science. We knew Dad loved the art of it as well.

Furthermore, though we were not permitted in the "office" part of the house when patients were around, the boundary between office and home was permeable. Not only did Mother and Dad move freely from home to office and back again; as the practice grew and Mother was no longer Dad's only employee, his medical associates also would appear in the "home" part of the house for a short coffee break. Then, too, when Dad was called away in the middle of meals, we of course knew it. When dinner was delayed because we were waiting for Dad, we learned how utterly unpredictable rural medical practice could be. But there was more.

Other people certainly seemed to think we were involved in a family business. Not only did we live where Dad's office was (I remember friends saying they did not want to come to my home because it "smelled like a doctor's office"), we were also typically referred to as a group: "the doctor's family." Everyone seemed to recognize us. Across a large swath of Dad's territory, wherever one of us went, someone was bound to say, "Oh, you must be one of the doctor's children."


Already before we started school, there were features of our early years that were not characteristic of the lives of our friends. For one thing, we each learned to answer the phone at a very early age. That did not mean just picking up the phone and timidly saying "Hello" in the cute way many small children do. We were taught to speak up clearly, and to say, "This is the doctor's office. May I take a message?" The rule was to get at least the caller's name and, ideally, a phone number. Even as we got older, we were not expected or even encouraged to take detailed messages about medical matters. But it was drummed into us from the beginning that the phone was a piece of equipment crucial to the business of medicine. Personal calls were to be kept to a minimum.

Another thing that set us apart was that although, like most children, we were taught always to tell the truth, there was a kind of footnote to that rule. We were also told explicitly that if a friend or someone else asked whether we had seen so-and-so at our father's office, the answer was simply "No." Strictly speaking, that could not always have been correct. Coming home from school, for example, we might recognize a car pulling up in front of the house or see a familiar person entering "our" front door. That was the office entrance (we used the back door), used only by those coming to the house for medical reasons. We were to "forget" what we had seen, no matter who asked.


I don't remember exactly how the acceptability of this fudging of the truth was conveyed to us, but I think we understood a negative answer in such cases was less a matter of not telling the truth than it was a polite way of saying, "So what if I did? It's none of your business or mine." Thus we were given an early lesson in medical ethics: patient confidentiality trumped strict truthfulness.

None of this illustrates contributing to a "family business" in quite the way that farmers' children or a shopkeeper's offspring might be seen respectively as part of their family's "business." But with Dad's office and examining rooms taking up much of the prime space in our family's home, we learned that a building can house both a home and a business. There were strictures about where in the house we children were allowed to go; the downstairs lavatory was off-limits, for instance, because it was where x-rays were developed. Chores assigned to us also at least indirectly connected us with the medical practice. Indeed, beyond being indoctrinated in the principle of confidentiality, we also learned about hard work and skill, integrity, and a host of other virtues closely tied to the "family business." We were daily witnesses, not to the particulars of patient care, but to the art of medicine and the business of being a community doctor.


For example, by the time we were teenagers at the latest, we could earn pocket money by doing certain kinds of jobs related to the family business. Pulling out and re-filing patient records was an endlessly recurring task. Each day, clinical records had to be retrieved from the banks of file drawers in the "business office" (converted from the family's living room). The records were on 4" x 6" cards inserted in special envelopes. Once out of the drawers, the envelopes had to be set out in the order patients were to be seen; that meant we had to check the appointment book. All the while we were wiping our minds clean of any memory of which records we had handled. We certainly knew never to look at any of the cards inside the envelopes. Later—ideally the next day, though sometimes things got badly backed up despite this employment of child labor—each envelope had to be re-filed after the clinical record had been updated.

How much we were paid for this job I have no idea. That we were helping out with the family business in a very direct way was clear to all of us, and we were glad enough to be earning something. I do remember the pay scale on another job, however. Cleaning the Dictaphone® cylinders onto which Dad dictated clinical records for Mother to transcribe brought 2¢ a cylinder. Careful cleaning was important; if we did not gouge the cylinders while shaving off the old recording, they could be re-used.

Occasionally there were more dramatic ways of helping. One brother recalls being the only one available to rescue Dad with the second car when he called to say he had two flat tires. We might on occasion have to deliver lab specimens and x-rays to the hospital in the next town for specialists to double-check Dad's diagnoses. These were simple ways we could, and were expected to, assist. In a family business, whoever is available helps.


On one particularly memorable occasion, it was my turn. Making my way toward the back door, I could see that Dad was leaning half-way into a car parked in front of the house. I averted my eyes, but when Dad yelled to me to get the stretcher, I sprang into action, running up the driveway to the garage where the stretcher was stored. I raced back and helped Dad maneuver the patient—to whom, it turned out, Dad had just given a shot of adrenaline—onto the stretcher. Then, with the patient's wife and me on one end and Dad on the other, we carried the patient into the house where Dad could further tend to him. The man was so ashen that only several minutes after I had left the scene did I realize I knew him. Patients were friends and neighbors, figures on the same large canvas with the doctor and his family.

Another dramatic story of a family member needing to play a role in the medical practice came one evening when we were all out together. Dad always left word with the local telephone operator to let her know where he was headed. She could, if necessary, alert the state police dispatcher to find Dad. On this occasion an officer in a cruiser tracked us down, and having pulled Dad over, explained what the operator had made sound like an emergency. Neighbors of an elderly woman had tried to reach Dad, concerned that they had not seen or heard from her for several days; she didn't answer the locked door, and she didn't answer her phone. Dad reversed course and followed the trooper to the woman's house. Neither of them had any more luck rousing the woman than had her neighbors, so the policeman used a heavy flashlight to smash the large bottom pane of glass in the window nearest the front door. He then cleared as much glass out as he could and carefully handed one of my younger brothers through the window with instructions to unlock the door. He did as he was told, being both scared and proud (he later admitted) to be helping. The drama basically ended there, however. Once the policeman and Dad got inside, they found the old lady lying quietly in bed, recovering from a bad cold. No doubt she wondered what all the fuss was about; she had just been too weak and tired to respond to neighbors.


In the summers, the whole family would pile into the car and Dad would deposit us with a picnic basket in some farmer's pasture while he went off to make house-calls. He would then return to share what was left of the picnic. When my oldest brother was very young and out with Dad for a father-son outing, a message was delivered by someone who tracked Dad down. That necessitated abruptly ending the picnic father and son had expected to share. A patient's tiny baby had died unexpectedly, and Dad—as the local medical examiner—had to collect the body. How much he explained to his own first-born I do not know. All in a day's work for a country doctor; he and the family simply adjusted to circumstances as they arose.

Pitching in was just part of the life of a doctor's family. We grew up helping with the household chores and cooking not merely because our parents thought those were skills we should learn, but because our doing so helped free Mother to work alongside Dad. And there was the filing and other little jobs we did as well. Surely that is a paradigm of a "family business." Long after we children had grown up and left home, our parents were still at it, engaged together in the art and the science of medicine. They still cooperated in a variety of indirect ways and often worked side by side. A doctor's family can help humanize his work, turning a medical practice into not just a family business but a work of family art.


CONSTANCE E. PUTNAM, PhD is an independent scholar from Concord, Massachusetts who specializes in medical history (19th and 20th century, United States and Hungary), bioethics (doctor-patient relations, death and dying), and the history of medical education (especially in the United States). She has published a wide range of articles and book reviews in professional journals, magazines, and newspapers; among the several books she has written is Hospice or Hemlock? Searching for Heroic Compassion (Praeger, 2002).