"I'm not sure I'd go to medical school if I had it to do again."


Maria Kramer is the medical director of a small ambulatory care clinic on the lower East Side of Manhattan. She is thirty-six and went from an LPN (Licensed Practical Nurse) to an MD, never being an RN..

There's a joke about two medical students hiking in the forest, and they see a grizzly bear. So they start running away from the grizzly bear and then one of the medical students sits down and takes off his hiking boots and starts putting on his running shoes. The other medical student looks at him and says, "Are you crazy? You can't outrun a grizzly bear." And he says, "I know. I just have to outrun you." It's more fitting for premeds than medical students, actually.

I felt it most strongly because I was a little older than everybody and I was just there to get some decent grades so I could get into medical school. I would hear rumors of tests being stolen and passed out, and it made me feel lousy. I was doing okay on my own. In fact I did extremely well in my premed days. In medical school I eventually found my friends and we helped each other by studying together and teaching each other. When I originally graduated from college in 1978 with a double major in anthropology and psychology, I noticed there weren't any jobs out there. I hadn't thought about anything medical since I was six and wanted to be a psychiatrist. A friend told me about a one year training program to become an LPN, so I signed up for that. I wanted to join the Peace Corps and I thought nursing would be a really useful skill to have. I turned out to be wrong about that.

When I finished the year of training I actually applied to a lot of other things besides the Peace Corps, but it turned out the LPN just does not travel well. While I was waiting for a Peace Corps assignment that I would like, I worked as a temporary nurse in Seattle, Washington. That was actually a lot of fun. I worked in all the different hospitals around and became a regular in a psych unit because most temporary nurses don't like psych units and I loved it! I got various job offers but I was planning to leave, so I continued as a temporary.

The Peace Corps did not have room for a practical nurse, only for RNs, so I went as a health educator. I was in West Africa, but the culture and the setting didn't work out for me. I stayed just about four months.

When I first got to Fresno I didn't have a California license and couldn't get hired as a medical assistant in a hospital without a medical assistant certificate. While I was waiting, I took this job in a nursing home and ended up really liking it. My father had been in a nursing home for a while and they were my least favorite place. But I ended up knowing all the patients on the different floors. When I got my license I stayed on there.

I had looked into an accelerated RN program at Boston University and was planning on doing that after working for a year. It was at the nursing home that I finally decided to go to medical school. I thought I'd go into geriatrics. My cousin suggested I should become a doctor, and I took it to heart. It's odd because I had always been intimidated by doctors. I thought I could do a better job than they did, but it didn't occur to me that I could actually do the job.

Premed courses took one year, but you had to complete them all before taking the Medical College Admissions Test, so I had another year to do the MCAT and the application process. I was fortunate, because I was able to take premed courses and not work as a nurse.

I got wait-listed four places and one day in July two places called me and told me I was accepted. I went to a University of California school, which was not my first choice, but I'm really glad I went there. I don't have major debt problems now and I can work in this little ambulatory care clinic without having to worry about it.

Having worked with patients, I had some idea of what I was heading for, which kept me more motivated. Through medical school and even now, another major advantage nursing has given to me is that I had a different outlook. I'd already struggled, even in nursing school, with some of the issues about patients who were really sick. You could either go home and worry all night about them, or you could go home and get a good night's sleep. I tried to teach myself that I had to take care of me in order to take care of these people. I still struggle with it.

Nurses know an awful lot about the patient. I only visit the bedside for a short while; the nurse is there all day. I remember even back in nursing school I would talk to a patient who would tell me all this stuff and then I'd watch the doctors come in on rounds and they would ask the patient questions that I knew the answer to. The patient would lie there and say, "I don't know." And I would typically chase them down the hall and try to pick the kindest looking person and say, "Excuse me, but earlier today the patient told me this is when their stomach hurts and this is how it is."

So I have always been very willing, not necessarily to do what nurses told me to do, but to listen to them and weigh that in all the considerations. Which not only teaches you more about what's going on with the patient, but makes the nurses a lot nicer to you. Some of my colleagues in other departments were not as willing to listen to the observations the nurses would make. A nurse can let you have a good night's sleep. Nurses can do a lot for you, if they trust you and respect you.

In many ways I felt my medical training tried to knock out all my common sense. They made you concentrate so much on lab values that you'd forget to ask the patients how they feel. Then in residency they were interested in my recovering basic common sense.

As my geriatric experience faded I was open to everything as a specialty, which makes the clinical years a lot nicer. I began to realize I'm the sort of person who needs to know a bit about everything rather than everything about one thing. In my first rotation I was learning how to run ventilators and manipulate people's electrolytes, and my friends would come and ask me about things like warts, and I didn't know! I think some of those experiences made me decide I really needed to be a family practitioner.

The reason I had stayed in the nursing home was primarily because I liked my patients: I liked relating to them, and explaining things to them. That became more apparent as I went through the clinical years as well. Making patients understand what was going on and why I was asking them to do these things was more important to me than being the brilliant diagnostician, although it would be nice to be everything.

In the nursing home setting, physicians just came and wrote orders. Nursing home patients are the bottom of the hierarchy for many physicians. I felt horrible doing some of the things that physicians ordered, keeping certain people alive. I had very close contact with that and thought a lot about it. Nobody trained me very well in medical school to deal with the issues of when do you shut down treatment and how do you do it. In my residency we struggled with that a bit more but it's hard because there are so many laws.

I've had a much closer view of it than most physicians. On the one hand is ordering all these tube feedings on comatose patients, while on the other hand there is administering them. Having had that experience as a nurse made it a whole lot easier for me when I was a second year medical student and my grandmother had a stroke. She was not comatose but she was living in a way I knew she would never have chosen to do.

My experience as a nurse made it obvious to me what to do when the doctor called to say he thought maybe she had pneumonia and wanted to send her to the hospital for a chest x-ray. I had to explain to my family that this was not what we were going to do. But they had no problem with that. They were happy to have somebody who knew something. She died about five days later, and it was time.

So my experience of being a nurse there leads me to be one of the less aggressive doctors I know, at least at my clinic, as far as dealing with those issues. There are always legalities and that's another complication, but as far as the basic feeling about it, I know there's a time to let go. I just don't always know how to get around the barriers to do it.

By my residency the nursing was fading. I still had a lot of respect for nurses, and knew what I could and couldn't ask them to do: what was realistic, what wasn't. I knew what the hospital routine was, but I spent a lot of time terrified I was going to kill somebody. During internship I recalled the lessons about taking care of myself, so I could take care of patients.

Being family practice in a university setting you were farmed out to a lot of different places. I had some hundred hour a week months, and I had some sixty hour a week months, whereas some programs are just always hundred hour a week months. But we carried a beeper twenty-four hours a day, seven days a week, to deliver our own babies. That added a little twist.

I remember being a resident and trying to say a few encouraging words to the student nurses, but not having time. I would try to be as open to them as I could. If I would just invite them a bit, some of them would be extremely helpful to me. They had spent all this time with the patient, but I didn't always have the patience to deal with them.

The two kinds of nurses that I'm the most amazed by are the intensive care nurses and the obstetrical nurses. They spend immense amounts of time sitting at the bedside of the patient and they're the ones who make it clear to me that nursing is not a step below doctoring, but is its own profession, and very different. It should be a team, not a hierarchy.

That's one reason I'm glad I'm not in the hospital now. I can be friends with everybody in my clinic and have dinner with whoever I choose to, not based on what their status is.

We have medical students at my clinic every summer. There are a few things I'd like to give them, but one of the most important things is: Everybody who's been there longer than you can teach you something. If you take the time to do that, you're going to get ahead much quicker and you're going to have more pleasant relationships and fun doing it.

I had sworn up and down all my life I would never move to New York City. My former boyfriend, a fellow resident, owed time to the State of New York and I moved here with him. He has since left and I'm here.

I love my job. I carry a lot of work home with me, being the medical director, but as far as the clinical hours go, it's nine to five except one day a week I do an evening clinic. We don't have any kind of call except a telephone call system so you can direct people to the hospital if they need to go. That's pretty reasonable.

Sometimes I'm envious of nurse-midwives, because they get to do that whole labor thing in a more close and intensive way than even an obstetrician or a family practitioner. But my temperament is more suited to being a doctor than a nurse. I'm not sure I'd be good at that many hours of closeness. I'm good at talking with my patients and explaining to them what's going on. I do home visits and get very close to my patients, but as far as that extremely close relationship that certain nurses are able to have with their patients, I'm better off as a physician.

One can do a lot of the things I do as a physician assistant or a nurse practitioner. You can't be the director of a clinic and I really do like having a hand in shaping the kind of care we give, but even those folks, if they get themselves in the right situation, can do that, too. One of course doesn't earn as much money, but that's more secondary.

I'm not entirely sure I would go to medical school if I had it to do again. I think I could also be happy as a nurse practitioner or as a physician assistant. I love what I do. It's just the getting there, I'm not sure I would do over again. Honestly, your emotional development is stilted for nine years. It took up so much of my time that I felt like I left out other sides of myself. I didn't really know, aside from being a physician, what I wanted to do with my life.

Going through medical school and through residency I always had good friends, but perhaps not as diverse as I would like. They were mostly people who were going through the same experiences I was. And as much as I love them, all of us wanted to have people who were outside that whole experience.

Now that I'm in this setting where I have a little more of my own time to arrange, it's great. I'm able to make different kinds of friends and stretch out into different kinds of lives. At this point the one thing I would like is a few more doctor-type friends, who are outside of my setting.

I don't think I'm the type who will ever get married, and that's not a major goal of mine. But I don't know how that would have been different if I'd done something a little less intense. I've decided I'm probably not going to have children. That might have been different if I'd done it differently.

When I came here with my boyfriend it was like, Oh, buy a house and remodel it? That sounds like fun. I absolutely hated that. You would think by the age of thirty-two I would have some clue that that was not something I had any interest in. When I finally got out of training, I had a lot of catching up to do about what was really important to me and what wasn't. I entered a bit later, but not that much later. Medical training shuts down an awful lot of general development, whether it be relationships, interests, priorities in life. Now I feel like I've caught up and figured some of those things out, but I'm three years out now.

When I get tired of being in New York City, I don't think I'll seek out another administrative position. I'll probably seek out just a patient care position, so I'll have to get used to that. I'm also thinking about getting a master's in public health, which would lead me to more administration, so I'm mixed up about what I really want to do, but I'm not in any hurry to move anywhere at all.

I do feel like I'm putting on a band-aid now and I would like to do something a little broader. On the other hand I escape from my administrative duties into patient care. When I get tired of my administrative duties, I practically literally go out in the street looking for patients. It isn't that hard finding them. I could walk out and somebody would say, "Oh, Dr. Kramer," and I'll say, "Well, why don't I just see you now?"

Our clinic has a house call program. When my AIDS patients get so sick they can't come to the clinic, I go see them. I also fill in when our house call doctors aren't available. I love doing it. The two months I spent during my residency doing community medicine with a home health nurse really influenced my thinking about medical care. Going to people's houses casts a whole new light, not only on that patient but on all the other ones I see. Because I come from an upper middle class background, I don't know what life in the Lower East Side is like. But when I get to go to people's houses, it changes my perspective on many people.

The nurses are the ones who have to deal with pain, and they aren't great with this issue, either. Nurses will ignore a doctor's order to give pain medicine because they don't want to give pain medicine to junkies. I work with a lot of drug addicts and I'm under the impression that drug addicts feel pain just the same as the rest of us.

I take care of a lot of drug users and people with HIV and people who don't take very good care of their health, but a lot of those people don't take care of their health because they feel really put off by the providers of health care. They feel very judged. I honestly think it might decrease health care costs if we could make all of the preventive health care measures that we think are important readily available to people. Let people establish relationships with physicians. We'd have to change a lot of attitudes on the part of the physician, but I long for universal health coverage.