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‘Doc Quixote’ Tilts at His Final Windmill in the ‘Hood

ASSOCIATED PRESS

Where’s Kramer?

For a month, everyone on Avenue D has had a rumor. Kramer had been killed. Kramer was in the hospital. Kramer had run off with his secretary.

One thing is clear: Dr. Joseph I. Kramer, who treated the Lower East Side’s poor for a quarter of a century, who became one of the city’s most honored and loved physicians, is gone.

There was the message on his answering machine, the sign on his battered door: “THE OFFICE WILL BE CLOSED UNTIL FURTHER NOTICE. PLEASE GO TO THE HOSPITAL IF YOU HAVE AN EMERGENCY.”

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In fact, Kramer is at home in suburban New Jersey. He’s quit, for a reason less dramatic and more tragic than the street talk could imagine.

It wasn’t the 40 patients a day. It wasn’t the rise of AIDS, the spread of TB, the resurgence of measles. It wasn’t his 71 years, and it wasn’t the money.

It was the paperwork; he burned out on paperwork.

“Those morons tried to tie me up with their red tape,” he growled. “They buried me with their forms.”

“They” are the bureaucrats who have taken over the economics of health care. They are the voices on the line, the signatures on the letters, the ones who determine--as much as the doctor--who gets treated and how.

Kramer came up when things were different, and maybe it’s simply time for him to go. But the passion with which he insists he’s burned out suggests he really isn’t.

He’s a big man--6-5--and looks 10 to 15 years younger than his age. As he talks about medicine--cursing and laughing, holding his head, waving his arms--you realize that any room Joe Kramer leaves feels empty, especially a doctor’s office.

When he came down to Avenue D, the Puerto Rican ghetto was hopping with outsiders: flower children, welfare advocates, revolutionaries, poverty lawyers and doctors.

“When the ‘60s ended, everyone went back to White Plains,” he cackled. “But I said, ‘I’ll hang in one more year.’ ”

He never left.

*

Kramer was a baker’s son from Brooklyn. He worked his way through college, knocked around a little, and was 41 when he finished medical training in 1965. He had a wife, a child and no money. So he joined a group pediatrics practice across the Hudson in affluent Bergen County, N.J.

He began to feel rich, but he didn’t feel needed. The kids were not that sick, the parents not that appreciative. “I felt like an expensive baby-sitter,” he recalls.

One day Kramer and his wife drove through the Lower East Side, where his grandparents had settled after emigrating from Eastern Europe. “All these children,” he exclaimed, “and not a single doctor’s shingle!”

Kramer got so bored in New Jersey that each morning he’d sit outside the office in his old Buick convertible, hands gripping the steering wheel, trying to summon the will to go inside.

One night he arrived home after a particularly unnecessary house call to the home of a particularly arrogant mayor. His wife, Joan, pregnant with their second child, was already in bed. “I don’t know if I can take this any more,” he told her. “I gotta get out.”

Joan Kramer regarded her meal ticket and said the words that set him free: “So go.”

Kramer moved into a storefront on Avenue D and waited for patients to stream in. Weeks later, he was still waiting.

He went looking for patients. He saw a woman with an infant in a carriage at a fruit stand. “Do you have a baby doctor?” he asked.

This was Ida Evans. Two weeks later her baby had a fever and she was in Kramer’s office. She was struck by how blunt he was. “When are you gonna get that fixed?” he said, nodding toward the baby’s foot.

Evans had thought something was wrong, but the doctor at the hospital where the baby was delivered did not. “Clubfoot,” Kramer said, and referred her to a Park Avenue specialist he knew. The foot was in a cast for 12 weeks. When it came off, the foot was straight.

Word got around, and other patients followed. One was a 2-pound, premature baby with badly twisted intestines. In the suburbs, the boy would have had all sorts of doctors; on Avenue D, he had only Kramer.

In his first year, Kramer learned to recognize drug withdrawal symptoms in newborns and to ask 13-year-old girls with stomachaches if they’d been having sex. When he took his first vacation, he knew there’d be a burglary. To avoid a ransacking, he left the syringes out on a table where the junkies could find them. They left a few behind, he recalls, “in case kids needed shots.”

“I had to think entirely differently,” he said. “I realized I was practicing a specialty--slum medicine.”

But Kramer resolved never to talk down to his patients. He always wore a tie, and he learned Spanish.

If patients couldn’t afford the medicine he prescribed, he waived his fee; if they still couldn’t afford the medicine, he paid for it himself.

Kramer was the only doctor in the ZIP code with hospital privileges, and the sole medical school professor. Dismayed by the neighborhood’s Third World immunization rates, he led a group of med students on a door-to-door “inoculation sweep.”

He carved out his own network of specialists, composed of doctors who admired Kramer, received his patients like VIPs and charged them little or nothing.

But CRAY-mah, as they called him, was more than a healer. “He was like a therapist,” said Evans. “If you had a half-hour to talk about something, he had a half-hour to listen.”

Sometimes he did more than listen. “Sometimes, he’d scream at you and you’d scream back at him. . . . But we loved him because he wasn’t a phony.”

And they watched out for him. Although he’d often work late--if a mother couldn’t get out of work early, he’d wait around--Kramer was never attacked or robbed.

The Doctor of Avenue D became a hero. He was invited to speak at medical school graduations, and the head of a medical foundation said Kramer personified “what medicine is supposed to be about.” Village Voice cartoonist Stan Mack portrayed him as a character called “Doc Quixote.”

When he was profiled on “60 Minutes,” a patient told him, “I’m so glad one of us finally made it.”

But while Kramer was doing good, everyone else--from Medicaid crooks to fancy specialists--was doing very well. Health care costs kept rising and around 1990, things began to change.

To hold down costs, health insurance companies formed limited networks of physicians that emphasized primary and preventive care--exactly what Kramer was already doing. He signed up.

But when Kramer’s old patients wound up in other networks, they often kept coming to see him and he felt obligated to treat them for free. When patients needed a specialist or a hospital, they now had to go to network members that, without Kramer’s personal connection, were less welcoming.

Kramer spent more and more time on the phone, fighting with insurance companies or Medicaid to get patients into hospitals or specialists’ offices. “All they care about is money,” he’d mutter.

He’d threaten to quit but then a new outrage would arise. “Before I knew it, I had the phone in my hand, screaming at somebody on the other end.”

Ruefully, he recalled what the older doctors told him during his medical training: “You did the best of everything for the patient. You were the patient’s advocate. You never asked yourself, ‘Can I get away with not doing this?’ ”

Paperwork was the curse of the new medical order. “Every patient who came in the door generated four pieces of paper,” he said. Kramer was once told that if he wanted $1 for an immunization, he’d have to write a report.

The paper took over half an examination room. It spread across the floor, up the wall, across his leather exam table. Each Friday night he went home with a pile in his bag.

Other doctors hired office managers and bought computers but Kramer could afford neither. Other doctors formed groups but Kramer could find no one eager to join him in professional Siberia.

He dropped most of his managed-care connections and fell behind on his paperwork. One patient says she stopped going to Kramer because she knew he wouldn’t bother to file the forms to get paid.

There may have been a way to beat the system but Kramer was beyond seeking it. He had always sustained himself with the hope that he could improve the system; now, he felt, it was getting worse.

When he was invited to speak to students at Cornell Medical School, he told them, “If any of you are thinking about doing what I do, don’t. The system won’t let you.”

Now, like years earlier, he’d sit outside his office each morning, gripping the steering wheel, trying to gather the strength to begin the day.

By the end of last year, the outrage that long fueled him had finally depleted him. When his secretary quit, he decided he would too.

*

Kramer’s last day ended an hour early.

Ida Evans was in the waiting room when a young man walked in. “Give Kramer a message,” he snapped.

“Tell him yourself,” replied Ida.

“If I tell him,” he shouted, “I’m gonna kill him.” He pulled a large carving knife from his bag.

Two men who had been waiting walked out the door; two toddlers sitting with their mother began to cry. Kramer walked out from the examination room to see about the fuss.

The intruder had come in two weeks earlier, faking a cold to get a note excusing him from a city workfare detail.

“Go get a job,” Kramer had told him with customary diplomacy. “There’s nothing wrong with you.”

“He dissed me,” the man told Ida.

“You want an apology? I’M SORRY!” Kramer screamed. He turned and walked back into his examination room, where the woman and children had fled.

Ida persuaded the man to leave. You know how Kramer talks, she said.

Of course the man knew. He’d been Kramer’s patient for most of his 24 years. He’d been the 2-pound preemie with the twisted intestines.

After he left, Kramer gathered his things and went home. Ida noticed that he did not stuff any paperwork in his bag.

*

A month later, Kramer was back in his office for an interview. He’d insisted on an early-morning meeting, to reduce the chance of bumping into patients.

“It would be very painful for me,” he said. “I feel very guilty about leaving.”

When Kramer told one patient he was quitting, “she just sat there with her mouth open. ‘You’re gonna close? What am I gonna do?’ I can still see the look on her face.”

The pharmacist across the street says he’s never seen anything like the outpouring of emotion--sadness, anger, fear, sense of loss--that has attended Kramer’s departure. Several people have even offered to help Kramer with his paperwork.

As the phone rang and the answering machine clicked, Kramer surveys the exam room turned file cabinet.

“Patient Encounter Forms,” he said, lifting a box. “I’m going to send them back to the president of the insurance company with a note: ‘I don’t encounter patients. I treat them.’ ”

Now, he says, he wants to practice for a while on an Indian reservation out West where he won’t have to worry about office management and to write about the troubles he’s seen.

He left the office with its fax machine tucked under his arm. It was cold and windy, and few people were on the street. It looked as if Kramer would make it to his car without incident.

But then he was spotted by a thin, middle-aged Latino woman in a neon-blue overcoat.

“Oh oh,” Kramer muttered.

“Hello Maria,” he said, and they hugged and kissed. He has treated her, her three children and the rest of her large and rather troubled family.

She demanded to know the name of the man who threatened him on his last day. “We’re gonna mess him up good.”

“Oh no, no,” he said, shaking his head, profoundly uncomfortable.

“You comin’ back?” she asked. “You gotta come back!”

Kramer mumbled something about trying to get someone to cover the office a few days a week, and moved on.

He sat in his red Toyota Camry, the most ostentatious vehicle he has ever owned. “I came down here from the suburbs and felt like I had found a problem and had got my hands around it,” he said. “It took me all these years just to find out that I didn’t.”

“But I went down swinging,” he said, turning on the ignition. “I had an impact.”


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