This article initially appeared in the June 2010 issue of The Washingtonian.
Joseph Ricotta was an old-fashioned family doctor. He started practicing medicine in the early 1940s, seeing patients in an examining room in the back of his home right up until the day he died in 1990.
He was a first-generation American, the child of Italian immigrants who settled in Buffalo. Many of his patients were immigrants and children of immigrants. In his day, family doctors were something of a one-man medical band. Along with being a general practitioner and an ob-gyn, he did a bit of surgery or psychiatry when the need arose.
He made house calls—often with his grandson and namesake, Joseph, helping to carry his black bag. On the rare occasion when patients couldn’t pay in cash, they mowed the doctor’s lawn or offered him a chicken or some eggs or a bushel of tomatoes.
His son John Ricotta, 60, is now chairman of surgery at Washington Hospital Center. His granddaughter Lise is an anesthesiologist in Baltimore. His grandson Joseph performs state-of-the-art endovascular surgery at the Mayo Clinic.
Their family’s story embodies the arc of modern American medicine over the last half century. It’s a tale of astonishing technical breakthroughs—from organ transplants to CT scans, antibiotics, chemotherapy, statins, and other treatments that save lives. The explosion of knowledge has been so rapid that, as the physicians in the Ricotta family say, the challenge now is to manage that knowledge, not memorize it.
American medicine since the mid-20th century has also become so specialized that care can be fragmented, adding to the costs and complications of chronic diseases. There are so many new treatments and drugs and protocols that doctors don’t always know which to use, when to use them, or whether to use them at all.
Patients have become “health-care consumers” and doctors are “providers,” a change in terminology that the Ricottas say reflects new assumptions about doctor omniscience and patient autonomy. Mom-and-pop businesses—with Pop practicing medicine and Mom keeping the books—have morphed into a $2.3-trillion health-care system. Today Mom is just as likely as Pop to be the doctor.
And while one in six Americans is uninsured, it’s hard to envision many patients in 2010 paying off a doctor’s bill with a bushel of tomatoes.
The Ricotta family’s experience is the story of three generations of doctors who, despite the dizzying pace of change, are inspired by the lessons they learned at their grandfather’s knee, trying to do their best for patients in a confusing, miraculous, litigious, and rapidly changing world.
Neither Lise, 33, nor Joseph, 38, saw medicine as a family obligation foisted on them. For each, it was a choice—and a good fit.
“We were well educated, and we were very well taken care of,” Lise says. “We were raised with the assumption that we would give back to society—through medicine or something else. It just so happens the skills that run in our family manifest in medicine.”
Ride the Metro and you might see an ad for Washington Hospital Center, where John Ricotta has been chief of surgery since October 2008. In his dad’s day, hospitals didn’t advertise on billboards.
As a youngster, John respected his father’s commitment to patients but didn’t understand the lure of medicine, which often interfered with family life. As a teen, he earned pocket money by spending his evenings filing the charts of patients his dad had seen that day and pulling charts for those who would be seen the following day. It was tedious work. He dreamed about becoming a lawyer or a history professor.
While he was an undergraduate at Yale, law and history lost their allure and medicine beckoned. John Ricotta began seeing his father’s relationships with patients in a new light, understanding why his father found it so enriching—even if it meant time away from his wife and kids. John went to medical school but decided he didn’t want a general practice like his dad’s, partly because he planned on going back home to Buffalo—which he did for several years before practicing in Long Island and then DC. He wanted his own professional identity in a community where his father was beloved. “You couldn’t go someplace without someone knowing him,” John says.
John Ricotta also came of age amid a trend toward specialization in medicine. He became not just a surgeon but a vascular surgeon. The technology interested and challenged him. The ability to diagnose a problem and fix it in an operating room suited his temperament.
If you’re lucky, you don’t know what vascular surgeons do. These physicians treat abdominal aortic aneurisms, deep-vein thrombosis, carotid-artery disease, peripheral vascular disease, and other circulatory conditions that can be disabling or deadly. In his father’s day, they often were.
John tries to keep some of his father’s ethos, seeing a patient as a whole person and not as a collection of leaky blood vessels. It isn’t easy. In our current medical system, patients tend to have multiple specialists who don’t always communicate well with one another—and aren’t paid to coordinate care.
“Patients very often have many doctors, and everybody is busy,” he says. “It’s not that easy to coordinate. I try to do it for a complex patient. I try to get on the phone with the other physicians.” But there’s a lot of telephone tag.
Vascular disease does lend itself to more of an ongoing patient/physician relationship than other surgical specialties do. The patients are usually elderly, and if they have one vascular problem, they’re at risk for another. So Ricotta tends to take care of them over the years. For him, that mix of surgery and continued care, along with responsibility for patients in both the hospital and the office, is the best of both worlds.
“My father had a relatively low-tech, highly interpersonal relationship with his patients,” says Ricotta. “I’ve had less intense though very rewarding relationships.” He still has former patients from Long Island who call him, trying to find another vascular surgeon who has that same human touch.
While John Ricotta is a specialist, his children Lise Ricotta Asaro and Joseph Ricotta are part of the superspecialist generation. (Their sister is a speech pathologist in New York.)
Lise isn’t just an anesthesiologist. At Kernan Orthopedic Hospital, part of the University of Maryland medical system, she specializes in nerve blocks for orthopedic surgery. The nerve blocks give patients who may be poor candidates for general anesthesia—for instance, because of a heart condition—a chance at bone or joint repairs that can restore mobility or reduce pain, improving the quality of life.
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.”