Midlife

Getting older

I was, by this time, beginning to feel the effects of age.  My knees and right foot and ankle began to give me more trouble.  I had given up golf and quail hunting, as the pain and discomfort after a day’s hunt or a round of golf took several more to improve.

 I was thinking more and more about a career change, but did not really know what it would be.

 In the early 80’s, I became interested in personal computers.  I first learned of computers from conversations with Dr. Don Logan in the doctor’s lounge at Medical City between cases.  Don is an urologist who is now retired.  He had a Radio Shack computer and spoke of its virtues.  I had a patient at this time who managed a store downtown that sold Xerox equipment, including their new personal computer, the Xerox 820.

 I bought a Radio Shack pocket computer.  It was really a programmable calculator, but it was a start.  I bought books and started reading.  The first real “application” of a computer in my practice was a program that helped me figure percent hearing impairment on patients who were referred to me by the Social Security Administration.

 My brother, also a physician and a psychiatrist, had also become disenchanted with the private practice of medicine.  He left practice and began to work for the Social Security Administration.  His job was to review medial files of people who were applying for Social Security disability benefits.  He began referring me people who were claiming hearing loss as the result of their federal employment.  Most of the patients came from the Texarkana area where they had worked or were working for the armory operated by the government.  One of the tasks of this armory was to work on rehabilitating tanks.

 I learned that while someone might be on the inside of a tank working on the electrical system, someone else might be using a chipping hammer on the outside taking the paint off.  Tanks are mostly made of aluminum.  You can imagine how loud it would be if you were sitting inside an aluminum pot and some on the outside was hitting it with a hammer.  They did this in the days prior to our knowledge that loud noise impaired hearing.

 The SS Administration had a formula used to calculate percent hearing loss based on average hearing loss in designated frequencies.  My friend Mark Hebert, an anesthesiologist who was young enough to have actually taken computer programming classes in college, created a program written in basic to help perform the calculation.

Office automation

 About this same time, I wanted to computerize my office.  I understood that the Southwest Clinic had recently begun using a computer in their office.  In the early 1970’s, I made an appointment with Mr. Bob Wright, their manager, and he showed me their system.  It ran on an IBM mini-computer.  It was way more expensive than I could afford as an individual practitioner.  My associate at the time, Dr. Claude Winborn, had absolutely no interest.  He was in the declining days of his practice.  I put ideas of a computer on hold.

  In 1974 I began to look around for computer systems.  I looked around and found a company in Houston that sold a small PC based system that sounded interesting.  I visited their company and bought one of their systems.  My good friend W.D. Hollon was working in Houston during the week and he was willing to stop by and pick up the computer on his way home one week.  I lent him my Chevrolet Blazer to haul it.

 We worked with the computer for about two weeks, and quickly learned it did not do what they said it would do, and fortunately, I was able to return it.  W.D. took it back for me.

 My patient who managed the Xerox store offered to “lend” me a Xerox 820 computer to try out.  It was a desktop model with two eight inch floppy disks.  I remember is had 64,000 bytes of RAM.  It had a Motorola 8086 microprocessor.  I was hooked immediately and began to move things to the computer.

 I gave a talk at the 1984 Texas Medical Association annual meeting on how to use a computer in a medical practice.  One of the first things I learned to do was to use a spreadsheet called VisiCalc.  I remember putting down all of the various insurance policies I had in force and for the first time was able to determine dollar/thousand costs.  I was able to reduce my insurance enough to pay for the cost of the computer in the first year.

 I also learned to use Word Star, and began to write my own letters, including referral letters.  I remember telling about learning typing skills when I was in high school.  I was now using those skills on a daily basis.

 It was not long until IBM came out with their first “personal computer” the PC.  I bought one for myself and one for my older son.  I had previously bought him a Sinclair computer that hooked up to a TV.

 I took a computer programming class at Eastfield Junior College, but quickly learned that I was not interested in becoming a programmer.  I wanted to learn how to use applications, not create them.

 My friend Don Logan had computerized their office with a system bought from Medic, a small Lubbock company.  The hardware was a Texas Instruments mini-computer.  I don’t remember how much it cost, but I have probably suppressed it, as it was very pricey.  My office staff was very resistant, as they remembered our misadventure with the computer from the Houston company.  A group of neurologists and neurosurgeons who practiced at Medical City also bought a Medic system.

 We bought and installed the system, and it worked well for us.  As we look back on this now, we wonder why we waited as long as we did.  We were on the “bleeding edge” of the use of computers in a small medical office.  The two doctors who shared our waiting room were not interested in using the computer at all.

 Our older son, Mark, had just graduated from Texas Tech with a degree in management information systems, which was the use of computers in business.  Our younger son, Paul, helped me wire our office with the help of one of his classmates Corey.  We installed computers in two exam rooms and in my office.  We bought a file server, and IBM Model 80, and I remember we paid nearly $9,000 for that unit.  We installed a local area network using IBM token ring cards.  I developed software based upon an application called Q&A.  It was a DOS based program that had an integrated word processor and database system I used to create our medical records.  Mark wrote a program in COBOL that wrote prescriptions.

 I was afraid that using a computer in front of a patient would be considered a negative experience by the patient.  It turned out to be very positive, as the patient helped me put in the correct information.  I designed the placement of the computer so that the patient could see the screen as I was typing in the information.  They often made suggestions for corrections.  By the time a patient left my exam room, their medical record was printed and placed in their chart, their prescriptions were written and they took their medical record back to the front desk to check out.  I no longer had to stay behind the rest of the office staff at the end of the day to finish hand writing my records.  Now anyone could read my records and my prescriptions.

 The prescriptions were interesting.  I would get calls from pharmacists, as they thought maybe they were fakes.  They had never seen a prescription typed out on a form before!

Dallas Integrated Systems Company

I tried to get other doctors interested in using computers, but did not have much luck.  By this time I was selling computers through a relationship with the patient who managed the Xerox store.  They also sold IBM computers, and I became an IBM “value added reseller” through her store.

 I did not sell many computers to other doctors, but I did sell several to Houston’s restaurants.  My friend Bill Biel, whose brother owned Houston’s, had left Dallas and his job with Atlantic Richfield to work for his brother George.  He was using IBM PCs in their back office operation.  He was my best customer.  I learned a lot about computers and business.  I also developed a relationship with Epson and sold their computers and printers.  This business went on for several years.  When what is now CompUSA went into business, it was the downfall of my business.  You could buy a hard disk and RAM from them for about what I was paying for them wholesale.  When the IBM clones became available, I gave up this business.

 I need to back up a little.  Just before I turned 50, I considered getting a MBA degree at SMU.  I visited with one of the professors there and gave it strong consideration.  I think I would have done it, but I was unable to get the doctors with whom I shared after hour’s calls to agree to cover my practice every other weekend including Fridays for a two year period.

 I consulted with one of my church friends, Johnny Fooshee, who was a successful small businessman.  He suggested rather than going back to school, I start and work in a small business.  That was the impetus for becoming an IBM PC dealer.

 The idea of doing something other than the private practice of medicine would not leave my mind.  I was enjoying practice less and less.  I was concerned about the ever increasing cost of maintaining an office.  As a solo practitioner, I knew that soon I would become like the dinosaurs.

 I became aware of an organization called the American College of Physician’s Executives.  They had sponsored the seminar at the Menninger Clinic I mentioned before.  They offered three courses for physician executives.  The first course was advertised as containing all of the material typically taught in a MBA program.  It was delivered in a week’s time.  I signed up for their course to be taught in Chicago.

 I have a cousin, Dr. Charles Henderson, who worked for Blue Cross in Chicago.  He had recently retired from a general surgical practice.  I visited him while I was in Chicago for the course.  I found the material interesting and very helpful.  Charles encouraged me to seek a job working for a health insurance company.

Peer review

 I became a reviewer for the Medicare Peer Review System.  The local PRO office was run by Dr. Allen Fain, who had been a general practiconer I knew from my time spent at Dallas Methodist Hospital.  The job of a peer reviewer was to look at the medical records of cases retrospectively and try to determine if the care was delivered in an efficient and proper manner.  It was an attempt by the federal government to have local physicians monitor health care.  The Texas Medical Association had lobbied and succeeded in getting the entire state of Texas designated as a single entity for peer review. 

 The PRO was a grand experiment, but time proved it to not be of any real value and it ultimately was dropped.  I did get some experience with peer review, and it appealed to me.  I felt that I could possibly contribute more to the practice of medicine in some administrative capacity than as a solo practitioner.  I also felt that we would soon have socialized medicine with the government as a single payer.  I thought it would be better to be one of the controllers rather than one of the controlled.

Career change

 I learned that Blue Cross and Blue Shield was looking for a medical director.  I met Dr. Gwynne Harwell, who was the senior medical director.  My friend Dr. Aubrey Godfrey was working for Blue Cross and thought it was a good job.  I was offered a position, but the salary was $100,000 less than I was currently earning in practice.  The only “perk” was they furnished an automobile.  I already had a car that was paid for.  I did not take this position.

 A partnership between Children’s Medical Center and Presbyterian hospital was in the process of building a new hospital in what was then “far” north Dallas.  I contacted them to see if they were considering having a full time medical director.  I don’t remember the name of the person who was to be the administrator, but I met with him.  We talked about a possible position.  It sounded attractive to me, as I could continue to have some practice if I wanted.  The job never materialized.

 I saw an advertisement in “Texas Medicine” the journal published by the Texas Medical Association for a medical director position with Prudential Life Insurance Company of America.  I had a relationship with Prudential through peer review work I had done for them in the past.  I knew Prudential to be a good strong company.

 I answered the ad and had an interview with Dr. Bob Jacqmin, and internal medicine specialists I had known casually when I practiced in the Baylor area.  The interview went well and a second meeting was scheduled with the executive director, Mr. Victor Lazaro.  I remember this date (1/16/91) very well, as I drove to the dinner meeting, I listened on the radio about the beginning of the desert storm war.

 I was offered a position as an associate medical director at a salary that was $50,000 a year less than I was currently earning.  I consulted with more people, and everyone thought I was crazy.  My wife thought I was making a big mistake.

 I took the job and started in February, 1991.  It took a while to close down my practice.  Dr. Bob Peters had recently joined Dr. Dansby in practice, and he agreed to take over the lease on my office.  He bought some of my equipment.  He agreed to maintain my clinical records.  I felt I was fortunate to find someone who I trusted to take over what portion of my practice was willing.  At this time, there was no such thing as being able to sell a referral practice to anyone.

 A referral practice is not like the practice of a primary care physician.  I had nothing of tangible value to sell.  Patients came to me and some stayed with me because of my care and personality.  There was no assurance that any of them would stay with Dr. Peters.

 I discovered my work with Prudential was nothing as I had anticipated.  There was a steep learning curve.  I knew nothing about the health insurance business and needed to learn quickly.  I remember attending meeting and after a few, Vic asking me if I understand half of what had been said!

 I had good teachers in Bob Jacqmin and Pamela Lewis, our nurse manager.  Pam had been with the company since its beginning and had done several jobs on her way to becoming the nurse manager.  She came from a case management background.

Computers again

 As I have mentioned before, I had become a computer user and advocate.  When I went to work for Prudential, I had no computer.  I had a dumb terminal connected to the company mainframe.  I asked Vic about a computer, and he looked at me very puzzled and asked “what on earth would a doctor do with a computer?”  I took my IBM model 80 that had been the file server in my office to work with me and it became my computer.  After using it for several months, I think Vic understood that I could use a computer in my work.  The company bought me a computer.  At the time I went to work for Prudential in 1991, there were only a couple of PCs in our office.  Vic’s secretary used a Wang word processor to do letters.  The PCs were in the hands of Ritu Singal who was the IT person in our office.  Things would change greatly in a very short time.  We moved to new offices in 1992 and everyone had a computer.  It was soon to the point if you could not use a computer, you could not work for Prudential.

 I had several disappointments from Prudential.  I had always been very active in organized medicine, and was a delegate to the Texas Medical Association from the Dallas County Medical Society.  When I asked permission to continue to attend meetings, I was told that they did not hire me for such activities.  If I wanted to continue in organized medicine, it would have to be on my own (vacation) time.  That put an end to those activities.  This canceled any leadership dreams I had.

 I organized a group of local medical directors of other health care organizations.  I wanted to utilize the umbrella of the Dallas County Medical Society and meet at their office.  Dr. Jacqmin was very reticent, as he had tried a similar venture and the company did not like it for fear we would give away trade secrets.  As his group had met in various insurance company offices, he thought it might be OK to give it a try through the DCMS.  It worked well for some time.  There were several local medical directors who became involved, including Dr. Gregorio Cortez, who was the Medical Director for MetLife in Irving.

 After meeting for several months, Dr. Cortez approached me about coming to work with him at MetLife.  He had recently moved from the Medical Director position to be the Executive Director.  He was trying to hold down both jobs.

Job change

 I was not unhappy at Prudential, especially since we had moved our offices close enough to home that I often went home for lunch.  It did not seem there was much chance for personal advancement.  A move to MetLife would put me in a better position as “the” Medical Director.  MetLife was interested in me as I had recently gained some experience with going through a survey by the National Committee for Quality Assurance (NCQA).  The Dallas MetLife plan was programmed to have a NCQA survey, which would be the first MetLife plan to do so.  The negative was the travel.  MetLife’s office was in Los Colinas at Irving.

 I made the move to MetLife.  It was a much smaller company nationally and a very much smaller plan locally than Prudential.  Everyone was friendly and happy to have me.  I was given much latitude in how to run my portion of the office.  I made several trips to MetLife’s national headquarters in Westport, Connecticut.  I made several contacts at the national office.

 This was a great time for me to expand and use my computer skills.  Dr. Cortez was very much in favor of technology.  His enthusiasm was 180 degrees from the attitude at Prudential.  It was a great time for me.  I met and made friends with Tom Bice.  Tom was an ex-Yale professor and was attached to the corporate office.  One of the things he did was to help the executives write speeches.  He was an expert in the future of health care.  He was also very interested in technology and how we could use personal computers to facilitate our work.

 Part of our strategy was to develop a way to quantify our ability to measure the quality of health care delivered in our network.  It is very difficult to measure health care quality.  You can measure how happy your customers are with the health care they receive, but it still does not measure the quality of medical care.  Patients are more influenced by the treatment they receive on a personal basis.  They like being treated well, especially by the doctor’s office staff and the nurses in the hospital.  Patient’s have a difficult time evaluating the quality of the health care they receive.  Most illness will resolve by themselves.  One of the old Hippocratic oaths, little used by the current health profession today, is “first do no harm.”

 With Tom’s help, we developed an application that databased several factors.  It wound up giving a numerical score to each individual doctor.  We called it the Individual Provider Quality Score (IPQS).  NCQA liked it.  MetLife had a meeting in the summer in Phoenix and we won national recognition as the “best” quality improvement measure in the country for MetLife health plans.  MetLife wanted to roll this out to all of the plans in the nation.  This was late summer of 1995.  There was talk about moving me to the corporate office in Westport to facilitate this plan.  Not long after, we learned that MetLife Insurance Company of America, the parent company, planned to sell MetLife Healthcare.  This was a shock to all of us in the Dallas office.  I dropped all thoughts of moving to Connecticut.  I had visited the area and it was very nice, but a very expensive place to live. 

 In the fall of 1995, MetLife sent me on a lobbying trip to Washington, D.C.  We met with various members of Congress.  It was an interesting event.  How much good it would do was left in question.

Move to El Paso

 My return flight was cancelled due to bad weather.  While we were waiting for the weather to clear, several of us from Dallas gathered in the airport coffee shop.  I was sitting at the table with my former Prudential boss, Vic Lazaro.  It was this evening I learned that Prudential was looking for Medical Director for their El Paso plan.

 I could see the handwriting on the wall that I was not to be a survivor with MetLife.  After much discussion with my wife, we decided that a move to El Paso might be OK.  It would put us close to Jane’s parents, who were in a nursing home in Carlsbad, NM.  Jane had spent some time in El Paso when she was in graduate school.  We thought it might be a step toward our eventual retirement.  Our plan was to move to El Paso, work a few years then retire and divide our time between our wonderful vacation home in Cloudcroft and El Paso.

 The move to El Paso was good for me professionally, but was a nightmare for me personally, as Jane hated it.

 We looked for a house, and had a hard time finding something we liked.  There were few choices, as it was a seller’s market.  There were three geographic areas we considered.  The area close to downtown, very similar to Highland or University Park in Dallas.  We found a wonderful house, but it needed major updating.  It had the “original” kitchen, for a time when you had a maid and the wife of the house did not worry about how nice or well equipped the kitchen was.  The view from the front of the house was the lights of El Paso and Juarez in the distance.  Since there are almost no trees in El Paso, there was a sea of light.

 The other area was in the valley along the Rio Grande.  We were told the mosquitoes were bad in this area.  We did not find anything that appealed to us, and Jane’s attitude toward mosquitoes led us away from this area.  Mosquitoes loved Jane!

 The third area is up on the east side of the Franklin Mountains.  The mountains are about 6,000 feet high.  El Paso is the only large city in Texas built in mountains.  We were told El Paso is also the largest border community in the world.  The population of El Paso was about 600,000.  The population of Juarez, across the Rio Grande in Mexico was 2,000,000+.

 We found a house we liked on a street that was a cul-de-sac off North Stanton.  It was new and had a wonderful view of the valley toward Las Cruces, New Mexico.  The sunsets were spectacular.  The dust storms in the distance were too!  The house proved to be the house from Hell!

 The first inkling of things to come was when I went to the closing, I learned that it was built too close to property line on the south side.  The builder who was at the closing, assured me that it was no problem, as a “variance” could be obtained easily.  Jane was not there, and I signed the papers.  She later told me I should have never done so.  She had experience as a real estate agent for a while in Dallas.

 Much later, when the builder failed to take action to obtain the “variance,” with the help of one of our employees whose husband worked for the city, I was able to obtain that by myself.  I had to appear before a board of people who read me the riot act and threatened to fine me.  They had apparently had prior dealings with our builder and other builders on this issue.  With much pleading of innocence on my part, they did grant the variance.

 The next mistake we made, after buying the house, was to spend too much money enlarging the dining room to accommodate our dining room furniture.  Jane is very proud of our table, a reproduction of an antique, which we had bought shortly before leaving Dallas.

 We bought a new refrigerator for the house, and when we got it home, it would not fit in the “standard” place in the kitchen cabinet work.  The cabinet maker was able to sand enough material to allow it to slip in, just barely.  Later, Jane came home one day to find several inches of water in the down stairs portion of the house.  A plastic valve in the new refrigerator had exploded and caused a huge water leak.  We learned the water pressure was too high and had to put a pressure reduction valve in the main line. 

 Our son and his family came from Dallas for a visit in the summer after we moved in.  As they were leaving, Mark said something seemed to be wrong with the upstairs toilet, as it wasn’t flushing properly.  We thought probably our young grandson, who was about 4 years old at the time, had probably flushed a toy.

 We called a plumber out.  They ran a plumbers snake through the drain and water that had backed up in the bathtub drained out.  The only problem was that it drained out down the upstairs wall into our west bedroom wall.  The glass in the window cracked as water leaked down the wall to the floor and out on the carpet.

 We called the builder, and he sent out his plumber who had done the original work on the house.  He discovered the snake had broken through the plastic drain line just below the tub.  He started looking for the clean out on the outside of the house and could not find it on the expected place.  He broke through the stucco, and found the clean out.  It has been stuffed closed with carpet padding which had stopped up the line.  For the lack of a $1.69 plug, we had big trouble.  Fortunately, the builder paid the costs of the repairs.

 We had a roof that leaked.  You only knew it leaked once a year as it only rained in July.  We would fix it, and had to wait another year to know if it was really fixed. 

We learned that the contractor had saved a few bucks and not used the right kind of external paint.  The house was stucco with a tile roof.  We learned that stucco is permeable to water, and a paint that provides a water seal should have been applied.  We had to repaint the house with the proper paint.

 The wind was terrible.  It came across the mountain from the northeast and formed what amounted to a tornado parallel to the ground.   It blew our furniture off the patio.  We had a large metal table with a glass top.  It lifted the glass off and it wound up in the arroyo behind the house.  After a wind storm, I would go up on the roof and straighten out roof tiles that had been dislodged and twisted.

 We had an upstairs guest bedroom that had a door on the northeast that led out onto a nice deck.  When the wind blew, the door leaked so much it would howl.  I put two kinds of weather stripping on, but never made it completely tight.  We had friends, Charlie and Jane Maxfield, who spent a weekend with us.  It happened that we had a windstorm that weekend.  When Jane left, she told Jane to warn future visitors to fasten their seat belts when they went to bed if they slept in that room!

 My study was upstairs.  When the wind blew, the whole house would shake so much the monitor of my computer would move enough to sometimes make me sea sick trying to read from it.

 The only good thing was we did not have any mosquitoes, only scorpions.  They were so bad we had an exterminator under contract who came monthly to spray.

 We developed a leak in the shower in the master bathroom.  It turned out to be one of the easier things to fix, only requiring replacing some of the grout in the shower.  How long before that needed to be replaced, we would not know, as we did not stay there that long.

Back to Big D

 After we had been in El Paso for about a year and a half, things changed at my company.  We learned that The Prudential Insurance Company of America intended to sell the health care division I worked for.  It would leave me in El Paso without a job.  Jobs are very hard come by in El Paso.  I began to work on a plan to get me back to Dallas prior to the sale.  Fortunately, I was able to convince Vic Lazaro that I could manage El Paso from Dallas by making trips there monthly.  He needed more medical director help in the Dallas plan, as it had grown considerably.

 It was also during this time that the medical director in the Albuquerque office decided to leave, as he found another opportunity.  I flew to Albuquerque weekly and spent two days a week working in that office.  We were able to completely close that office, as the company decided to not provide health insurance in the entire state of New Mexico.

 In the early spring of 1997, I moved back to work in the Dallas Prudential office.  After our house had been on the market for three months, it appeared it would not sell.  By this time, there had been a devaluation of the peso in Mexico, and the residential real estate marked in El Paso was dead.  Fortunately, Prudential had a buy out plan, but the problem it proved to be a “buy down” plan.  We lost considerable money on that house!  We were just glad to be rid of it.

 I moved back to Dallas in the spring of 1997.  Jane stayed in El Paso trying to sell our house.  We rented a furnished apartment with the help of Debbie Hollon Irons, daughter of our friends, who at the time was working for Ebby Halliday.  Jane came to Dallas on the weekends, and we started the search for a new Dallas home.

 The housing market in Dallas was hot and it was definitely a seller’s market.  If you found a house you liked, you needed to buy it quick.  We decided we wanted to be south of 635 (LBJ Freeway) and west of 75 (Central Expressway).  Jane had worked in real estate in Dallas and knew where the properties were most likely to hold their value.  We had been burned by our experience in El Paso, were we lost money on our home there.  I learned to consider a home as an expense, not an investment.

 We were very discouraged, as many trips to Dallas and looking at quite a few houses found nothing that suited us.  We would not consider a house with a pool.  That severely limited our choices.  We were looking for a house that we could live in for a number of years, certainly past working into “retirement.”  We looked at both new homes and old homes.

 One weekend, Jane did not come to Dallas and I drove around in the neighborhood I had lived in 25 years before.  I stopped at an open house where they were having an estate sale.  The house was still for sale.  I contacted our realtor, Peggy Jones, a woman Jane had worked with in her realtor life.  Peggy looked at the house and said it “had good bones.”  I put a down payment on it, pending Jane’s approval.  Jane came to Dallas the next weekend and approved of the purchase.

 The house was built around 1960 and was across the alley from where I had lived with my first wife and children.  I talked with daughter Sharon and asked her how she felt about us buying it.  She thought it would be OK as long as the Bernstein’s did not live next door.  When she was a child, the Bernstein’s kids were the scourge of the neighborhood.  We bought the house, as the Bernstein's had moved.

 Jane began making plans about what she wanted to change.  As I look back on it now, I think we would have been better of if we had bulldozed it and started over.

 We hired my friend Johnny Hastings’ son-in-law as our contractor.  He drew up plans to Jane’s specifications and we got started.  This was in July of 1997.  He thought he could have the job finished in about six months.  We moved in December while the last of the construction was still in progress.  We spent a great deal more than estimated or planned.  Jane did a wonderful job and we really liked the result.

 We moved in before the job was complete in December of 1997.  There were still some minor finishing work to be done.  We were very anxious to get out of our apartment and start living in our new home.

 Last edited April 27, 2017

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