{"@context":"http://iiif.io/api/presentation/3/context.json","id":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/iiif/6w9668bf3c/manifest","type":"Manifest","label":{"en":["Dr. Patrick G. Guiteras"]},"logo":"https://d9jk7wjtjpu5g.cloudfront.net/organizations/logo_images/000/000/246/original/CenterForHistoryFamilyMedicine_2c_RGB.png?1773344256","metadata":[{"label":{"en":["Date"]},"value":{"en":["1989-11-05 (created)"]}},{"label":{"en":["Format"]},"value":{"en":["audio file"]}},{"label":{"en":["Keyword"]},"value":{"en":["Society of Teachers of Family Medicine","Dr. Patrick G. Guiteras","family medicine","family physician"]}},{"label":{"en":["Subject"]},"value":{"en":["Dr. Patrick Guiteras (personal name)"]}},{"label":{"en":["Language"]},"value":{"en":["english (primary)"]}},{"label":{"en":["Rights Statement"]},"value":{"en":["\u003cp\u003eThis item is protected by U.S. copyright and related rights. It is being made available by the Center for the History of Family Medicine as its rights-holder for noncommercial use, including sharing and adapting the work. No permission is required for noncommercial use so long as attribution is provided. All other uses require permission from the Center for the History of Family Medicine.  Disclaimer:  The views presented in this broadcast are the speaker’s own and do not represent those of CHFM or the AAFP Foundation. The information presented is for general, educational, or entertainment purposes and should not be considered legal, health, financial, or other advice. \u003c/p\u003e"]}}],"requiredStatement":{"label":{"en":["Attribution"]},"value":{"en":["\u003cp\u003eThis item is protected by U.S. copyright and related rights. It is being made available by the Center for the History of Family Medicine as its rights-holder for noncommercial use, including sharing and adapting the work. No permission is required for noncommercial use so long as attribution is provided. All other uses require permission from the Center for the History of Family Medicine. \u0026nbsp;Disclaimer: \u0026nbsp;The views presented in this broadcast are the speaker\u0026rsquo;s own and do not represent those of CHFM or the AAFP Foundation. The information presented is for general, educational, or entertainment purposes and should not be considered legal, health, financial, or other advice.\u0026nbsp;\u003c/p\u003e"]}},"provider":[{"id":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/aboutus","type":"Agent","label":{"en":["Center for the History of Family Medicine"]},"homepage":[{"id":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/","type":"Text","label":{"en":["Center for the History of Family Medicine"]},"format":"text/html"}],"logo":[{"id":"https://d9jk7wjtjpu5g.cloudfront.net/organizations/logo_images/000/000/246/original/CenterForHistoryFamilyMedicine_2c_RGB.png?1773344256","type":"Image"}]}],"thumbnail":[{"id":"https://d9jk7wjtjpu5g.cloudfront.net/public/images/audio-default.png","type":"Image","format":"image/png"}],"items":[{"id":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/collections/3180/collection_resources/150638/file/277820","type":"Canvas","label":{"en":["Media File 1 of 2 - Guiteras_G_Patrick_1989.11.05_-_Side_1.mp3"]},"duration":3597.488,"width":640,"height":360,"thumbnail":[{"id":"https://d9jk7wjtjpu5g.cloudfront.net/public/images/audio-default.png","type":"Image","format":"image/png"}],"items":[{"id":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/collections/3180/collection_resources/150638/file/277820/content/1","type":"AnnotationPage","items":[{"id":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/collections/3180/collection_resources/150638/file/277820/content/1/annotation/1","type":"Annotation","motivation":"painting","body":{"id":"https://aviary-p-centerforthehistoryoffamilymedicine.s3.wasabisys.com/collection_resource_files/resource_files/000/277/820/original/Guiteras_G_Patrick_1989.11.05_-_Side_1.mp3?1750276389","type":"Audio","format":"audio/mpeg","duration":3597.488,"width":640,"height":360},"target":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/collections/3180/collection_resources/150638/file/277820","metadata":[]}]}],"annotations":[{"id":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/collections/3180/collection_resources/150638/file/277820/transcript/81254","type":"AnnotationPage","label":{"en":["Dr. Patrick Guiteras Interview Transcript [Transcript]"]},"items":[{"id":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/collections/3180/collection_resources/150638/file/277820/transcript/81254/annotation/1","type":"Annotation","motivation":"transcribing","body":{"type":"TextualBody","value":"This is an interview with Patrick Guiteras, Chapel Hill, North Carolina on the fifth of November, 1989.\n\nDr. Guiteras: I was going to say, one of the people you ought to get your students to interview is – you know, they    \n\ndon’t have anyone at Camp Jones. -- been around longer than anybody here --, because he goes back even farther.\n\nYeah, -- actually mentioned, the other time when I saw him, that Vick’s retirement -- a little bit.\n\nDr. Guiteras: Yeah, he’s marvelous.\n\nSo, anyway, what I wanted to start out with, I guess, is tell me a little bit about how you ended up in Chapel Hill. What got you here in the first place? And kind of how that went.\n\nDr. Guiteras: Well, it was romantic sentimentality entirely. (Laughter.) As you know, my wife is a native and her family goes back for many hundreds of years. And I had come here to medical school. We enjoyed our time here. We thought we wanted to be sophisticated urbanites and went off to Montreal and Washington, D.C. Lived there for training and kind of our stint in the NIH. And we liked it there a lot. But then Judy’s father was killed in a train accident up here on North Estes Drive in 1974. And we were just sailing along, having a lovely time in Washington and this really brought us back to earth and made us realize where it is we wanted to live and what we wanted to do. And so we pulled up stakes, sold our house in Washington and came here fairly quickly in early 1975. I opened on April 15th, 1975.\n\nWhere we you located?\n\nDr. Guiteras: At Glen Lennox (?), in that shopping center (?). There we me, the doctor, and Judy was my receptionist and business, office manager. And I had one nurse, Marie Mann. A nice woman. And then after about a year, a year and a half, I guess, we moved up to Estes Drive, to the old office. The original office being only temporary from the start. We came in when there was a building moratorium in Chapel Hill. You could not build anything. There were no sewer connections. So I had to wait around and this building here on Estes Drive became available. And, of course, we moved up here after about twelve years in that location. Came here. So we’ve grown from one doctor and two employees to three doctors and I guess about twelve or fifteen employees. \n\nA small industry now?\n\n\nDr. Guiteras: Yeah. Well, it’s much bigger. Even though it’s not big, as you know, by comparison to a lot of clinics and so on, it is much, much bigger than when I started. And I keep thinking when these managerial problems up that I have no comprehension of, no ability to take care of, part of me says wouldn’t it be nice to go back to the old way, you know, when the overhead wasn’t so important and there weren’t personnel issues to be taken care of and this and that and all the things that go on. And just to be with a nurse and maybe a secretary or something like that. There was a doctor in my neighborhood when we lived in Washington who was a one-man operation entirely. He had no nurse, no receptionist, nothing. It was a waiting room with a door and his office. He didn’t mess with Medicare, Medicaid, insurance, anything. Everybody paid $5. They came in, they put their $5 down on the table. They sat down, told him their problem. He checked them over, did what was needed. Usually wrote them a prescription and sent them out. And made a pretty fair living at it. There were no appointments. The last of his breed.\n\nDid you intend to go solo when you came down here? Was it by choice that you started solo?\n\nDr. Guiteras: I wanted to. The practice that was here, they were all a little bit older than I was and their style of practice, as best I could perceive, was a little bit different than what I wanted. Not that mine was any better or theirs was any better, it was just different. And I didn’t feel comfortable joining up with them, so I didn’t. I just went by myself, but certainly with their help. In fact, Fred Patterson … When I came to town I had to go around and pay my respects to everybody. And I saw Fred Patterson and he and Bill -- at Camp Jones (?) were all sitting in a room like three judges. And I walked in and they all shook hands, how are you doin’? Good to see you again. I’m glad you’re getting a start. What can we help you with? And we chatted back and forth. Fred finally said, here’s the question we really want to know. I said, what’s that? He said, how much are you going to charge. (Laughter.) And I said, well, I think I’ll charge $8 for a routine visit and $30 for a complete physical. He said, sounds alright to me. And that was that. (Laughter.) I mean that’s what they wanted to know.\n\nI wonder if they were worried about you charging more than them?\n\nDr. Guiteras: More or less or something. And I guess it was pretty well what they would charge.\n\nSo you really had it in your mind to start by yourself from the beginning of coming here?\n\nDr. Guiteras: Yeah, I really did.\n\nDid you pretty much stay that way for …\n\nDr. Guiteras: For eight years. And then took on an associate. He stayed a couple of years. That didn’t work out. And then Jeff came in ’85 and that’s worked out very well. Then Robin came. \n\nYou mentioned with some nostalgia the ability to practice solo. What were the advantages that you felt?\n\nDr. Guiteras: First of all, I was completely in charge of everything and there were no scheduling problems, for one thing. You know, I would always be on call and I would be at work. There was no negotiating to be done. If a problem came up, I’d think about it. I might talk to Jane about it and holler it down the hall: Oh, Jane, this is the way we’re going to fix so-and-so. This is what we’re going to do. And that would be it. I think, now this may be more nostalgia than reality … But I believe that the patients were more considerate at that time because they knew that I was by myself. And many was the occasion where they would come stumbling in on a Monday morning having put off giving me a call. And I always knew that if somebody did call me at night or on weekends, you could be pretty darn sure that it was, by any set of criteria, a medical necessity. There was not a lot of unnecessary medical calls. There were some that really stick out in my mind. I was thinking about them coming over here. This was maybe not quite so medically necessary, but one night I got called. It must have been around 3:00 in the morning. And this woman came on the phone with a heavy, heavy Hispanic accent. And I’d never heard her before. She said, Dr. Guiteras, Rudy is going crazy, he’s going crazy! What is it? What’s happened? What’s wrong with Rudy? And I knew who Rudy was. And she said, well, he got some Columbian gold. He said we brought up some -- from Columbia and he’s driving me crazy! (Laughter.) I said, godamnit, tell him to just lie down and stay cool, you know.\n\n(Laughter.) There was one time I got called, we bought this used, it was about a ’72 Mercury station wagon. It was as big as an M1 tank. Just this huge, this sort of deep purple smoke would come out of it, out the driveway. You remember our house up in the country. And it must have been in late afternoon or after supper sometime and Judy was out of the house and I was at home. And Raymond was just a little boy. He was probably less than one year old. I don’t even think he was walking then. I got a call from the local undertaker’s wife who said that Wallace was very sick and wanted me to come see him. It sounded pretty bad. He was having chest pain, trouble breathing. And I don’t know, I was sort of young and foolish and instead of just saying take him to the emergency room … Or maybe I did but he didn’t want to go. I got into the car and came barreling in to town and I had Raymond in one arm like this and I was driving with the other. And I got to thinking, the stupidity, the position I was in, I had this toddler with me going to a man who was possibly having a very serious medical emergency. And not being able to get there quickly. So I just leaned on the horn and started plowing through downtown Carver (?), on Main Street, running through traffic, blowing my horn, flashing lights and everything. Went all the way up Franklin Street, pulled into Walker’s Funeral Home, had this chubby little guy under my arm. Went running upstairs, gave Raymond to Wallace’s wife. Went in and there was Wallace. To make a long story short, he was having a hyperventilation. (Laughter.) But, I mean, just the incongruity of it all. \n\nThat’s a wonderful picture.\n\nDr. Guiteras: Oh, I know. And there was another one. Oh, when the police came. One night I was so tired, I took the phone off the hook. I did not want to be called. I had a beeper which people could go through to get me. But it was about midnight and I had drifted off to sleep and was just thanking God, nobody is going to call me tonight. And fell asleep and within a half hour or so there was banging on the door. I went down there and there was the sheriff. Somebody wasn’t able to get me on the phone and sent the sheriff out to get me. I forgot what the problem was. But, you know, you couldn’t escape. Another one I was thinking about was the time I found I had mitral valve collapse. Judy’s uncle called and he was having trouble breathing. He had a bad heart. So I took time to go over to see him and I couldn’t find my stethoscope, so I was racing around the house trying to find it. I came across Little Kitty’s stethoscope that one of the kids had. And I picked it up and I listened to my heart just to check out the heart sound and I heard this little click, click. Oh, God, that’s me. I was so rattled because I was trying to get over to see her uncle, that I couldn’t quite integrate what it was, but knew it was abnormal. But I determined the stethoscope worked, so I went over and saw him.\n\nWas he impressed with your stethoscope?\n\nDr. Guiteras: He was not in good shape, had pulmonary edema. So I don’t think he really noticed. But we got him fixed up. And I walked out of there and got to thinking … After a while it came back and I thought, damn, you have a murmur. So I put the stethoscope back on and sure enough it was still there. I took it away and put it back and listened again. I went a couple of days and refused to do anything about it. Refused to listen. And then I did find my good -- stethoscope and I sneaked it under my shirt to listen. And, sure enough, it was the --. Finally I broke down and I went to see my doctor, --. And he listened to me and said, oh, yeah, I heard that a couple of years ago but I didn’t know what it was at the time. That was the time when -- were just sort of coming out, you know, coming out of the closet. Anyway, so we determined that I had mitral valve --. You know, I have a model for house calls which I think fits in with a lot of what you’re talking about. When I was a medical student, second year student, we lived way out new Bethel Baptist church, about six miles west of Harbor (?0), out highway 54. Rented a little farmhouse there. And there was this community of people around. And the house down the road, down a dirt road, it must have been about 300 yards away, was an old woman in her late eighties who was blind and her daughter. And her son would come out there and stay occasionally with them when he was on a drunk. He would vanish from his own house and go out there. One night in November they called me up and said that Mama was having trouble breathing, she was about dead. I was a second year medical student. Just no hope of doing anything. Anyway, I went over there and at least had the presence of mind and the powers of observation to say, well, you need to call a doctor right away – and they did. And about twenty minutes later, Kent Jones comes out. He was wearing a coat and tie and had a black bag and a hat. And comes out there and just kind of looks at her. He may have listened to her breathe, I don’t know. Listened to her heart. I expect he did. He goes through his bag, gave her an intravenous injection of something. I presume a diuretic. I don’t know. And he gave her an IM injection. Gave her a pill. To this day, I have no idea what it was. And in retrospect, I think she was in full -- edema. And I was just kind of standing in the corner just watching all this, really not understanding anything. And he just sat down beside her and patted her hand and talked to her for about five, ten minutes, and she fell asleep and was breathing a lot easier. He just packed up his bag and took off. \n\nIt was just amazing.\n\nThat’s not supposed to happen!\n\nDr. Guiteras: No, no. But that was impressive, to see that.\n\nSo you went to medical school here. You didn’t grow up here, did you?\n\nDr. Guiteras: No, I grew up in --.\n\nWhat was it like for you to come back to a place where you already had, in a sense, a community that you knew something about? What were the advantages? What were the disadvantages? What were your concerns at that point? Do you remember?\n\nDr. Guiteras: Well, we had a lot of personal concerns. We had bought that old house and were trying to renovate it. The day we brought our first baby home, we had no kitchen, no heat in the upstairs and pretty shaky plumbing. I was still wondering whether I would be able to make it in this town or not because even at that time, 1975, the place was pretty over-doctored and still is. I was very ambivalent about it. On the one hand, I had no doubt that I would make it. But on the other hand, the evidence was not immediately forthcoming for a year or two. And every now and then I would get the, damn, we never should have left Washington. But it was compelling that we come here. I mean the family ties and everything was just so strong, it all seemed to have reached the point where we had to come back at the time Judy’s father was killed. It was like a magnet drawing us here. It was interesting about the connections that we had because we never really left here because all the time we were gone we kept shuttling back and forth and spent a lot of time visiting here. So we were able to see some of the changes that developed in the town over that period of time. The reaction of a lot of Judy’s family and friends was interesting because many of them would come to see me simply because I was married to her and to her family. But others were still fiercely loyal to their old doctors and wouldn’t change and still haven’t changed to this day. Judy’s brother was a senior in college when we moved here. Was still going to see Bob Sr., the pediatrician, when I came. And he was so embarrassed about it that what he would do is dress up in a business suit, take a briefcase and go sit in the lobby so everybody would think he was a salesman or an insurance guy or something like that. (Laughter.) And he didn’t stop seeing Bob until he was about twenty-five or so.\n\nBy that time Bob had become an adolescent pediatrician?\n\nDr. Guiteras: Right. \n\nBut on the whole, you felt that having the family connection and history and existing relationships was a support rather than a complicating …\n\nDr. Guiteras: Oh, very much so. Yeah, I wouldn’t have traded it for anything. I couldn’t imagine going cold into a town where I did not have that kind of family support, either my own or my wife’s family. It meant a great deal. And I don’t know how much it computed financially to my stability and eventual success. But just the knowledge of having been here. Plus the professional support. I knew most of the doctors mainly at the hospital who had been my teachers. But I also knew the doctors here. You know, I’d had my pre-material exam by Kent Jones. I’ll tell you about that some other time when it’s not on the tape. (Laughter.) And I knew Bob Sr. and I knew Earl Summers, the psychiatrist. And Woody Burns came into practice a couple of months after I did and he and I were in medical school together. And I knew Buddy Harper. \n\nSo it felt comfortable to get back in this environment?\n\nDr. Guiteras: Yeah. And everybody here was very helpful. I was not sure how I would be received because, you know, the town really did not need another doctor. But they were gracious about it.\n\nYou mentioned … One of the issues that comes up frequently in my conversations with people is one about in a community which is small, which I think in many ways, even though this is … I don’t know what it was when you moved in here, 25,000? (Yeah.) There’s a lot of overlap between, you know, your life as a physician and your neighborhood and the people you buy things from. And it’s a small town in a lot of ways. And issues of privacy, for example, which may have been, I’m speculating that it may have been easier because you were a little bit of a distance out of town. But I think intrusions into your private life, was that a phenomenon? I mean your patients were very considerate, but were there other ways that people got to you, ways that you hadn’t anticipated?\n\nDr. Guiteras: I never found it a problem because I felt relaxed about it. I didn’t feel that there was any image that I had to uphold. Having been here as a student – and it helped a lot, the fact that there are so many doctors here. I mean there’s nothing too important about being a doctor. I think doctors are held in esteem in the community but it’s not like we are put on a pedestal. And you don’t have to dress the role. You don’t have to play any part at all. I think it is important to at least present yourself as a responsible, sensible person. I mean you can’t be a complete nut. But I never felt that I had to dress up in any particular way. I frequently saw patients at my house and, you know, would be wearing whatever I happened to be wearing. And spent a lot of time doing manual work out there and had a tractor and all of those things. And people would come out and I would just hop off the tractor and I had a little office set up and would see them. And the same thing was true when I came to town. Now, here’s one thing: I can remember early on when I would get a call weekends or something to see people, I felt compelled to take a shower and put on clean clothes to see them. After a while I realized it was a colossal waste of time and it only made the house visits all that more difficult. So I would just stop what I was doing and go and nobody cared. They couldn’t care less. And it would save time and it made it more convenient for me to see people. I also found early on that house calls were a marvelous way to save time and to create friendship and establish rapport. And still it’s true in the town. You can see somebody at home faster than you can at the office and certainly much faster than at the emergency room. It’s like getting caught in a --. \n\nYeah, especially this one.\n\nDr. Guiteras: It just goes on and on. And most things you can really figure out on a house visit. And I’m sure you know that as well. Oh, there’s another house call story I wanted to tell you. The biggest frustration of my life. Had  patients who lived out beyond Calvander (?), a couple and two young children. The daughter was asthmatic. And they would always call me. And so typically true of asthmatics, their symptoms get worse after the sun goes down. So I would go out there. They had a little farmhouse way out on old 86. I would go out and I would give Alice a shot of epinephrine (?) and get everything cooled off, then come back. She had had a sub-total gastrectomy many years ago for ulcer disease and she had had troubles off and on with her medacrid (?) because she had dumping syndrome, she didn’t eat well, things like this. But this was something she had some … It had gotten better. I don’t know why. And her medacrid (?) was running about 38, 39 over the past couple of years. And she came in one year and her medacrid (?) was something like 33. And I looked at it and I looked at it. And we had done a stool for an occult --. She was just not eating well or something. And I ignored it. Well, to make a long story short, three or four months later she underwent a bowel resection for a -- carcinoma. And I had to face her. And she had been to another doctor. She had severe mastoid problems way back and she had been seeing an ENT, a person at Duke for many years for that whenever she had a flare-up. And they did a CBC and they noticed her medacrid had dropped even further, like 27. And this led to an investigation over there. So this made it worse to me that another doctor made a diagnosis. You know, so you have to explain. And she’s an experienced person, medically and otherwise, and she understood. And so far she’s doing okay. But things like that happen. And it’s made all the worse because she is a friend.\n\nMy sense is, and maybe this is based upon wishful thinking more than reality, that having a longstanding relationship with someone and them understanding and them knowing you, not just the doctor who’s in the office building downtown but the guy who is related to these people who, you know, she’s got a relationship with your mother-in-law and knows where you live, knows your wife, knows your … That somehow people are more forgiving or understanding. I don’t know if you have a sense that that’s true or not. Rather than this kind of anonymous doctor in a medical building in downtown wherever?\n\nDr. Guiteras: Because they see me as a person and many of them have known me for a long time before I was a doctor and they know my family and my children and so on and so forth. And it must also affect how they perceive me and what I do. And their tolerance or their expectations have to be affected by that, just as mine are, you know. It does make it harder for me, in one sense, in that I feel the impact of whatever problem it is more, I think, than in people who I don’t know. But as you well know, John, you get to know people pretty well when they’re sick. \n\n(Break in conversation.) What were we talking about? \n\nForgiving and …\n\nDr. Guiteras: I have two ways of look at it. I am very thin-skinned about it and feel things like that pretty strongly. But on the other hand, I’ve been around long enough now so that I know that when things don’t work out the way you want to, that No. 1, you’re not the first doctor who ever didn’t have a good outcome. That it happens within all levels of the medical profession. I mean I’ve seen some of the finest academic specialists blow things too. I also realize that it’s not always all within the doctor’s power to make things right. Also, I think it was helpful that my father was a doctor, so I sort of picked up on a lot of this before I got started from him and realize that you can’t be all things to all people. You can’t always be the smartest and the first and get everything right all the time. And a lot of things just aren’t within your power to do anything about.\n\nBut you said it took you a while to come to some comfort with that?\n\nDr. Guiteras: Oh, yeah. And I still have to rationalize. I still have to think through it every time. So I still have to think it through each and every time. And it helps to have other physicians in the office that you can talk to about it. And I didn’t have that before. So you just have to take it all on your own at that time.\n\nHow do docs in solo practice do that?\n\nDr. Guiteras: I don’t know. I wasn’t in total isolation. I don’t know how it would be if I were the only doctor in town with no other doctors around to talk to. I think that would require a great deal of -- and confidence and understanding of the world and yourself and your patients and all of those things. I could come up to the family practice once a week and talk to you or whoever and could talk to the doctors in town. But there were times when I might as well have been out in the middle of Montana with nobody to talk to. You know, if you’re down here at the office on a Saturday night at","format":"text/plain"},"target":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/collections/3180/collection_resources/150638/file/277820#t=0.0,660.0"},{"id":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/collections/3180/collection_resources/150638/file/277820/transcript/81254/annotation/2","type":"Annotation","motivation":"transcribing","body":{"type":"TextualBody","value":"with a baby with a temperature of 105, you’re kind of on your own in terms of making a decision about what to do at that point. Or seeing somebody in the middle of the night who’s in congestive heart failure. You know, deciding are you going to treat this person at home or are you going to send them up to the hospital? What are you going to do? That could be a little lonely. But all in all, as I said earlier, I look back on those days with some nostalgia. It was much more personal then. Had fewer patients and in many ways was much more manageable. I did get a little fatigued. About every six months or so I would take off for … I had somebody come in for a week or two weeks and just relax. But I was much younger then too. I don’t know that I could do it now. And I don’t know how these guys coming in new manage.\n\n They hit some kind of rhythm that seems to be, I mean they’re long distance runners, they’re sprinters.\n\nDr. Guiteras: Yeah. I knew a doctor in Washington, when I was practicing there before we came here, who was in his eighties, who was one of these old guys who did it all. He set bones and he delivered babies and he did gall bladders and appendectomies. He was the old style GP, probably one of the last ones in Washington. And he had a good reputation. I think he did it all and did it all well. And he told me his secret was to still be practicing at his age, I never hurry. (Laughter.) That’s great. I suppose if you live to be in your eighties, you don’t need to hurry. \n\nOne of the other things that comes up in discussions had to do with kind of the flipside of privacy, which is confidentiality. I mean when you’re in a small town, and especially this is a very peculiar kind of small town where people are … On the whole, a lot of educated people who know each other in a lot of different ways. How has that been? Have you found that to be a situation that was difficult?\n\nDr. Guiteras: You have to be very careful about it because demands are put on you to breach that. People will just come by and ask you about or start telling you about things that they know about, that you know about through patient contact, and you have to … I think I probably go overboard to avoid breaching confidentiality. Because if it got around that, well, so-and-so talks about his patients, or whatever, that will get around pretty quickly. I find the hardest thing is dealing with family members. Not my personal family members but with family members of my patients. And I’m sure that’s true for any doctor in any setting as to what you can tell and what you can’t when you haven’t been instructed by the patient. Here’s an example of it: I think this fits into what you’re concerned about. The father of the woman who introduced me and Judy is a patient of mine – and he’s sick. We don’t know yet but he probably has bowel cancer. And he came to see me a couple of weeks ago and had vague symptoms. He couldn’t --. But very unusual. About seventy years old, a robust guy, a wonderful guy. And no sooner do I get home and Judy says, well, Kathy called. And I said, oh, dear. So Kathy gets on the phone and very worried, excitedly worried about her father. Of course, she knew as much as I knew at that point. So it’s just a matter of listening and saying is that what your father told you. And just confirming, yes, that’s right. And fortunately, in that case, she had all the information from the original source, so it wasn’t my --. But now we’ve progressed a little beyond that original point and I’m sure that she will be calling again. However, I have taken the step of asking him, is it okay. And, sure, tell her anything you want. I know she wants to know. That’s okay with me. So that makes it easy.\n\nHas Judy ever been in a position where she … I’m not sure how I should ask that, the whole question of how you bring her into your kind of medical life. Because that’s another issue which surprises me how differently people manage it.\n\nDr. Guiteras: Well, she knows a lot about patients because when they call the house … You know how people are, they’ll want to talk to anybody. She’ll come in and say Mrs. So-and-so called and her baby’s got a fever and is throwing up and I told her to do so-and-so, but you better call her. It went so far one day that I did call up – and the person I called said, oh, that’s okay, I talked to your wife. Everything’s okay now. She just needed somebody to talk to.\n\nDo you give each other some implicit ground rules about her being … Because in a funny way, I think people contract with their physicians around confidentiality. They’ll make contracts with the physician’s family. Now, I don’t talk about patients with Benj (?). He’ll overhear a few things now and then. But I certainly do talk with Julie, more to just have somebody to review things with. And she’ll say what are you upset about and I’ll tell her. But I never kind of said to her … I mean she kind of understood that information like that doesn’t … But, of course, people would come up and talk to her. Not many, because my practice isn’t that large. But either to get information or give information … And what’s the role that …\n\nDr. Guiteras: Well, I rarely, if ever, tell Judy anything. You know, there will be times when something humorous will happen and I’ll just have to tell her. Like one time a person called up and, again, in the middle of the night … If this hadn’t been so funny, I would have been angry. And said, how did she say it? Oh, John, this is classic. I wish I had recorded it. (Laughter.) I’m worried … Can you catch athletes foot? At 3:00 in the morning. And I said, yes, why? And she said, (Laughter) because my son and my new to be a teenager has it and I kiss his little feet goodnight every night and he’s got athletes foot. (Laughter.) It was crazy, just whacky. \n\nMy favorite one was one time somebody called and said, my diagram has a hole in it. (Laughter.) And I wasn’t quick enough to do this, but I got back and talked to her about what it means and all this kind of stuff. And I didn’t ask the important question. But when I got back to bed, Julie said who was that? I said, somebody called and said there was a hole in her diagram. And she said, did she find out before or after? (Laughter.) I said, I didn’t ask her. \n\nDr. Guiteras: There was a time that I took a phone call in bed, I fell asleep while I was listening to it. (Laughter.)\n\nI don’t tell her much. Sometimes, when something like that happens, you just have to tell it because it’s so priceless. And sometimes, you know, things that are long past I might bring up. But she knows so many of these people anyway that I don’t think it’s fair to burden her with their problems because she sees them all and then she might be under pressure to discuss it. And I think the less she knows the better. As it turns out, especially with so many of our friends, she knows anyway because people have confided in her or she’s heard from other sources about so-and-so’s got such-and-such ailment. So they tell her directly. So she ends up finding out a great deal about my patients anyway. But I really try to keep it at a minimum. I think in the long haul it’s better that way. Again, you know, I can’t imagine that she might slip up or something and it gets out, but it could present a problem. And I also feel it important to be somewhat protective because so much of what we do you and I just take for granted as, you know, all these horrible things that happen. And I think we forget. We have become so immune to remembering how tough these things are, what an impact they have on other people. And there’s enough trouble in the world without heaping it on, I think. \n\nIt also raises the question for me sometimes about whether information that you know in your role as a physician affects your dealing with people when you’re in another role.\n\nDr. Guiteras: Oh, absolutely.\n\nHow does that work? How do you …\n\nDr. Guiteras: Well, you can’t forget the things that you learn at the office, you know. And if you’re doing business with someone … I mean there are certain people in town that I just steer clear of because I know that they’re unreliable or devious or nuts or whatever. And I also know, dealing with him in any capacity outside the office, what all the background is, what they told me here. And I certainly use that information. I mean you cannot just turn it off. And I think it’s helpful to avoid dealing with people who you know you can’t trust or who are unsteady, unreliable. And you know who the people are who are trustworthy and honest and forthright and so on. So, sure, I mean you use that information. \n\nDo you ever get in situations where because you know their medical conditions and because you’re their doctor that when you’re in another situation like a dinner party or at the grocery store or the soccer field or something like that … do you respect and do they respect the sense that doctor stuff happens at one point and other stuff happens at another? Or is that something you don’t worry about?\n\nDr. Guiteras: Well, you know, there’s the usual thing about you’ll be out to dinner and somebody will be eating lobster and they’ll make some crack about their cholesterol or something like that. So that sort of stuff. People do ask about their medical business on the soccer field or at the grocery store or whatever. I used to be a little uppity about it, but I don’t mind anymore. People worry about things and I really don’t have much reservation about that. I don’t think people overdo on that really. Do you remember Don Vaughn (?) from Rocksborough Yeah. He was a family practitioner up here. A hell of a guy. Anyway, (Laughter), he said he finally realized that he had to take that job at the emergency room at -- Hospital when he was out to dinner at the only restaurant in Rocksborough with his family and some guy came up to his table and stuck his hand right in front of him, had a big sore on the back of his hand, said, hey, doc, what’s that? And his son gagged. (Laughter.) He said I knew I had to get out. I haven’t had anything so egregious as that. But people do some up. And you know how people are, it’s like you’re the crossing guard person. You know, they’re willing to talk about anything, and Judy will be there, you know, and they’ll just blab away.\n\nThat was ten years ago for me. And I think time does a lot. And part of it is it just calms me down about the issues and where things belong. I think there are certainly boundaries, but they are different boundaries than there were ten or fifteen years ago.\n\nDr. Guiteras: Oh, yeah. My boundaries get weaker and weaker or less distinct, I suppose. Because if you  keep trying to put obstacles around you, it’s impossible in a town like this and the kind of work we do. I suppose if I were a neurosurgeon or something like that, not a whole lot of people would come up to you talking about their glioma or whatever. But they might come up to you and talk to you about their bad back.\n\nOr their hemorrhoids. I was at a restaurant one time and one of the waitresses was a patient of mine and I said, hi, how are you? And she said, oh, they’re much better. (Laughter.) (Inaudible.) But it was really funny. And, again, it tends to be us putting things into categories and boxes for patients. And it’s probably a lot less of an issue.\n\nHow did you develop a social system? And how did that relate to … Did you have friends initially, or even now, outside of your medical system? Are there places you go where you’re away from all vestiges of your practice?\n\nDr. Guiteras: That is a good question. I’m trying to think who my friends are here and are any of them unconnected, in any way, from my practice either as you and I are connected professionally and as patients or solely as patients or who work here or whatever. I would have to think about it. There are no examples that jump to mind. You know, there’s you and there’s Jeff and Nate and Rick Suberman (?), Woody Burns. Some of my friends who are not doctors or patients … I’m trying to …\n\nWere they patients are they were your friends or before?\n\nDr. Guiteras: Some of both ways. I didn’t become friends with them because they were patients here. In fact, I really can’t think of anybody whose only other connection has been as a patient that I became friends with. But, you know, we had children in school together or in nursery school. Or one friend of mine’s wife is a doctor. Our kids were in school together and he became a patient and now we’re friends. Things like that. Surely there must be someone who is outside the network, but I can’t think of anyone.\n\nThat’s what makes this a small town, at least for me. I started thinking that same question. I mean even with what I’m doing now over in Durham, there’s some funny connections about that whole experience.\n\nDr. Guiteras: Sure. And also interconnected because there’s so few people. And I think people are attracted to a doctor whom they like and share something with. And it’s also going to be reflected in who your friends are, obviously. I think the only place I can go and not be a doctor is when I go back to my hometown and visit with some of my old buddies there who knew me when I was a kid, a teenager. You know, they couldn’t care less if I were a doctor. That’s immaterial. (Laughter.)\n\nHave things ever gotten to the point where you and Judy have thought about changing, about leaving here, doing anything different?\n\nDr. Guiteras: Well, yes. There are times when I wish, from the bottom of my heart, I were a dermatologist. (Laughter.) I love dermatology, I think it’s great fun. But, no. I mean it’s impossible. First of all, about leaving here, that is impossible. It would take something unimaginable for me to shake us from here. And as far as changing specialties, you know, John, I’ve thought about it. And I suppose in reality I could do it if I wanted to badly enough. I think about dermatology or some high ticket item like radiology where it’s easy at the same time. But it’s kind of like wishing you’d win the sweepstakes or whatever. I mean it’s nothing you’d really do. \n\nBecause one of the things that comes up … And I guess, in a sense, this is a different kind of a community, too, because with the guys in the small towns …\n\nSide 2: … They seem to get to the point where their kids get in school, particularly in the rural areas, and that becomes a major family discussion about what do we gain, what do we lose and so on. But it’s less of an issue here. I think we’ve got a decent school system and that particular … But then there are other things having to do with … I don’t know, the normative adult changes. In other words, you went eight years solo. What have been the changes, I guess, as you think back on the fifteen years that you’ve been here? What have been the kind of changes in your practice and in your professional life and how they manifested themselves and what have you done?\n\nDr. Guiteras: Well, I think I can say with honesty, and I hope will come across as modesty, I think I’m getting better at what I’m doing. When I say that, that also implies that there’s still a lot to be done. You know, you’re never the best. But when I compare myself to when I first started practice, I just shudder to think how green I was and what little understanding I had. I remember a young woman who came in, I’ll never forget it. I was just getting started, in my early thirties, and she was about my age, I guess. Had a one year old child and was having crying spells and upset and  had all these somatic (?) symptoms and everything. And to her credit, I mean I listened to the whole thing and was very sympathetic. I said, well, I think the problem is this: Now that the novelty of your baby has worn off, you need to get a job. (Laughter.) You know, just so shallow and so pompous in a way. Well, I know, you’re bored and this baby isn’t as fulfilling as you thought it would be. And, you know, I just feel I can handle this. I’ll set her down. (Laughter.) Keep in mind, there was none of this interpersonal stuff.\n\nLike one of the people I talked to said he breaks out in a cold sweat every once in a while when he thinks back when he started out in practice. He said, I had more guts than brains.\n\nDr. Guiteras: Oh, yeah. I can imagine what it would be like if you were medically isolated. I mean at least we have a hospital here and a lot of backup and everything like that. I feel more competent, but that’s an ongoing process. I think fifteen years from now I’ll look back to today and say you were deluding yourself at that time when you thought you were --. And I feel that I have a greater capacity to absorb peoples’ problems and to understand them. And, again, that’s something that has to continue to develop. Before, if somebody didn’t get well quickly or if I didn’t understand what was going on, I would get irritable about it. I’m much more willing to take the colonel (?) approach with some patients. Not all, but with some. And to use such phrases as “in my experience this is what this means” and feel reasonably confident in that. Whereas ten years ago, hell, I had no experience to substantiate anything on. And I just feel calmer and I feel I’ve become a better listener. Before I used to think I had to do all the talking or I couldn’t make an impression – and, obviously, that’s incorrect. I feel, in a whole other arena, much more responsible for the business aspects of this practice because this practice, as it’s constituted now, is very much a business. Whereas before, especially when I was on my own completely, money was hardly an issue. There was enough money. And I could see as many or as few patients as I wanted in one day. And if I didn’t feel up to working, I would just say, okay, I won’t schedule any more. Or I would leave early to go see so-and-so’s soccer game or whatever. And I really can’t do that anymore because it’s an illusion to think that the bigger your practice gets the lower your per doctor overhead goes. It gets higher and higher.\n\nAnd the kind of control… When you’re solo, and, again, I’ve heard this from different people … But when they’re solo they feel more control in their lives than they do when … In some ways, people get into groups because you look at things like coverage and you see your life as being somewhat easier in that situation. But it’s harder for me to arrange vacations, not being in anywhere near full time practice, than it would be for somebody who is a solo doc.\n\nDr. Guiteras: You’re absolutely right. You trade one set of problems for another and you have to be aware of what the tradeoff is when you get into it. I think I could go back to being solo. I’m content – I mean Jeff and Robin are great and we work together well in all the ways you need to mesh a practice. But I also know that I could go back to going it alone and I would feel fine with it. But I want to try this. I don’t want to retire when I’m seventy-five, that’s when I’m going to retire, not having done this. I want to make a success of this. And who knows, twenty years from now I may go back to being solo again. I don’t know. \n\nWell, talk to Bob Murphy in Hillsboro. He is seventy years old and he is back in solo practice.\n\nDr. Guiteras: Is he really?\n\nIn the back of his house. He built himself a little office. It was interesting. Starting out in practice, he had everything set up the way he wanted to have it. And I think it was the sense of …\n\nDr. Guiteras: I’ve got to go see him.\n\nYou really should …\n\nDr. Guiteras: I had no idea. I was quite surprised to hear about that.\n\nYou know, when you get to the point periodically, which everybody does, where you have a certain kind of, not crises of confidence but a moment of two existential inquiry about why am I doing what I’m doing … What is it that keeps you doing what you do?\n\nDr. Guiteras: Oh, money and prestige! (Laughter.) No, I don’t know. (Laughter.) Well, I can’t do anything else, John. I can’t sing, I can’t dance, I can’t dunk a basketball. It’s in the blood, you know. I probably told you this already, but as far back as I can remember, my earliest memory is of how I was going to be the doctor. And my father was a doctor, both my grandfathers were doctors and my uncles on both sides, great uncles who were doctors. And it felt to me to be the doc. I knew my brother was not going to be a doctor because he couldn’t stand the sight of blood. He would get nauseated at any little … He couldn’t squish a bug in the road. So I knew that. I cannot imagine doing anything else. I mean my imagination is so limited, I cannot … I don’t know what else I’d do. \n\nBut doing this particular kind of work with the demands that we were talking about tonight, what keeps you going?\n\nDr. Guiteras: I enjoy it. You know, despite all the hassles of modern day medicine and Medicare and HMOs and the loss of the pedestal and all of that, it is still a privilege. I mean I feel that I have won a lottery ticket. It’s doing the phenomenon a disservice, it’s understating it tremendously to say the variety and interest that you encounter every day keeps you going. I mean that doesn’t come anywhere near to describing it. I mean you know. The intimacy, the responsibility. I think the importance of what we do keeps me going. I wasn’t being entirely facetious when I said money is part of it. Because like a friend of mine in Washington drove an XKE and was a family practitioner, he said if I so much as sit down to take a crap, I will go bankrupt. (Laughter.) You know, you have to keep working to keep the bank and the IRS satisfied. That is part of it, no question about it. \n\nI think the other half of that, I mean the prestige part of that … My sense is that prestige is not so much … I think the esteem in which you are held by the people who you take care of has got to be part of what keeps you going.\n\nWell, it is. I mean when you really sit down with it … I mean, it’s hard for us to say that, I think, at times, that being needed, being respected and needed and in some way held in esteem is what we need also as well as being able to make the house payment, send the kids to school.\n\nDr. Guiteras: Yeah, it’s important to me. Also, the fact that I started this, that I started it on a shoestring, literally, is important to me. And  would not give it up lightly. I mean I wouldn’t give it up, period, as far as I know.\n\nSo kind of a sense of ownership in …\n\nDr. Guiteras: Yeah, proprietary interest – or whatever you want to call it. \n\nIt certainly seems to be one of the hallmarks of people who are in family practices that they own, if you will. Practices that are there. In contrast to people who are holding a job in a practice …\n\nDr. Guiteras: It’s like a family business. Everybody chips in. It’s more than just what meets the eye. There’s a lot of investment, emotional and money investment, and time and everything else.\n\nSo you foresee yourself doing this as long as you want to?\n\nDr. Guiteras: Yeah, as long as I can. I thought about … You know, a lot of guys retire at sixty-five. Well, I’ll be sixty-five in nine more years and I can’t imagine retiring then. I might retire at seventy-five simply because I’m not sure I could do it much beyond that time. And there are a few things I might want to do, trips to take and things like that. But I think I know myself well enough to recognize that if I couldn’t do this, I would really be a loose ends. I really wouldn’t know what to do.\n\nThat’s what I kept telling my father when he was talking about retirement. I said, they may take me out and shoot me … But I suppose I have to retire … I was still teaching at that point full time and – retirement, but I’ll find some way to keep busy.\n\nThe other thing, as you reflect back on the time you’ve been here, kind of the things you’ve learned?\n\nDr. Guiteras: About the colossal foolishness of it all when I first started because the economic situation was not right. It was in the middle of a recession. There was a building moratorium here. There was really no need for another doc. I was coming here purely for personal, family reasons. And I would do it all again if I had to, but I think I would recognize that the suicidal nature of it all (Laughter) … More guts than brains? Yeah, exactly. It was probably helpful to have patients(?). \n\nDr. Guiteras: I think I would have done it in a much bigger way. I mean I sort of opened up on a shoestring. I tried to keep things modest and small and ungrand. And my original office, when I think about it, it was pretty bare bones. I borrowed $15,000, which was not a whole lot of money, not even then. I had about $35,000 or $40,000 in savings at that time, which is pretty much what we lived on the first year. But I think if I had to do it all over again, I would have borrowed as much as I could have gotten and started out in a much grander fashion – a bigger office, better facilities. I think probably medical marketing being what it is and people thinking --, my practice probably would have grown more quickly early on if it had been more of a splash. But I didn’t and that’s the way it is. In a way, I think it helped me because I think if it had grown too fast, I probably wouldn’t have known what to do with it, how to manage it.\n\nThe other thing, you were talking about how the pace and everything seemed to be more tolerable, in a way, when you were on your own.\n\nDr. Guiteras: Yeah. We had only one child then. Our mortgage payment at that time was about $450 a month. Things like that. Money was not uppermost in my mind at that point. \n\nIt gets farther and farthermost up just in terms of when you talk about college education.\n\nDr. Guiteras: I can’t imagine. \n\n(End)","format":"text/plain"},"target":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/collections/3180/collection_resources/150638/file/277820#t=660.0,3597.488"}]}]},{"id":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/collections/3180/collection_resources/150638/file/277819","type":"Canvas","label":{"en":["Media File 2 of 2 - Guiteras_G_Patrick_1989.11.05_-_Side_2.mp3"]},"duration":1118.264,"width":640,"height":360,"thumbnail":[{"id":"https://d9jk7wjtjpu5g.cloudfront.net/public/images/audio-default.png","type":"Image","format":"image/png"}],"items":[{"id":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/collections/3180/collection_resources/150638/file/277819/content/1","type":"AnnotationPage","items":[{"id":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/collections/3180/collection_resources/150638/file/277819/content/2/annotation/1","type":"Annotation","motivation":"painting","body":{"id":"https://aviary-p-centerforthehistoryoffamilymedicine.s3.wasabisys.com/collection_resource_files/resource_files/000/277/819/original/Guiteras_G_Patrick_1989.11.05_-_Side_2.mp3?1750276388","type":"Audio","format":"audio/mpeg","duration":1118.264,"width":640,"height":360},"target":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/collections/3180/collection_resources/150638/file/277819","metadata":[]}]}],"annotations":[]}]}