“Meatball Medicine”

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Residents of the Pittsburgh region are blessed with access to sophisticated health care that is often not only state-of-the-art, but also, in many instances, at the cutting edge of medicine and surgery provided by the two major systems, AHN and UPMC. Furthermore, both systems provide excellent training for medical students, residents, and fellows. Even some of the smaller facilities offer sophisticated care. Unfortunately, in twenty-first century America, that type of care is not available to all.

Dr. James Strosberg, a lifelong friend from childhood, was a classmate of mine in medical school in Buffalo, NY. Until his retirement a few years ago he practiced rheumatology in Schenectady, NY, part of the Capitol District (along with Albany and Troy, our hometown). Jim recently published a book containing anecdotes of his two years (1968 – 70) as a medical officer in the U.S. Public Health Service (USPHS) on a Sioux Reservation in South Dakota1. As I read Jim’s book, some of the events he described brought back memories of my own service in the Air Force. The difference, of course, in our experiences was that while I practiced in a modern medical center (Wright-Patterson) in Dayton, Ohio, with all medical and surgical specialties available, he was in a small

(23 bed) hospital with an adjacent clinic. Jim was one of four physicians, all just out of internship, along with one dentist and a pharmacist. There were no specialists on site and the nearest ones were hours away in either Rapid City or Pierre. And so, with the limited facilities and resources on-site, Jim and his colleagues had to “MacGyver” it and practice “Meatball Medicine”, making do with the limited resources on hand.

In his book, Jim describes administering care that included the “bread and butter” conditions seen by every family practitioner as well as reducing fractures, delivering babies and, on occasion, performing amputations. The most common conditions he dealt with were injuries sustained as the result of alcohol consumption. He and his colleagues would often accompany patients during their medical evacuation to either Rapid City or Pierre1. Out of necessity he and his colleagues had to use the resources available to them, often playing a real-life MacGyver.

“Meatball Medicine” is a derivation of the term “Meatball Surgery”, coined by Dr. H. Richard Hornberger (1924 – 1997), better known by his nom de plume of Richard Hooker, the author of MASH 2. Hornberger’s dark comedy was based on his experiences as a combat surgeon during the Korean War. He defined “Meatball Surgery” as a distinct specialty. He wrote, “We are not concerned with the ultimate reconstruction of the patient. We are concerned only with getting the kid out of here alive enough for someone else to reconstruct him. “Up to a point, we are concerned with fingers, hands, arms, and legs, but sometimes we deliberately sacrifice a leg in order to save a life, if the other wounds are more important. In fact, now and then we may lose a leg because, if we spent an extra hour trying to save it, another guy … could die from being operated on too late. Our general attitude around here is that we want to play par surgery. Par is a live patient.2” Those of us who have been in the military, particularly those who served in a combat zone can relate to this.

I had similar experiences moonlighting during my residency at Duke (1970 – 73), working with several fellow residents in a community clinic in rural Yanceyville, NC, the county seat of Caswell County, along the North Carolina – Virginia border. The clinic was owned by Dr. Tom Lea Gwynn, the only remaining physician in the county after his father, with whom he was in practice, died. In 1970, Caswell County was the poorest county in North Carolina, where the average annual per capita income was $1,200, mainly from tobacco farming. The clinic had been built with the support of the Sears Roebuck Foundation. In 1957, the Foundation established the Community Medical Assistance Program (CMAP) to assist rural communities in attracting physicians. Between 1957 and 1970, 163 such clinics were built, financed primarily through community ownership3. The Yanceyville clinic had a waiting room, three office/consulting rooms, three examining rooms, a small laboratory, an x-ray room, and a small operating room. When I was there the x-ray room and its ancient equipment were inoperative.

The nearest hospital was in Danville, VA, fifteen miles up the road. Complicated cases were referred to either Duke Medical Center in Durham or North Carolina Memorial Hospital in Chapel Hill. Both were approximately 50 miles away. “Ambulance” service was provided by the local sheriff using his pickup truck with a mattress in the cargo bed. This was, indeed, a medically indigent community.

My colleagues and I had all served two years in the military, where we were all General Medical Officers, in military parlance, prior to beginning our residency. We provided three hours of coverage two evenings a week as well as on Saturday afternoons. Our arrangement with Dr. Gwynn was that we kept 80% of any fees generated. He paid the receptionist from his 20%. Each of the resident physicians was paid the net proceeds depending on the number of shifts worked. This was preferable to moonlighting in emergency rooms since the Yanceyville clinic was only an hour away from Durham and we were able to sleep in our own beds at home, ensuring we were ready for work at Duke the next day.

Most of the patients we saw had the typical diagnoses seen by any busy family practitioner or at a modern urgent care clinic – colds, ear infections in children, cuts and scrapes. Dr. Gwynn managed his regular patients with diabetes and hypertension. I asked him what we should do if a woman was in labor and was close to delivering a baby. (None of us had any obstetric experience beyond that which we learned in medical school.) He said, in that case, call him and he will come in and handle the delivery.

So, why were we practicing “meatball medicine”? A few examples stand out in my memory. One of the most frequent diagnoses we made was gonorrhea (GC), which I thought was endemic in the community. As each patient was treated, my colleagues and I dutifully notified the county health department, as the law required. One evening, the county health commissioner paid me a visit and asked me to stop reporting cases of GC. He said he didn’t have the resources to do contact tracing. “Just treat ‘em, Doc,” he told me. “That’s the important thing.” I made a correlation between the incidence of GC and the frequent revival meetings staged by itinerant preachers, who promised salvation in return for the few dollars his flock provided him. North Carolina is the buckle on the “Bible Belt”. An old-fashioned revival is something everyone should experience once in their lifetime regardless of their religious affiliation. When the preacher would extoll his flock in his deep Southern accent to “Cleeeeng to your loved ones”, they would literally heed his word when they left. Hence, the high incidence of GC.

One night I saw a local farmer who had cut his forearm on a corn picker. The laceration was about a half inch deep, but surprisingly was not bleeding at the time he came to the clinic. The man’s arm was covered with cakedon dirt, and it was also obvious that personal hygiene was not important to him. I took him into a treatment room and handed him a scrub brush to clean the wound so I could suture it. Fifteen minutes later I returned and was surprised to find that he had no laceration. He had over a half inch of mud on his arm, and that was what had been cut through!

The most serious injury I had to deal with was a man who walked into the clinic with a knife stuck in his back after he had been stabbed during a drunken brawl. After assuring that his vital signs were stable, and his lungs were clear, I taped the knife in place, started “an IV and waited for the sheriff, whom “the receptionist had called to take the man to Danville Hospital. He sat in the ““back of the pickup truck with my receptionist holding the IV. “He miraculously survived.

I mentioned the poverty in the county. Most of the patients we saw were on welfare. Nobody had health insurance. Even so, the cost of a “nofrills” visit at that time was $10. Blood tests, urinalysis, and wound suturing were charged extra (but way below today’s prices). Some patients bartered fresh vegetables, fruit, or eggs in lieu of cash payments (Dr. Gwynn received 20% of whatever was used for payment).

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There still are communities where poverty is common, and lack of sophisticated medical resources necessitates practicing “meatball medicine”. My fellow residents who worked at Yanceyville agree with my friend Jim Strosberg that our shared experiences allowed us to see another side of society. We feel we became better physicians for that experience.

References

1. Strosberg JM. Two Years on the Cheyenne River Sioux Tribe Reservation. Troy, NY, The Troy Book Makers, 2022

2. Hooker R. MASH: A Novel About Three Army Doctors. New York, William Morrow & Co., 1968.

3. Kane RL, Warnick R, Proctor PH, Olsen DM, Gourley D. Mail-order medicine. An analysis of the Sears Roebuck Foundation’s community Medical Assistance Program. JAMA 1975; 232:1023-1027.

Dr. Daffner is a retired radiologist, who practiced at Allegheny General Hospital for over 30 years. He is Emeritus Clinical Professor of Radiology at Temple University School of Medicine.

Congratulations to the Doctors' Day honorees from the Allegheny County Medical Society and the Pennsylvania Medical Society.

On March 30th the ACMS celebrated Doctor's Day by visiting doctors across the city to hand-deliver their recognition certificates. This year, PAMED received over 300 nominations from the public, patients, and colleagues, recognizing physicians across Pennsylvania who have gone above and beyond in their care.

Yesterday, today, and every day, we celebrate Pennsylvania ’s physicians.

The full list of Honorees can be found at: www.pamedsoc.org/DoctorsDay

If there is one thing I learned in law school, it is that we cannot always make a law to solve every problem in our society. This thought came to mind after reading articles and letters in the last few issues of the Bulletin on the subject of elective abortion.

It is not my place here, or my intent, to engage in the debate about the rightness or wrongness of elective abortion. We have all heard both sides, and I don’t think I can add anything to it that will change anybody’s mind. But we should not conflate that debate with the debate about how we regulate or prohibit elective abortion and the ripple-effects that follow. We should question the view that those who oppose criminal or burdensome civil penalties are “abortion supporters.” The uncertainty among physicians and their patients created by some of the state legislation (or would be created by proposed legislation) that has followed the Dobbs decision cannot simply be brushed aside.

In some instances, attempting to change behavior by enacting punitive measures, whether effective or not, may produce a greater harm than it seeks to eliminate. Not true, of course, for most activities we consider criminal.

Before the 1973 case of Roe v. Wade, safe abortions were available to