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In Granddad’s Footsteps
Comments () | Published September 10, 2010

She wasn’t sure she wanted to do anesthesiology. In fact, she wasn’t sure she would be a doctor. In college, she majored in religion and classics, then worked briefly in the fashion industry and later on an Israeli archaeological dig before finding her way to med school. When she got there, she didn’t like it—for the first two years at least. “It was very didactic, lots of science,” she says.

In her third year, as she started working with patients, she began to feel at home. Childhood memories took on new dimensions. She understood why her dad’s eyes welled with tears after the death of a patient. And why every Sunday her grandfather Poppy had stopped at the hospital on his way home from church to check on patients.

She chose anesthesiology partly because she found it interesting and challenging and partly because, like many women in medicine, she hoped that its relatively predictable hours would make it easier for her eventually to combine career and motherhood. Her practice is far more orderly than that of her husband, an emergency-room physician.

Joseph, the child who carried Poppy’s black bag on patient visits and who, as a teenager, watched his father perform surgery, took a more direct path to medicine.

“I always wanted to be a doctor, based on my dad and my grandfather,” he says. “They were my idols. I saw how much satisfaction they got from their jobs and how they touched people’s lives.”

From the start, he was drawn to surgery—which he calls the medical version of immediate gratification: “I have that mentality, trying to fix things right away.” At the Mayo Clinic he’s at the forefront of minimally invasive vascular surgery, one of a handful of surgeons in the United States who can repair a life-threatening aortic aneurism with tiny instruments inserted through a small puncture. His techniques are so groundbreaking that many colleagues elsewhere have never seen them. He publishes articles with titles such as “Novel Surgeon-Modified Hypogastric Branch Stent Graft to Preserve Pelvic Perfusion,” addressing surgical challenges and solutions his grandfather never would have imagined.

“My grandfather would have been amazed by what we can do,” Joseph says, “all the advances and technology—minimally invasive procedures, fine-slice CT scans, what we do with wires and catheters and stents.” He can operate on a 75-year-old with an aortic aneurism, slipping stents up through a puncture in the groin, and have the patient home in two or three days. In the old days, patients would have been sliced open from chest to abdomen and would have taken weeks to heal—if they healed. And if the aneurism was even detected in time.

Many other aspects of Joseph’s practice and his life as a physician would have surprised his grandfather, he says. The patients who come to Mayo from as far away as Bangkok, for example. And the complexity of the system: “He’d be amazed at how the bureaucracy of medicine has grown, the amount we have to keep track of. The payer systems and the insurance companies make it tremendously more complex and more confusing.”

At Mayo, Joseph Ricotta is cushioned from some of that. Physicians are on staff and receive a salary—they aren’t just affiliated with the hospital and paid per procedure. People who want to change how US health care is financed and delivered often point to the Mayo Clinic as a model, not only because it gets such good results but also because the care is well coordinated and relatively cost-effective.

It isn’t just money and machines that have changed since the time of Joseph and Lise’s grandfather. Patients are different, as are their relationships with their doctors. Physicians, says Lise, worry more about having a patient sue them; she thinks her grandfather would have been taken aback by her experience as a resident: “We had so much supervision. I think there was less back when Poppy trained. We are such a litigious society.”

It isn’t just fear of lawsuits that has changed doctor/patient relationships. There was a more paternalistic model then—patients came in with questions, and doctors more or less gave them answers. Now patients are swamped with data and studies and choices. They see those ads on the Metro, commercials on TV, ever-changing headlines hailing breakthroughs, and of course that bottomless pit of health information and misinformation, the Internet.

Along with a tidal wave of information has come new terminology. Sometime in the mid-1990s, doctors became “providers” and patients “consumers.” John Ricotta thinks that semantic shift has hurt the relationship between the two, making it more adversarial and more commercial. He doesn’t necessarily want to harken back to the old models. Treatment decisions are complex today, and patients should share in the decision making, he says. But he sometimes wonders if something has been lost. Decision making isn’t more complicated only because the science isn’t always clear; the roles are no longer clear, either.

“I think that may be the biggest difference in how we deliver care now,” says John Ricotta. Patients are informed—not always well informed but armed with information. Yet even his most knowledgeable and “empowered” patients still—usually—want his guidance. The trick is finding a balance: respecting that the patient makes choices but helping ensure that the choices are good ones and then trying for the best outcome under the chosen path.

What can really sour a patient/doctor relationship, he suspects, isn’t so much the abstract questions of autonomy versus authority; it’s when doctors fail to understand they’re treating human beings, not just repairing plumbing problems.

The second and third generations of the Ricotta doctors don’t second-guess their decision to become specialists, to practice in high-tech hospitals. In 2010, those settings let them help patients in ways that would have been unimaginable in a home office in Buffalo circa 1950. But the vivid memories all three carry of the first Dr. Ricotta—sometimes seeing a sick patient in his home office late at night—have helped his descendants remember that a patient is more than the sum of his or her body parts.

The three Dr. Ricottas—father, son, and daughter—know that big changes in medicine are on the way. Either we’ll find methods of delivering high-quality care more efficiently or even more cracks will appear in the system.

All three are a bit ambivalent about health-care reform. They welcome expansion of coverage; none is comfortable with the millions of uninsured who are at risk for getting care that’s too little, too late, and too expensive. The Ricottas welcome the push for computerized health records—although the thirtysomethings are more comfortable than their dad—knowing that it may address some of the challenges of duplication and coordination of care. But they aren’t really sure what this new health-care world will be like, what “delivery-system reform” or “medical homes” or “accountable care organizations” will look like for their patients and themselves. And for the next generation of doctors.

In Rochester, Minnesota, Joseph’s five-year-old son is already practicing carrying dad’s black bag. “I’m going to be a surgeon,” the little boy says. “On aortas.”

“That’s his grandfather putting the idea into his head,” Joseph says with a laugh. “Not me. But I’ve taken him on rounds. Maybe he’ll be the fourth generation.”

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