Politics and Medicine in a Small Southern TownBy Seth Borgos and Joshua Miller
Vol. 1, No. 1, 1978, pp. 11-12
The first time we heard of Dr. Wayne Smith he sounded like a character out of Ibsen or Sinclair Lewis. A courageous, reformminded doctor criticizes the corrupt local hospital and thereby incurs the wrath of the medical establishment because he violated the unwritten rule that doctors protect their own. He incurs the hostility of the community because the rate of patient attendance of the hospital rapidly drops.
What we found in Keber Springs, Arkansas, did not quite match the scenario. Wayne Smith is a combative man, a perfectionist. His criticisms are probably legitimate, but they're conventional. The doctor may never be vindicated because the community may never reach a consensus on whether or not he was right, and there is no deus ex machina to supply the answer. The argument over Wayne Smith will go on for a generation. In the meantime, the town is bitterly polarized, and the hospital suffers.
Heber Springs is a pretty town. It sits 60 miles north of Little Rock and is the county seat of Cleburne County. Wayne Smith began his Heber Springs practice in July, 1968, deciding as he did to pursue a medical career after a decade of service in the Armed Services as a personnel counselor. It was his first private practice; after completing an internship in Little Rock he had moved to Heber Springs because his wife's family was from the area. When Dr. Smith arrived in town there was no public hospital. A new county-owned hospital opened in October of that year and Smith promptly joined the medical staff.
Soon after Dr. Smith began taking patients at the hospital he witnessed a number of disturbing incidents. Once, he found the blankets supplied for newborn babies full of holes. Another time he rode out with the hospital ambulance to pick up a man and the door of the ambulance jammed and Smith had to tear it off.
On one occasion a Jehovah's Witness was admitted to the hospital. The family of the patient informed the hospital staff that, because of his religious beliefs, the man could not receive any kind of blood or blood products. The nurses assured the family that they would not give the patient any plasma; instead they gave him "packed cells." When the family discovered that "packed cells" were in fact a blood product, the family telephoned their physician in outrage. The doctor said in reply, "You're damn fools."
A major problem at the Cleburne County Hospital was the constant squabbling among the personnel. The medical staff was riddled with petty jealousies. The nurses found that many of the doctors were far from receptive to being called at their homes after hours for medical advice, even when the doctors were on emergency room call. Sometimes the nurses were subjected to abusive language; other times the doctors would simply refuse to take the call, or relay instructions through their wives. It got to the point where the nurses were drawing straws; the loser had to call the doctor. The doctors could be equally uncooperative when the nurses wanted them to come down to the hospital at night to deal with special problems. The nurses deeply resented the doctors' attitude. As one of them said, "I take pride in knowing my job as a nurse. I 'don't call a doctor on small things, so if I do call him I expect him to come."
In the Spring of 1974, Smith felt he could no longer accept
Page 12the situation quietly. He decided to go to the hospital board with a list of specific grievances and proposals for improvement in hospital procedures. He showed the list to some of the nurses, one of whom showed it to another doctor on the medical staff. The doctor approached Smith and threatened to "stomp" him. Smith replied, "You may stomp me once, but if you do, you'd better kill me, because if you don't kill me I'll be back with a gun and kill you."
After this incident Smith resolved to go along and get along th the rest of the medical staff. He intended to do his work quietly within the existing structure and not make waves.
"I tried this for about two years," Smith said, and I found I couldn't live with myself, knowing that patients were going into the emergency room... not being mistreated, but being ignored." On July 2, 1976, Smith informed Sam Rector, the hospital director, that he intended to resign from the medical staff in the near future, and that he would no longer schedule anything other than emergency surgery at the hospital.
Smith stopped attending hospital staff meetings, and the medical staff invoked the hospital bylaw which automatically suspends doctors who miss three consecutive staff meetings.
Smith responded by joining with one hospital nurse, one former hospital nurse, and two of his patients in a one million dollar lawsuit against the hospital staff and the Board of Governors. The suit, filed on April 26, 1977, in Federal district court, listed 21 alleged violations of the Hill-Burton Act, the Medicare and Medicaid Acts, and the equal protection clauses of the Fourteenth Amendment.
Three days after the suit was filed, Paula Penn--the hospital nurse who had joined in the suit-was fired by Sam Rector. She asked the court to issue a preliminary injunction ordering her reinstatement, but was turned down. The suit is now scheduled for trial this Fall.
While many of Dr. Smith's patients are old-time residents of the area, his most vocal defenders are newcomers like Mrs. Helen Puckett, who moved to Heber Springs from Memphis, Tennessee, three and a half years ago. The Hospital Board, on the other hand, is an appendage of the local Democratic party, and is entirely composed of long-time residents. In the words of Mrs. Puckett, "These men grew up together ...When this controversy began they stuck together sort of blindly."
The hospital controversy is instructive for what it tells about the relationship between politics and medicine in any small community, including those which are far less dynamic than Heber Springs. The key to that relationship is the dependence of the community upon its doctors and its hospital. In a larger city, there is a choice of hospitals, and no one doctor's opinion would carry so much weight.
"You've got to examine the doctor/patient relationship to understand all this," said John Barnes, editor of the Heber Springs newspaper, The Arkansas Sun. "If you go to your doctor here and he says the hospital is no good, you're going to be very reluctant to go to that hospital. If you go to your doctor and he says there's nothing the matter with the hospital, you're likely to believe him. You'd put your life in his hands. People are divided on this thing along the lines of who their doctor is. Dr. Smith's patients believe Dr. Smith, and the other doctors' patients believe their own doctors."
Smith's detractors consider him rigid, combative, and quite possibly paranoid. And indeed, Smith is a Puritan. He has ferocious contempt for medical mediocrity and political cowardice. He says, When a patient is sick and needs the care of the doctor and the doctor doesn't come down because he's too lazy, or ornery, or drunk--then he needs to be criticized."
If there is a touch of arrogance in Dr. Smith, his patients are unaware of it. They describe him as a doctor of unusual warmth and concern for the dignity of the patient. "Most doctors treat the symptoms of disease; Dr. Smith treats the whole person. Most doctors treat high blood pressure by giving the patient a pill. Doctor Smith may prescribe the pill, but he'll also try to deal with the problem which caused the high blood pressure in the first place," said Helen Puckett.
One reason why many citizens are reluctant to criticize the hospital and are anxious to "put this matter behind us" is that the community cannot afford to see the hospital go under. With the next closest health facility thirty miles away, the dependency on the hospital is even more extreme.
In additicn to its medical value, the hospital is a potent symbol of community achievement, and that is why it has become a political football. Dr. Smith says that he does not understand the political connection. "I'm not conversant enough with politics to decide what their motive 5.1 smell a rat, I see it, but I can't dissect it. I can't see what makes it tick." What he's missing is simply an essential political dynamic, the peculiar process by which power becomes an end in itself regardless of its value to the person who pursues it. In a small comriunity like Heber Springs, there are only a limited number of political arenas.
"You don't touch the church; that's sacrosanct," says Peter Miller, a former editor of the Arkansas Sun. "You can only screw around with the schools so much. So what's left? Generally, you get politically involved in things that really don't mean a damn, like whether to hire a new policeman. What under normal conditions would be a local, minor situation, becomes a major confrontation. It's crazy, but it happens here all the time. That county gets polarized over anything."
What lies at the center of this controversy is not opposing medical philosophies (e.g. professionalism vs humanism), but the paradox of professionalism itself. Professionalism has earned its bad name in medicine, law, and teaching. It has come to mean a cold, bureaucratic approach to personal, human tasks; protection of incompetence and mediocrity; mystification and elitism. Of particular relevance to the democratic citizens' movement is the tendency of professionals to feel more loyalty to their institutions than the needs and demands of the community. They want to mask political decisions as matters requiring only professionals' judgements.
Yet, Wayne Smith is a professional, and his fierce dedication to his work, his sense of a special calling, is responsible for bringing the issue out into the open. He looks at his work as a vocation, not a job. A vocation entails a set of standards, a sense of responsibility, and pride, and commitment. From his point of view his fight has been to prevent the erosion of professional standards in the face of the indifference of the hospital administration and the governing board. The problem, Paula Penn says, is that the members of the hospital board are "plain ordinary people" who "don't want to admit that they don't know what's going on at the hospital."
The solution to the problem ot making institutions responsive to the community cannot be as simple as the catchword "community control" or "deprofessionalization." To deprofessionalize medical care in a town like Heber Springs is to hand it over lock, stock, and barrel to the local Democratic chieftans, some of whom take the attitude that running the local hospital is not different than running a warehouse. Community control in Heber Springs means placing medical care in the hands of a small segment of the community. In this matter, as well as in many other things, the answer may lie in finding the right balance between democracy and authority, and in not mistaking all politics for democracy.