BEACH CONGER, M.D.
CARETAKER AND CONTRARIAN
Windsor, Vermont
Beach Conger started into medicine with an eye on public health. He worked in Mississippi as a medical civil rights worker, led a job action at the Boston City Hospital to improve patient care conditions, and spent two years as an epidemic intelligence officer for the Centers for Disease Control. Thirty years later, though, he is the quintessential personal physician, practicing in a small town in Vermont, watching illnesses come and go, families grow up, and the elderly pass on. When he finally began practicing medicine, it turned out that he loved it.
His vocation is internal medicine, but his avocation is professional contrarian. He enjoys gently telling people the truth about their health (some day they're going to die), the doctor (he doesn't know everything), and their part of the world (it has some strange medical habits). His handson engagement with life and his eye for the humorous started him writing, first a column for the local newspaper and then two books of auto-biographical musings. The cover of the first book, titled Bag Balm and Duct Tape, advertises itself as “How a doctor taught a town to be proper patients and how the patients taught the man to be a doctor.” The second
Conger counts himself an activist generalist who happily handled all manner of medical challenges that face a small-town physician. After adjusting to life in the country, he came to take pride in his ability to cope with most of the medical problems that came his way, calling on specialists only occasionally. But the environment is changing, and a determined generalist such as Conger is finding mounting pressures to join networks, to refer, and to rely on technology for diagnosis and treatment. “Today I feel more like an endangered species than a role model,” he observes. “Kind of like the gray wolf or the cougar. It seems my feeding grounds are gradually being replaced by multispecialty clinics and CAT scanners. Still,” he concludes, “I can't think of anything else I'd rather do.”
I HAVE ALWAYS BEEN INTERESTED in public health. I used to think that I would wind up being the Surgeon General. Who wouldn't want to battle the scourges of history—tuberculosis, infant mortality, malnutrition? Medical school reinforced my interest. We studied salmonella outbreaks, cholera, and clean water strategies in the second-year epidemiology course, and I loved it. This was the era when we thought we had beaten infectious disease, before AIDS, before Legionnaire's disease and hantavirus and drugresistant TB. Smoking wasn't much of an issue then, and diet and exercise were still the concern of health food types. We had no idea how important public health would become to medicine and to all of us.
But it turns out that medicine involves a lot of acting, and I'm a bit of a ham. You can't crack jokes when you're trying to solve the problem of infant mortality, but I can with my patients. I have spent time working in public health. I enjoy the problem solving and dealing with public issues like access to health care, abortion, and prevention. I've been active in local politics and, for a while, served as chairman of my local school board. But it turns out that for me it isn't as much fun as the one-to-one with patients. As things have developed, I'm a country doctor, not the Surgeon General—and I love it.
I started in the city. I was born in 1941 in New York City but was raised in suburban New York, first in Hastings-on-Hudson, and then in Pleasantville, a suburb about thirty miles outside New York City that is known as the home of the Reader's Digest. My parents were both writers.
Pleasantville was your basic town, all that its name implies. In the 1940s it had about 5,000 people and was just far enough out that most people who lived there did not commute to New York City. We had one African American in town. His name was Sidney Poitier. I went to a small high school, where about 40 percent of the kids went on to college. They tended to be the ones from educated families who worked in New York City.
My decision to become a doctor was basically the result of my doing well in school; that was one of the things that kids who did well in school then were supposed to do. I went to Amherst College, where I majored in Russian and traveled to Russia in 1962. I thought it would be more interesting to become a Russian scholar than a doctor, but I couldn't see far enough on the horizon in that field, whereas medical school was pretty clear.
I went to medical school at Harvard. I found the first two years tedious, and I didn't apply myself much. I'm not good at compulsive learning, so if it wasn't interesting I tended not to study it, with the result that I didn't do very well. One day after I got a D in physiology, I was called into the dean's office. Since you've been accepted to Harvard they assume you're smart, so if you're not doing well they think you're having some problem at home. Just before entering medical school I had married. The dean asked me if my home life was happy. I replied, “Yes, I think that's fine.” After that I realized it was in my interest to have been a little bit unhappy, otherwise they thought there was something wrong with me. The second two years were better. I enjoyed the practical stuff.
During my junior year I did my medicine rotation at Boston City Hospital, which I loved. A city hospital setting is much more egalitarian than places like the Massachusetts General and the Brigham Hospitals [now the Brigham and Women's Hospital]. It's much more forgiving, both in terms of what the patients expect from you and the way people treat each other. I did my medicine and surgery rotations there, as well as my internship and residency.
Between my second and third years of medical school, in the summer of 1965, I went to Mississippi. Jack Geiger, one of the leading spokes-men for the Medical Committee for Human Rights, gave a talk in Boston. As a newspaperman turned doctor, he envisioned health care as an instrument to raise people out of poverty. This appealed to my public health instincts. Geiger was very charismatic. He'd gotten a grant from the Office of Economic Opportunity to set up a clinic in Holmes County, Mississippi, and he was looking for summer volunteers to go south. I signed on.
After a week of training at the University of Pittsburgh School of Public Health, they sent me to Holmes County. My wife, who was similarly politically inclined, was teaching math that summer at Tougaloo University in Jackson, Mississippi. I wound up living in the house of a sharecropping family that was about five miles outside the county seat, Lexington, Mississippi. I was full of grandiose concepts about what I was going to do as a medical civil rights worker but I wound up working on voter registration and school integration—not the stuff of medicine but historic movements of the time. It was a remarkable experience.
The one medical experience I had was being called to the home of a child who was lying on a bed seizing. At that point, I probably knew something about the idea that children may have febrile seizures, but that's about it. “We'll have to take him to the hospital. This is terrible,” I said. The mother put him on the floor so he wouldn't hurt himself. “It's just a seizure,” she said. “And besides, they won't see us at the hospital.” I was horrified. I assumed that something drastic was going to happen to the child if they didn't get him to the hospital, and the family accepted it. They thought I might have a pill I could give the child. They never asked me anything again.
For my wife and me—as for many others who went south to work in the Civil Rights Movement—the experience was a politicizing one. Once back in Boston, we decided that we wanted to be active in local politics, so we moved into the Cabot Street Housing Project in Roxbury. We were the only white couple living there. The rent was $44 a month, which was a nice benefit, and my wife served on the board of the local Community Action Agency. I worked on the Boston arm of Dr. Geiger's project, which was opening a clinic in the impoverished Columbia Point section of the city.
Living in the ghetto at that time was very different than it would be today. People used drugs and alcohol and fell asleep on the sidewalks,
When I was a fourth-year medical student I still didn't know much, but I came and went in a white coat. My neighbor was a taxicab driver. One day, his wife came over to see me and said, “You've got to see my husband. He needs to go to the hospital and he won't go.” So I went over. He was sitting watching television with a Band-Aid on his forehead. “What's the matter?” I asked.
He said, “I've got a headache.”
Being a dutiful medical student, I began asking him a recently learned list of questions about a headache. “When did it start? Did it come on suddenly or gradually? Does it radiate, or do you feel sick to your stomach?” We didn't know each other very well, but I think he figured this was something he had to go through. Then I asked, “What's the Band-Aid for?” I thought it was some kind of funny thing he did to make him feel better. So he took it off and said, “That's the bullet hole.”
“What do you mean?”
“Well, I was driving my taxi and I went to let my fare out, and the guy put a gun to my head and said, ‘Give me your money or I'm going to shoot you.’ And I said no, so he shot me.”
“He shot you in the head?”
“Yeah.”
“With a bullet?”
“Yeah.”
I said, “You've got to go to the hospital! You've been shot in the head!”
And his wife said to him, “See, I told you he'd say that. Listen to the doctor.”
He says, “No, if I go down there, I'll sit around for five hours, they'll take an X ray, they'll say there's nothing they can do, and they'll send me home again.”
I said, “No, no, no. You've been shot in the head. I'll call an ambulance.”
He said, “I'm not going to take an ambulance.”
He went to Boston City. Five, six, seven hours later, he comes back. “What happened?” I asked.
“They took an X ray, they said there's nothing they could do, and they sent me home.”
So now, whenever anyone comes in for a headache, the first thing I ask them is if anybody shot them.
We lived in the project for the last two years of medical school and into my internship. My son was born while we lived there. We moved out of the housing project because we were no longer economically eligible after I began to make a salary. Because of my background, living in Roxbury provided me with a perspective I hadn't had. It gave me an understanding that, even in this country, there is a way of life that has nothing to do with what goes on in places like Pleasantville, where I grew up, or Vermont, where I have lived since 1977.
Going to Mississippi and practicing at Boston City Hospital were conscious decisions I made to work with people who were poor. Working with the poor was more rewarding for me. I was not comfortable as a student at Boston's upscale hospitals. I didn't feel smart compared to the doctors there, but also those hospitals seemed a little too classy, too detached. The Shah of Iran was a patient at the Mass General when I was there. That wasn't why I was in medicine. In contrast, I felt at home at Boston City Hospital, which was falling apart.
In 1967, while I was a fourth-year student at Boston City Hospital, we held a “heal-in” to protest conditions at the hospital. The heal-in was an alternative to a strike where we continued to admit patients but didn't discharge anyone. Interns were paid only $100 a month and wanted a raise. We also wanted better laboratory services, more nursing, and improved patient care all around. The city said, in essence, “Listen, we'll give you pay increases and some lab technicians, but we're not going to address nursing and patient care. We don't have control over that. If you fight this, you may not get the money you want.” The house officers were getting tired of the heal-in, so we settled for our money and the promise that they were going to work on our other demands.
In 1968 I became president of the house officers' association, and we became the first labor organization of house officers in the country, although I didn't find that out until I attended our thirtieth anniversary this past year in Boston. We hired a lawyer and, full of righteous zeal, we sat down to finish the business of improving patient care. At the time I felt I had really accomplished something. Now, years later, I am ashamed. The real tragedy of Boston was not how they treated the house officers, who would soon go on to rich and prosperous careers, but how they treated the poor people of the city of Boston and the health care
I was at Boston City Hospital for two years, then I joined the Public Health Service and was assigned to the Centers for Disease Control in Atlanta in a special program called the Epidemic Intelligence Service. Practicing public health appealed to me, especially given the choice of going to Vietnam or an assignment in the Public Health Service. My intent was to stay in the Public Health Service permanently, and the time I spent at the CDC substantially raised my estimation of the federal government. The dedication of some medical staff at the CDC was improved by the sense that if they weren't at the CDC somebody would be glad to take their places, and they could always be sent to Vietnam as medical officers.
This was pure public health work in a public health agency, and I liked it a lot. When I began, the entire focus of the CDC was infectious disease, but they were at the point of applying epidemiological principles to other aspects of health. I went to work with a gynecologist who was beginning a program of contraceptive evaluation using data from family planning clinics. I staffed rural health clinics in southern Georgia, where the local doctors, who were all white, wouldn't go, because public health clinics were believed to be a Communist plot. I traveled to these clinics, where a very pleasant, condescending white nurse would usher in her black clients, whose faces I would never see. When I would come into the room they were already in the stirrups, covered with a sheet, draped around so that it was physically difficult for me to talk to them, which was intentional. I would be either checking an IUD, or putting an IUD in. That was what these clinics were doing.
In 1970 New York state passed a law legalizing abortions, and I was sent there in 1971 by the CDC to conduct surveillance of outpatient abortions in New York City, tracking down complications and deaths. People came to New York from all over the country to get abortions, so it was really a national issue. For the first time the CDC recognized that the morbidity from abortions needed to be treated on a par with tracking down salmonella outbreaks and eradicating smallpox. Abortions had finally become part of the mainstream political debate in this country. This was 1969 and 1970, long before AIDS arrived on the scene.
We were still based in Atlanta, and we had had our fill of the South. My wife was involved in a class action suit against AT&T because she was one of many women who were being paid less than their male counterparts.
The clinic, called the South of Market Health Center, was just off Mission Street, smack in an area of dilapidated housing, soup kitchens, and rundown hotels. We saw people on a first-come, first-served basis and, often when I arrived in the morning, I would see my patients sleeping on the sidewalk, waiting to get in. Medical care at the clinic had been terrible before we started—Vitamin B-12 shots and antibiotics for everything. We came in with new money, new employees, and outreach programs. We treated patients with respect, practiced preventive medicine, and went door to door. Besides homeless alcoholics and heroin addicts, there was also a large immigrant Filipino population living in the same area who, in contrast, were very stable and upwardly mobile. Many had come from the upper classes in the Philippines, including some doctors who were working as housekeepers. Tension existed between these two populations over the clinic. The Filipinos wanted it to be their clinic, and after a while many of them joined the clinic staff. The alcoholics then tended not to show up as much.
I worked there for six years and discovered, somewhat to my surprise, that I liked practicing medicine. Although public health planning had been a lot of fun, I really enjoyed patients. At that time, of course, I had the illusion that you could do both population medicine and clinical medicine. I was no longer planning to become Surgeon General. But if someone said, “Would you want to become director of the city's health clinics, at some point?” I might have said yes. This was an activist time in San Francisco with many free clinics and a lot of federal money available to set up neighborhood health centers. The budget for our clinic doubled about every two years.
By 1977 I'd gotten an amicable divorce and married Trine Boh, who was a first year law student at Golden Gate University. My focus changed
The doctor who was leaving told me, “Oh, you don't want to come here. There are no patients to see.” I thought, “Why not? They're going to guarantee my salary, and I can do this for two years. In the mean-time, we'll figure out what we're really going to do.” That was nineteen years ago.
For the first six months I was petrified, because I was used to places where there was always somebody around to help you deal with a problem. If somebody got sick, I sent them to the hospital. I might visit them, but I didn't start the IVs, insert tracheal tubes, put casts on people. I prescribed drugs, and I talked. Suddenly I was dealing with everything—train wrecks and broken wrists, things I'd seen a hundred times and things I'd never seen before. I was the doctor. There were no diagnostic radiologists, no backup orthopedic surgeons, no backup anything. It was anxiety-provoking.
And then I got used to it, and realized that you do what you can do. For instance, I was treating a man with chest pain. I don't remember what went wrong, but he died suddenly. I told the family I felt just awful, and they could see it. “Doc, don't feel bad,” they said. “You did the best you could. He would have died anyway.” They were understanding of the idea that doctors don't always succeed. People in Windsor back then accepted the idea that doctors could fail or even screw up.
An example of the kind of thing I had to learn on the spot was caring for a patient with a fracture. In all my years of medical training, I was never taught how to place a cast. Internists didn't do that in city hospitals. When I worked in the emergency room at Boston City Hospital,
There were a lot of things I just gradually started doing. I practiced more intense medicine than many internists do today, largely because people expected me to. I referred very few patients out unless they needed a surgical consultation.
We now have six internists in Windsor, two pediatricians, a general surgeon, a full-time orthopedic surgeon, and a variety of visiting specialists. The specialists visit from the Dartmouth-Hitchcock Medical Center twenty miles to the north, or they've set up a private practice in which they circuitride to a series of community hospitals, of which we remain the smallest. So specialists are all around me again. Patients are now more likely to consider a specialty referral option, so I do a lot more referrals than I did when I first arrived here and a lot more than I would otherwise want to do. Several of our physicians have become employees of a huge physician organization whose brochure states, in essence, that “Primary care is the doctor you go to, to help you figure out which specialist to see.”
Fifty percent of my patients are on Medicare. Of the other 50 percent, everybody has managed care of some type. The only difference it makes to me is that I have to fill out more forms. Part of the reason it's not a problem is that there is no competition here in primary care. The patients who live in this town are going to have to come to see someone in this group, by and large, unless they hate us all, in which case, they could travel some distance. Managed care will never have the same impact here as it does in a place like California, where you have plans competing with each other, and there are real issues about patient jumping. I have patients who have gone through three plans in the last five years. I'm always the doctor. If they're in California, they would be changing doctors. But here there's nobody else for them to see.
What has changed is that if somebody came in with a headache nineteen years ago, I would have talked to them and, unless I had been really worried, I would not have ordered any more tests. Now, the chances are better than fifty-fifty that the same patient with a headache knows about CAT scans and expects one—regardless of the fact that I don't think one is indicated in the vast majority of cases. When I first came here, patients were not as educated about health issues as they are today. “What are you here for?” I'd ask them. “That's what I came to find out,” they'd respond. “You're the doctor, you figure it out.” This sort of attitude gave me latitude in where to go with things, but also showed that the patient remained marginally involved in what was going on.
Poverty in this area is not concentrated, the way it is in what's called Vermont's northeast kingdom in the northern part of the state, where people have no money and live in shacks with no electricity. Isolated poverty is quite common here, but most of my patients get by okay. Windsor is distinctive in that we had a maximum-security prison and several factories. Once the factories left town, a large apartment complex, initially designed for factory workers, became home for the wives and children of the prisoners, and that brought in an underclass. The apartment complex looks like something that was airlifted out of the Bronx. It's a huge brick structure. There's nothing anywhere like it in Vermont. So we have this small underclass population. I handled a case of lead poisoning when I first got here, a kid who lived on a back porch and ate lead, just like in an urban setting. Outside of the prison-related population, some immigrant Vietnamese, and a few adopted black children, it's still a white culture.
I have more access to specialists than I would like to have. It's kind of like having too many restaurants to choose from. You're also more likely to eat out when you have a lot of restaurants, and I'd really rather eat at home. For every disease there's someone who is smarter than I am. I could send every patient to somebody else for every complaint, but that's not what I choose to do. My practice is made up of patients I've known for a long time, and they tend to look primarily to me for guidance. An irritated cardiac surgeon to whom I had sent one of my patients called me once, saying, “We think your patient needs to have his mediastinum opened up because he's gotten a postoperative infection, and he wants me to check with you.” That's patient loyalty.
There's a group practice of younger physicians in a nearby town who don't even come into the hospital when they're on call. When somebody gets sick they send him to Hanover to the medical center. If somebody
When I was in medical school, cholesterol wasn't much of an issue. If you identified a patient with high cholesterol, it was really high—like 500 and they'd have huge globs of fat hanging from their eyeballs. You'd call people. Big hoopty-do. Now, everybody is potentially a patient because we've lowered the cholesterol standard so that nobody will pass. This means that there are people trooping in and out of the office all the time who aren't sick. People have gotten used to going to the doctor on the premise of not being sick—which is okay. But when they get sick, they think, “I've got to see a different doctor. This is not my doctor for sick. This is my doctor for cholesterol, and blood pressure, and maybe Pap smears. Now that I'm actually sick, I need a specialist.” Many younger internists and family practitioners collaborate in this by focusing on health maintenance and avoiding more intensive forms of patient care. And since everybody does get sick sooner or later, this kind of thinking has led to a doubling in the number of specialists in the country. A cynic might say that we were training too many doctors in this country and we didn't have enough sick people to go around. Since lots of the new doctors were becoming specialists, we had to find something more for them to do, so we invented diseases in well people.
One way to stem the tide of expense and futility in medicine would be to admit students into medical school who aren't quite so smart. Why don't we just conclude that we have enough medicine right now? We won't make any more improvements, and we'll live with what we've got for a while. Maybe thirty years from now we'll start working on it again. If our doctors were not particularly smart, sort of nineteenth-century doctors, we wouldn't invent new procedures. We'd just muddle along, and things would stabilize. The rest of the economy would grow for a while, and we'd stop spending larger and larger chunks of it on medical care.
When a patient arrives in my office I put this cuff around his arm and pump it up. “You've got hypertension,” I say. The patient says, “That's the silent killer,” and we start down the long, long road of antihypertensive treatment. Now the fact that everybody's going to die, and that
I think that the evolution now is toward primary care as very distinct from secondary care. Primary care, as I see it, is really wellness care, secondary care is general sickness care, and then tertiary care is caring for people with special sicknesses. Wellness care means dealing with the “presick” who have yet-to-be-determined diseases. I see my general internist role as doing secondary care as well as my own brand of primary care. That's what I was trained to do. What I like best about my practice is the interaction with people but, I have to admit, there still is a part of me that likes disease. I get energized when somebody comes in with an abnormality. But I've known most of these people for a long time, and it's always upsetting when I pass along a bad diagnosis. I had a medical student with me one day when a patient's CAT scan came back with an ominous spot in the right lung. The student was excited. “This person's going to have lung cancer.” I responded, “If your sister had this CAT scan you would not be very excited.”
I've lived in the community and know everybody here. A woman on chemotherapy just came in with a sore ear, terrified. I looked in her ear and it was okay; she felt great and so did I. I like that. I have to have a certain number of sick people to fuss with or I feel that I'm betraying my training. But I don't need a lot of it; I don't even need it every day. People in Windsor give doctors so much benefit of the doubt—more so than anyone else including the local clergymen. I can make a fool of myself, and people don't mind; I march in parades wearing wild outfits, I write crazy stories in the newspaper and, because I'm a doctor, people like me.
I'm an ex–Epidemic Intelligence Service officer, and I keep up with infectious diseases. In 1983 I made the diagnosis of Legionnaire's disease in a hospital patient. After another case was diagnosed and we found the source in the hospital's water heater, we were credited with what has
At the press conference I joked, “This is nature's revenge. You put people in buildings and nature says, ‘This is not what you're supposed to be doing,’ so it's got germs to try and combat you with this.” A guy there from the local newspaper said, “You've got a strange way of looking at things. Will you write an article about this?” So I did. They then asked if I'd write some more, and I did. The paper is called the Valley News and has a circulation of around forty or fifty thousand. I wrote a piece on herpes, and something on why doctors lie. A couple were sort of whimsical. Eventually, I wrote a column every other week under the heading “The Second Opinion.” It was never serious, though I always told the truth. I enjoyed the writing, and after three or four years my editor suggested I collect the pieces into a book. I sent them to a publisher, who responded, “I don't know how we're going to use this. There's no market for it. But maybe you want to write it into something that fits together.” I turned the articles into a sort of diary that, in 1988, came out as my first book, Bag Balm and Duct Tape. After that, I was off and running. My second book, It's Not My Fault, was published in 1995.
I really enjoy writing. It imposes a kind of discipline on me that medicine doesn't. My first and second drafts are usually gibberish. I have to rewrite probably six or seven times to get what I want. In medicine you don't usually have that chance. I'm working on a book that is much more difficult than my other two, which were just stories I wrote from my everyday experience. This one is about a doctor who practiced in my town one hundred and seventy years ago. She was a woman, but because women weren't allowed in medicine she had to practice as a man. It has been a real challenge to set myself in a time where doctors knew almost nothing and the only two medicines of any definite benefit were morphine and quinine. I'm not sure I am good enough to write it, but I'm working at it.
Trine and I have three children. Our youngest, Nadya, teaches Spanish in the Boston area and the oldest, Matt, teaches science in Woodstock, Vermont. He lives about one mile from us. Our middle daughter, Dylan, lives in Brooklyn, New York, with her husband. She is a research analyst for the Vera Institute, which does analytic work on social service programs. None of my children ever showed the slightest interest in medicine, which is okay.
Trine is a recovering attorney. After she got her degree here she went into private practice, which is not what she really wanted to do. One of the problems in the country is that you feel left out of the real problems of the world. She went into family law and had an extremely busy and successful practice for twelve years. In 1990, she became a family court magistrate. Then she quit it all in 1994 and went to Baltimore as an Annie E. Casey Foundation Fellow. She worked as a consultant for the Rhode Island Department of Children's Services and now for the state of Vermont trying to bring some sense into the way the courts and the social services deal with abused and neglected children. Unless Trine takes a job elsewhere (which is a possibility), I plan to practice here until I retire, because at this point there's nothing else I can do. I have an excellent practice, and I'm the senior physician in town. Everybody looks up to me, except the people who can't stand me. It's a very small pond, but I'm the biggest frog in it. In ten years, if I'm still in good health, I'll cut back my practice and start writing more.
I'm fond of telling patients something that is very clear to me. “You know, if I treat you long enough only two things can happen. Either you die or I die.” So I keep treating sick people, and I recognize the futility of it because they're going to die. But I keep at it because it's what I do.
