Friday, October 3, 2014

Gary W. Dorshimer, MD, FACP

By David Woods, PhD, FCPP

After some 28 years as a primary care physician in Center City Philadelphia, Dr. Gary Dorshimer, 59, decided that he’d had enough of ever more form filling and documentation and leaving less time for actual contact with patients. In fact, a survey conducted by Health Affairs showed that physicians spend roughly $80,000 a year processing insurance claims and their staff devote some 20 hours a week interacting with health plans.

So he started looking into concierge practice, sometimes known as retainer-based medicine, and, with his wife Deborah, attended a seminar by MDVIP, a leading company in the field. However, he decided to become part of a Penn initiative, Penn Personalized care, to be able to deliver a high level of care to patients.

His patient care coordinator, Cynthia Cross, and his medical assistant Charlene Griffin worked with Gary Dorshimer for 20 years or more in his former practice and have now joined the new one. Both say there’s more attention to individual patients’ needs, and more time spent with them. Along with a third staff member, Samantha Jacobs, the operation is much leaner, Cynthia says – and less pressured. There’s always a person answering the phone to talk with patients – not a voice mail system.

The whole idea of concierge medicine is said to have stemmed from a Dr. Howard Maron, a specialist in sports medicine and physician to the Seattle Supersonics pro basketball team. Gary Dorshimer, as head team physician for the Philadelphia Flyers and team internist for the Philadelphia Eagles may have spotted a kindred spirit in Dr. Maron.and Penn Medicine moved his practice to the 17th floor of an elegant building just a few blocks from his original base.

He got involved in sports medicine after finishing  his Chief Resident year at Pennsylvania Hospital. In July 1984 he joined Viner/Daniels Internal Medicine Associates, where Dr. Ed Viner was head team physician for the Phila Flyers and the Phila Orchestra.  He started to work with the Flyers.  Up until 1999, he says, you could become Board Certified in Sports Medicine  without having done a sports medicine fellowship but by showing on-going work in sports medicine, attending sports medicine courses, etc., and passing the Board exam. 

Gary has been a team physician with many other teams, including the Phila Phantoms, the AHL affiliate of the Flyers, before they moved to Glens Falls, NY when the Spectrum closed.  They are now moving to Allentown, PA. He has hoisted the Calder Cup twice when they won the AHL Championships.He has  cared for such teams as men’s indoor soccer (the Kixx), women’s soccer (Charge), and women’s basketball (Rage). Moreover, he has served as the NHL Internal Medicine consultant to the Olympics in 1998 (Nagano), 2002 (Salt Lake City), 2010 (Vancouver) and 2014 (Sochi). 

So as team physician at the professional levels, he practices general internal medicine for the players and their families, as there are orthopedic specialists taking care of musculo-skeletal injuries.  A major injury he cares for is concussion. “ Our knowledge of the physiology of concussion, the evaluation and treatment and return to play criteria has improved over his 30 years in sports medicine,” he says. 

In his concierge practice he has much less pressure; sees only a fraction of his former daily caseload, and can spend more time with patients, especially on preventive medicine. ‘At the end of the working day,’ he says, ‘rather than continuing into the night with a mountain of documentation to get through, I can walk away from my daily routine.’ Time and breathing space are the great benefits of his new professional life, says Dorshimer. ‘I don't mind working hard; but I found the hectic pace of my former practice to be very wearing.’

Not only that, but it means being  ‘captain of the ship,’ in other words, a general internist fills a leading role for patients, taking information and advice from other consultants and applying them to the patient’s specific needs.

For patients, it means no lengthy wait for an appointment, quality time spent with the doctor, and very personal attention. No wonder that the number of concierge practices in the United States is now more than 5000, and growing. The only downside appears to be, in the minds of some critics, that it caters to the wealthy and then creates two levels of care. In fact, Gary Dorshimer takes care of retired teachers, truck drivers, postal workers … a broad spectrum of patients across all income groups.

In 2011, he was voted one of the top US internists by US News and World Report. He is a fellow of the American College of Medicine, as well as the College of Physicians of Philadelphia.

In his spare time––which he now has more of––he likes to travel (most recently to Scotland between the two sessions of our interview) enjoys teaching (he's a clinical associate professor of medicine at the University of Pennsylvania) and is proud of the sports medicine fellowship he started in 1998 with Dr Arthur Bartolozzi. He is a frequent lecturer and serves on the editorial board of The Physician and Sports Medicine.


He and his wife Deborah and 30-year-old son Geoff live in Drexel Hill.

THE POETRY OF MEDICINE

I am not a poet but for years, poetry has been a part of my (almost) daily routine. In the early morning, coffee cup in hand, I enjoy Garrison Keillor’s online The Writer’s Almanac (http://writersalmanac.publicradio.org/); I savor poems found in our major medical and other journals; and discover gems sometimes in the most unlikely places. There must be thousands of poems in folders in my library while poetry books spill off their dedicated shelves. Perhaps it is not surprising, then, that poetry is a routine part of my medical armamentarium. Whether working with students or professional and lay audiences on a wide variety of topics, poetry informs, clarifies and “softens” almost every discourse.

For the most part, poetry relevant to medicine is spare. It conveys a depth of imagery, reality and emotion absent in most medical discourse. Poetry challenges our intellect while speaking to our deepest fears, hopes, dreams and uncertainties. Poems ensnare us with their shapes, rhymes, rhythms and cadences, their punctuation or lack thereof. Every word counts. We are challenged to read between the lines and sense what is unspoken or perhaps unknowable. Essentially, poems are like patients – they all require close attention and interpretation.

Recently, at my 40th medical class reunion in Australia, I shared with old friends a few poems, all written by physicians, which create a commentary on our experiences in medicine rather than those of our patients. I thought my fellow Fellows might appreciate this collection too. First, though, let me begin with a short poem by Honorary College Fellow, John Stone, who gave several marvelous readings at the College prior to his untimely death in 2008.
  
Death
  
                        I have seen    come on
slowly as rust
sand

or suddenly    as when
someone leaving
a room

finds the doorknob
come loose in his hand

                                                ― John Stone

Here in just eight short fragmented lines is the entirety of death – the slow erosion of the body by age or disease, or the sudden snuffing out of a life, the inevitability of it all.

For many of us our first intimate encounter with death was in Gross Anatomy. Are we surprised, then, that almost every major physician-poet and many students have penned a “dissection” poem, reflecting on their tenure in the Lab? Listen to the wonderful metaphors for elements of the body – caves, canyons, faults, flowers, minerals, oil – in College Fellow, Jack Coulehan’s poem “Anatomy Lesson”:

Anatomy Lesson

When I move your body                                    Do not mistake these tears.
from its storage drawer,                                    These tears are not
I brush my knuckles,                                         for your bad luck
Ernest, on your three-days                               nor my indenture here,
growth of beard. Cheeks,                                  but for all offenses
wet with formaldehyde,                                     to the heart―yours, mine―
prickle with cactus.                                            for the violence
My eyes burn and blink                                      of abomination.
as if a wind of sand                                            Think of my tears as rain
blew through the room.                                      staining your canyon walls,
                                                                           filling your stream,
Bless me, Ernest,                                               touching the blossoms.
for I cut your skin
to learn positions                                                                        ―Jack Coulehan
and connections
of your parts―caves,
canyons, fissures, faults,
all of you. Show me.
Show me your flowers,
your minerals, the oil
of your spleen.

Dr. Coulehan, internist and palliative care physician who has read from his work several times at the College, jokes that he and his table mates named their cadaver “Ernest” so they could tell their parents they were working “in dead earnest.” Ah, the stories we all could tell! In sharp contrast to Dr. Coulehan’s lyrical poem is this pungent little gem by one of my medical students:    

Reflection On Anatomy

Six students huddled around a body on a table
Like crapshooters in some morbid casino
The scent of human bodies
Like old stale beer
On my clean hands

                        —Ethan Payne
           
One way or another we finally became interns or the equivalent thereof. While tourniquets and other paraphernalia have given way to e-tools in our pockets, pulmonologist Phillip Cozzi captures so much of that year in this whimsical poem:

Intern

Beyond the handsome grey-haired men who grace our walls
with stately charm. Beyond the present chairman who
is warm and unassuming though he speaks in pearls
and has a world-class reputation, by repute.

Beyond the crease-sharp minds of our attending staff.
Beyond their certain fatherly intelligence,
mature beyond their years. Beyond their ready laughs
and smarts. Beyond the street-sharp, heart-wise residents

you find . . . O no . . . the lowly intern, awkward mole,
no friend to sun. Ridiculous, he looks the clown
with safely pin or tourniquet from every buttonhole
and only his ineptitude is near renown.

Yet you might fight to love the slow-foot worm
who plods and plods through daily chores so utterly
methodically for even he survives and even he’ll emerge,
despite his former grubby self, a butterfly.

                                                            ―Phillip Cozzi  

Oh yes, we remember those who spoke in pearls and the descending hierarchy of the hospital!     

When I came to the U.S. in late 1971, many things surprised me including the paucity of women in medicine (35% of my graduating class was of the “fairer sex”) and the differences in terminology and acronyms used in various medical settings in the American cities where I worked. This poem captures the essence of my disquiet:

Misunderstanding by Eric L. Dyer, pulmonologist

Morning rounds, the intern’s order:
Discontinue TLC,
a word and three letters puzzling to me,
displayed so near approaching death
and this cold robot of volume and flow
quantitating every breath.
How inappropriate, it seems,
to discontinue tender loving care
for this spare woman scored with tears―
strange enough for me,
embarrassed to inquire of love
with a stethoscope tickling my ears,
to ask her nurse
the meaning of this doctor’s order.

Oh, she reported,
that’s Triple Lumen Catheter in this ICU.

So, now I understand
the meaning of TLC in room 262,
where we are headed this morning,
what a difference three letters can make,
how much
the language of this work has changed.

It’s striking to see the “cold robot of volume and flow/quantitating every breath” counterbalanced with the soft fuzzy notion of “TLC,” and the poet’s empathy for the patient contrasted with her objectification as “room 262.”

Anesthesiologist Audrey Shafer captures another aspect of medical life, the often uneasy balance between work and parenting, in her lovely poem “Monday Morning”:

Monday Morning by Audrey Shafer

                                    In the prelight
                                    A heavy sound from upstairs
                                    I turn from the front door
                                       to investigate.

                                    My three-year-old son stands
                                                             naked
                                       in the soft penumbra of dimmed hallway light
                                    Clutching his favorite blanket
                                       picture book and well-rubbed panther
                                                   to his chest.
                                    His toes curl on the wooden floor.

                                    I am dressed and beepered―
                                    No snuggling in the warm water bed this morning
                                       floating back to sleep till sunlight wakens.
                                    Instead, we hug.
                                    I kiss
                                                   his thin neck.
                                    I feel his small breaths.

                                    His bedroom door stands closed,
                                       heavy in shadows.

                                    At the operating suite,
                                    The residents still at lecture
                                    The patient not yet here,
                                    I enjoy the rote motions―
                                       follow the green snake tubing to the ceiling
                                       barbotage dissolving drugs in syringes
                                       snap open the laryngoscope.
                                   
Around me all is bright  pristine  ordered
                                    Primed.
                                    Sterile instruments attend in precise, metallic rows.

                                    I try to recall his just awakened warmth
                                       in that brief moment
                                                 before

                                    The patient arrives
                                    Naked under hospital issue
Ready to sleep.

How many times have we all felt guilty about “abandoning” our children and then been forced to recognize the pleasure in our jobs?  

As we all know, “doctor bashing” is a popular sport, especially in the media, and “playing God” is a frequent charge levelled at the most humanistic of physicians. In this wry poem, oncologist Marc Strauss eloquently captures that tension between physician and patient:                                   

Not God

                                    I thought to delay the answer, camouflage
                                    it, by waiting until he asked another
                                    question. But he prefaced the question with

                                    I know you’re not God. This is commonly said
                                    to me, second in frequency only to What
                                    would you do if it was your father, or wife,

                                    etc. I accept this statement of my undeity
                                    to be rhetorical, a mechanism to permit me
                                    to be imprecise, to use phrases like “it depends

                                    upon many factors” and “a range of.” But lately
                                    I’m increasingly tempted to say, How do you know
                                    I’m not God? What gives you such certainty?

                                    Do you say this to your lawyer, accountant,
                                    or mother-in-law? And, if I’m not God then why
                                    Ask me a question that only God can answer?

                                                                                    ¾Marc J. Straus

(As a side-note, Dr. Strauss’s play Not God: A Play in Verse, in which this poem is to be
found, was performed at the College in November, 2008.)

While the nature of bedside rounds has changed dramatically over the years and many of us lament the current prevailing standard, endocrinologist John Wright gives us a wonderful “take” on this ubiquitous aspect of medical training through the lens of a landscape architect training an intern. One has to love that “punch” in the final stanza.
   
Bedside Rounds by John L. Wright

I thought of bedside rounds
when my landscape architect called to ask
if it was okay to bring an intern with her.
Of course, I say,
remembering the many years I enjoyed teaching
and the few times the housestaff
honored me
with the Best Teacher award.

So today she’s here to help me reshape
the back lawn to support
structurally and aesthetically
a new bluestone walk, its slow curve
leading to a new red cedar porch.

For sure,
this is not a matter of life and death
but after an hour
of traipsing around with her yellow tape
and spray can of orange, water-soluble paint,
asking the intern what she thinks of this border
or that elevation
I begin to resent them
―the little games they play.

Who’s lawn
do they think they’re talking over
anyway?

Without doubt we’ve observed amazing advances during the past 50 years in medicine. Surgeon Maria Basile captures the essence of that change and puts us medical “elders” squarely in our place in her poem “Dinosaurs”:                                     

Dinosaurs

Marveling at
stainless wires
they used to close
everything,
the skin over
an absent breast,
the bone over
an open heart,
how could we know
how could we know
cutting cracks in calloused hands
making sutures sing,
trying and tying
as silk became Vicryl
catgut turned chromic,
that we were the dinosaurs,
that heat would denature
blood vessels and tumors,
sound beyond sound
could cauterize and cut,
nanochips
would replace the retractors
we clung to
and the eyes so tired
from reading.                                               
―Maria A. Basile

How could we know? How could we know. But hasn’t it been exciting, rewarding, and, yes, fun along the way?

This last poem is by Tim Metcalfe who practices family medicine in remote, rural Australia. It is a tour de force that takes us from the shock of the Anatomy Lab to the trauma of our early clinical years, from anger at the injustices we so often encounter to sorrow at our own naivety and helplessness in the face of human suffering.  Drawing on the Australian aboriginal concept of “the dreamtime” and the wisdom attributed to aboriginal tribal elders, Metcalf ends with an image that is hard to forget. This doctor finds resolution to the exigencies of a life in medicine by simply being with his patient.     

STAGES OF DYING
            (after E. Kubler-Ross)

denial

In anatomy class                                               
we cut textbook lines
into the dull clay of our body.                                   
We shook dismembered hands,                       
and bragged of cricket with arms and balls           
for a joke.                                                           
We washed the formalin from our hands           
for the next two days.                                               

shock                                                                       

A pregnant girl collapsed.                                   
The scalpel cut quick and deep.
Her grey belly peeled apart.                                   
The monitors ticked:                                               
a mechanical requiem.                                   
White gloves pulled out the baby                       
cold and dead like the streets                                   
I wandered half that night.

guilt                                                                       

As an intern
I was anxious, and obedient.                                   
To cure at all costs
was the boss’ creed.
I had no time for the old woman
we made betray her faith.
Soon after the transfusion
She died of cancer.

anger

Some drunken bastard
hit this woman with his car.
Her young breasts quivered
each time we thumped her chest.
Over half an hour
her face, burned alive,
set cold, branding for life
the mind of her child.
     
sorrow

Was it happy, his final memory?
This poor bloke, purple-faced
and next in line for death?
I was naive, yesterday,
regarding his broken heart.
Today it wouldn’t go anymore.
Tonight I was drunk.
There were tears, briefly.

acceptance

I went to see an elder on his beach up north.
He didn’t say much.
There was this sky-blue dreaming;
the ocean its lucent mirror,
flawless like an egg.
I heard he died around sunset.
That night a warm breeze blew
the soothing tune of the sea.          

                        ―Tim Metcalf

I hope these poems have whet your appetite for more! Please watch for details of the College’s first Poetry Competition that will be launched in November and for a poetry event on April 21, 2015 that will honor the 25th Anniversary of National Poetry Month.

Poetry References:
“Death” by John Stone. From In All This Rain (1980), Louisiana State University Press.
“Anatomy Lesson” by Jack Coulehan. From Medicine Stone (2002), Fithian Press.
“Reflection on Anatomy” by Ethan Payne. Class of 2012, Drexel University College of
            Medicine. 
“Intern” by Phillip Cozzi. In Journal of General Internal Medicine, circa 1992.
“Misunderstanding” by Eric L. Dyer. From Annals of Internal Medicine. 1993; 118 (8):
647.
“Monday Morning” by Audrey Shafer. In Blood & Bone: Poems by Physicians, ed. by
Angela Belli & Jack Coulehan. University of Iowa Press, 1998: 72.
“Not God” by Marc J. Strauss. From symmetry. TriQuarterly Books, Northwestern
University Press, Evanston, Illinois; 2000: 17.
“Bedside Rounds” By John L. Wright. JAMA, 283 (14), 2000: 1795.
“Dinosaurs” by Maria A. Basile. JAMA 301 (17), 2009: 1746.
“Stages of Dying” by Tim Metcalf. In Verbal Medicine: 21 Contemporary Clinician-Poets
of Australia and New Zealand, ed. by Tim Metcalf. Canberra: Ginninderra Press,
2006.

                                                                                    — Rhonda L. Soricelli, MD. 9/28/14.