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Healthcare in my Dad's Time

Doctor Joe – Physician and Surgeon

Doctor Joe was my father, Joseph J. Raffetto, MD, who practiced in San Francisco, California from 1931 until his death in 1973. That Doctor Joe became an excellent medical practitioner surprised many. He had a manner about him that made his rural up-bringing evident, but in those areas where medicine was the subject, he quickly earned the respect of teachers, fellow students and his patients. Before entering medical school at the University of California -San Francisco (UCSF) he had already earned an engineering degree. At that time California did not require any additional training, so Doctor Joe applied for and was granted a teaching credential. He was teaching in San Andreas, California when he decided to become a doctor. He was accepted at UCSF > The “nay-sayers,” some being his medical professors, told him that his short, stubby fingers would prevent him from ever being a surgeon. He became a surgeon and won over those that doubted his surgical skills. After his graduation from UCSF Medical school Doctor Joe went on to become an excellent physician and surgeon. In those days being both physician and surgeon meant he could handle all aspects of medicine -surgery, births, pediatrics, elder care, even mental health. Doctor Joe delivered over 5,000 babies, did countless general surgeries and yes, even made house calls. Medicine was truly a profession when Doctor Joe started out, not the business it has become today.

There was a lot of social interaction between Doctor Joe and his patients. An office consult took whatever time was necessary without the pressure to keep consults as short as possible so more patients could be seen. That is a major change in the way medicine is practiced today, but remember we didn’t have the population boom we have today. And, of course, our medical knowledge between then and now has grown at an astounding pace. And, why not; our leaders allow providers, insurers, big pharma and medical equipment manufacturers to dictate terms and pricing, so health care costs keep increasing at twice the annual inflation rate.

Today, people provide a blood sample and within hours as many as 150 separate results come back. That’s thanks to the Coulter Counters that revolutionized hematology back in the 1050’s. Well, Doctor Joe had been practicing over 20 years by then. So, how was he able to accurately diagnose his patients’ illnesses before the Coulter Counter Model A began handling blood tests? He, as well as all other doctor’s had to use their powers of observation. They looked at skin color, eyes, tongue, fingernails, urine and feces and asked penetrating questions of the patient. Doctor Joe was so skilled at this, other doctors called him in to assist in their diagnoses. When Hurricane Katrina struck New Orleans, hospitals lost power with the flooding. They had to resort to the same tools as Doctor Joe used -their eyes! He also read avidly and made notations in the margins of what he was reading. I don’t remember Doctor Joe ever talking about being tested on his medical knowledge to keep his medical license valid, but I’m sure he paid the state a fee every few years.

When I mentioned the greater amount of social interaction between Doctor and patient you might think that applied to all doctors in general. But, I don’t know that for a fact. I do know Raffetto is an Italian name and most of Doctor Joe’s patients were Italian. The patients loved their no-nonsense doctor and took every opportunity to include him in their celebrations, like confirmations, weddings, anniversaries and many picnics. Doctor Joe loved all the special dishes that went with these celebrations. Celebratory dinner in an Italian patient’s home was always special. Always a salad a pasta, but also appetizers of shelled prawns, prosciutto and a variety of special Italian cold cuts. Sometimes the party served buffet style appetizers,food and wine. (Kids got to choose from a wonderful variety of soft drinks all cooling in a wash tub filled with ice.). Kids preferred buffet because they didn’t have to sit still in grown up chairs. They could dash back to the buffet table and take whatever they wanted. They always had jumbo pitted black olives, which they put on their fingers and then flapped them in front of the adults giggling all the while. As long as we weren’t too obnoxious the adults let us wear ourselves out before dinner was served.

Adults were served wine, generally homemade red table wine. Good-natured conversation carried around the table, but as more wine was consumed an argument might arise. Doctor Joe would only have one or two glasses of wine at most during these events, and when flare-ups occurred he was made the conciliator. Resolution to the argument came with another glass of wine, a joke, a hug and laughter. When we sat at the dinner table one was set for adults and another (usually collapsible card tables) for the kids.

Each dinner course lasted 30 to 45 minutes. Today that’s often the time it takes for the whole dinner. Appetizers were served as the first course of the meal. Often these included green salads, shrimp in aspic, fish and vegetable antipasto, green and black olives and a coarse-ground pork sausage called cottoghini. Second course -soup -often tortellini. (My great-uncle always added red wine to his soup and was chastised every time by Nonna (my grandmother) and her sister my Great Aunt Jenny, also Uncle Guido’s wife.

Bear with me; we’re just getting to the good stuff. Both parents and relatives admonished the kids, “Don’t fill up on (pick one): antipasto, soup, shrimp, etc.; there’s more to come.” And with that said out would come the 4th and main course a roast turkey, leg of lamb, roast beef, veal or chicken. With the main entrée came several vegetables, potatoes or risotto, stuffing, bread and condiments like cranberry sauce, chutney, or horseradish.

Fifth course was fresh fruit, assorted cheese crackers and coffee. Sixth course was dessert, like pie, cake, connolli and pastries served with more coffee and liqueur, brandy and dessert wines. Now, if that wasn’t enough when we ate at our Grandmother’s house, Nonna would come out of the kitchen to say she had Jello if anyone was still hungry! We’d just groan, but Doctor Joe, having had seconds on everything he liked, merely felt pleasantly comfortable.

It was not unusual after dinner was finished to see adults and children, one after another finding a place to take a nap. Doctor Joe soon could be heard loudly snoring. After reviving the men played cards -usually a game called Pedro.

At any family gathering or celebration with his patient s’ families Doctor Joe took note of people’s general health -both adults and children. He’d look at skin color, eyes and fingernails. He’d have people open their mouths so he could examine their tongues. Then he warned, “keep a close eye on this child over the next two days.” Sure enough the kid would fall ill. His skill for diagnosing illness became legend even among his fellow doctors. But, my wife was a skeptic when Doctor Joe said our daughter Mary would become ill. My wife would see our daughter with all the animation,energy and intensity of any 3-year-old and say something respectful while thinking, “no way.” Doctor Joe’s prediction proved correct; while my wife never understood, she didn’t doubt his diagnostic ability again.

Walk into any doctor’s office today and you will see computer terminals throughout the office. My doctors enter data on their computer terminals even when they are examining me. When Doctor Joe practiced medicine there were no computers. He used a Royal typewriter (not electric) to send out his bills (he always did it himself). He would have passed examination for compliance to the Patient’s Right To Privacy, because no one besides himself could read his hand writing. He always ran a one-man operation, which is probably just as well. I’d bet no one could work for Doctor Joe more than a week. That provides insight to the strength of my mother who stayed married to Doctor Joe for over 34 years.

Doctor Joe was an avid card player and after going into medical practice would play poker weekly with his fellow doctor-friends. He alleges that at several of these card games conversation focused on local hospitals efforts to form a health insurance plan. The Great Depression had left most area hospitals on the brink of closing and doctors weren’t faring much better. The hospitals’ new plan was called “Blue Cross.” The doctors copied the Blue Cross plan’s benefit structure and provided the professional service component. Collectively the plan became known as “Blue Cross/Blue Shield. Employers began forming health plans also. The City of San Francisco was a pioneer and offered a unique plan that contained a network of physician providers -one of which was Doctor Joe. If a city employee went to a “preferred” provider they had no co-payment and the city’s payment was accepted as payment in full.

At the end of World War II medical technology began expanding and medical students clamored for specialized study. Up until then, as with all other doctors, the patient came in for a consult, received a diagnosis, and perhaps a prescription -all in the first visit. If Doctor Joe wanted the patient to see a specialist he would get a lot of resistance. “Hell, Doc, I’m not that bad; can’t you treat me yourself?” But, where medicine was concerned it was no use arguing with Doctor Joe.

Contrast this with the way professional services are rendered today.  The initial visit covers “history and physical.” Blood and urine samples are taken. There is no diagnosis. Second consult: the results of the first visit are made known to the patient and most of the time the attending physician will order up either additional tests, such as x-ray, Cat-Scan or refer the patient to a specialist. The patient, in most cases, does not get a diagnosis and treatment plan until the third visit.

What about treating mental health issues? Doctor Joe, and his peers, handled patients with mental health problems until well after Word War II. Psychiatrists treated those who might endanger themselves or others in a mental health hospital that was more like a prison. But, Doctor Joe had many men patients with work related issues -feeling of inadequacy for being unable to find work and he provided the counseling. Hypochondriacs were treated with respect in Doctor Joe’s office. Many of them were given placebo prescriptions with sugar or licorice as the main component. I remember one hypochondriac calling Doctor Joe at home during dinner to say how thrilled that the new prescription had alleviated the imagined problem. Doctor Joe grumbled, “I’d be a lot happier if I got that kind of improvement from the medicines I give my patients that are really sick. Then I wouldn’t mind having my dinner interrupted.”

While Doctor Joe was an avid reader in his case being well read many times did not mean that he formed sound opinions on matters outside the field of medicine. But, he had the kind of personality that when he stated his mind one generally thought twice before challenging his wisdom. He could be pretty intimidating. However, he met his match with my mother-in-law, Kathleen, which probably explains why they were respectful, but not especially fond of one another. Kathleen held her biases and opinions just like Doctor Joe, especially where the occult was concerned. I’d say respect was earned by Kathleen rather than the other way around. And I think the occasion was the first dinner she hosted for my family when I was dating her youngest daughter. Everything went well until dessert. My future mother-in-law entered the dining room carrying a beautiful plate filled with home-made cream puffs…and tripped on the edge of the oriental carpet in the dining room. Most of the cream puffs went flying. There was dead silence until Doctor Joe leaned over and put his dessert fork into one of the fallen cream puffs. He blew on it and bit in. (The old five second rule in evidence.). Truly, as clean as Kathleen kept her house, Doctor Joe was absolutely correct. We suffered no ill effects and while they were worlds apart philosophically, never a cross word was uttered between them.

After World War II Doctor Joe started taking offense when one of his patients went to a specialist he had not referred. Today that wouldn’t even raise an eyebrow. But, in those days family practitioners and specialists worked much more closely than is the case today. For one thing, the specialist got Doctor Joe’s patient’s medical history right out of Doctor Joe’s patient chart. Well OK, he had to retype the history and physical part because of his illegible hand writing. Today, all specialists create their own patient chart to improve accuracy and prevent omissions. After the patient saw one of Doctor Joe’s patient that specialist communicated his findings back to Doctor Joe. Then Doctor Joe “sold” the patient on what needed to be done to treat the medical problem. Today the specialist’s findings are always discussed with the patient and Doctor Joe would not be involved.

Another idiosyncrasy: If a patient set up a patient chart with another doctor, Doctor Joe recommended that patient cease coming in and stay with the new doctor. But, after World War II the dire shortage of doctors in San Francisco that practice fell away. The  extreme shortage of doctors occurred when the military kept drafting doctors to treat the wounded as the war ground on. Doctor Joe ultimately took over the practices of seven other doctors who got drafted. That same shortage of doctors  also prompted the Kaiser family to create a new type of health plan, now called an HMO. Many employers signed their employees up for the new Kaiser plan. Those employees that were patients of Doctor Joe were told to get all their care from Kaiser doctors. Last idiosyncrasy, adult or child patients did not present themselves for an examination without having taken a shower or bath and were told to wear clean clothing. Those that did not would be sent home to clean up and then come back.

As school kids during the war years we often didn’t see our father for long periods at a time. Doctor Joe would be sound asleep as we went off to school and would still be working when we went to bed at night. Still, when it was raining, Doctor Joe would drag himself out of bed to drive us to school. He used those brief periods to find out how we were and what we were doing. Our mother told us that Doctor Joe only had time to catch a cat nap in the doctor’s lounge at the hospital after a round of surgeries or a delivering a baby. He’d then drive to his first house call and from there to his office where the waiting room always seemed to be full.

Doctor Joe liked being a solo practitioner. Early in his career it was common for doctors to book their own appointments and keep their patient medical and payment records. That would be impossible today. Many evenings after dinner Doctor Joe would go into his den to bring current patient records or to send out bill statements. He thoroughly enjoyed that den. On three walls were shelves that held all manner of books that interested him. For relaxation he sometimes would pull three or four books from the shelves and take to the big red leather easy chair and ottoman to read. Most of those books contained a book mark. Doctor Joe could open the bookmark and begin reading with full recall of what he’d already read. He had tremendous capacity to absorb information from as many as six books at once. I don’t think Doctor Joe ever went to a movie. He did like to listen to the news and read his Wall Street Journal. He’d listen to Walter Winchell on the radio, also the Sunday comedy shows and one radio drama, “The Barbers.” The lead in that soap opera was named Paul and he was a distant cousin of Doctor Joe’s. We heard heavyweight fights, first on radio than on TV. He also liked wrestling matches. No one was skeptical that these matches were staged for our entertainment. Could “Gorgeous George, he of the long blond tresses, be anything but real?

Doctor Joe held a strong bond with his alma mater, U.C. Berkeley. So we’d listen to the California Bears playing football. On the big RCA radio victrola at my grandmother’s we heard many a Rose Bowl game. No other bowl game interested us and really not many existed back then.  Doctor Joe wasn’t much of a fan of the San Francisco 49ers. They were a second-rate team that never won when it counted. But, thanks to our grandmothers personal friendship with the team’s owners, my brother Joe and I went to Kezar Stadium, a smallish stadium used primarily by high school football teams. Gratis from the team owners our tickets placed us on the 50 yard line. For Doctor Joe his medical practice was his most important element in his professional life. For leisure he thoroughly enjoyed spending as much time as possible gardening. Occasionally, he’d pursue other activities learned as a child –hunting and fishing and frog gigging.

Now, you have some insight on the man this book is about.

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One comment
  1. Mary Raffetto

    Reminds me to ask, where was his rural upbringing? I never knew he taught. Or that he went to UCSF — thought he went to Cal Berkley. Didn’t know he’d gotten an engineering degree. Did he use it for anything?

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