Chapter 18: Retirement

        November 25, 2015, was a day I both looked forward to and dreaded at the same time. It was the date of my last official day of work as a physician. I looked forward to it because at age 72 I was getting a little tired of working full time as a physician and was anxious to slow down and enjoy my remaining years of life. I dreaded it also because it was the end of a career I had worked so hard to obtain and had enjoyed so much. Besides my age I think the biggest factor in determining my retirement were all the changes that were being forced on physicians by insurance companies and Medicare in particular. With the advent of electronic medical records and Meaningful Use with Medicare I just felt it was time for me to move on. I was tired of going home after work and spending another 2-3 hours  at the computer entering data. I did not become a physician to be a data entry specialist. So with great reluctance about 3 months before I announced that November 25, 2015 would be my last day of work.

          My partner,  Dr. Teresa Benecki, took the news calmly and made the transition for me as smoothly as possible. It was to be a gigantic change for both of us. For her it meant she would be on call by herself 24/7 and would be responsible for the everyday running of the office and all that entailed. For me it meant saying goodbye to my partner, my patients, office staff and colleagues. Believe me this was no small task for either one of us. As I said goodbye to many of my patients we both managed to hold back a few tears. This was where the doctor patient relationship really displayed itself. Saying goodbye to someone you have cared for over 30 years was not easy. Many wrote warm and wonderful cards expressing their sorrow that I would no longer be taking care of them and thanking  me for all I had done for them. It was I who needed to be doing the thanking and I did  so the best I could. As far as the office staff a party was arranged to say our final goodbyes. Many of my colleagues called me when they heard the news to wish me well. A few even took me out to dinner. The biggest surprise came when I went to my last meeting of the Ob/Gyn Department at Brick Hospital. As I entered the room I was given a round of applause and then shocked as Dr. Paul Vetter, the current department chairman, announced they had a surprise for me. He held up a plaque which said the following. To Pieter J. Ketelaar, in recognition and appreciation for your dedication and service to Ocean Medical Center’s Ob/Gyn Department, the Labor and Delivery On-Call Room was named the Pieter J. Ketelaar OB Call Room by unanimous vote of the Ob/Gyn Department. I was completely blown away and immensely humbled that my fellow colleagues thought to honor me in this way. I was literally speechless but I managed to get out my sincere thanks to all involved and especially to Dr. Vetter for orchestrating the whole idea. That plaque now resides in our living room in Florida for all who visit us to see. I was then led up to the Labor and Delivery floor to see the new sign on the door to the Pieter J. Ketelaar MD On-Call Room. Many of the nursing staff greeted me outside the room and I posed for pictures with the whole group. It was a day and an honor I will always remember.

          Dr. Benecki and the office staff had arranged for a party to celebrate my retirement. Many of our former staff who had moved on to other jobs or themselves had retired were there. I had a great time reminiscing with them about many old stories we had shared over the years. Midway through the party a picture was unveiled showing a caricature  of me riding on top of an airplane while throwing my computer away. How apropos! Everyone had signed it with their best wishes and thank you notes. Dr. Benecki, a person who self admittedly was not much of a public speaker, got up and gave a rather heartfelt tribute to our many years together. It was then that I knew she forgave me for leaving her all alone. So now there was no turning back. I had said my goodbyes and thanks to those who had meant so much to me over the years and I looked forward to our move to Florida.

          Over the next week we packed up our belongings in preparation for our move. When I announced my retirement, our youngest son came to us and gave us an offer we could not refuse. About three years prior he had bought a lovely 3-bedroom home with a pool in a small community on the east coast of Florida named Sebastian. We had visited him many times in the area called Florida’s Space Coast because of its proximity to Cape Canaveral. Well when he heard I was retiring he said “my house is yours, so go and enjoy it.” I always knew he was a good person, but I didn’t know he was such a generous person also. So on 12/6/2015 we left New Jersey behind and once again we embarked on a trip to become Floridians again. It was an 18-hour drive which we unfortunately decided to do in one shot. We left our home around 4 AM and of course it could not be an uneventful trip. I had only a few hours of sleep that night and just below Washington, D.C. I fell asleep driving the rental truck with our personal belongings and collided with a traffic sign which jarred me awake. My son Patrick and my wife were driving our car behind me and had an up close view of a potential disaster. Fortunately I was able to stop the truck quickly without hitting anything else but my share of the driving to Florida was over. The truck sustained a broken window on the passengers’ side and some other minor damage. I don’t remember much of the rest of the trip because I slept most of the way in our car with my wife driving it and my son driving the truck. Later that night we arrived at our new home in Sebastian. I learned a good lesson that day the hard way. When your body tells you to rest you had better listen! Somehow it had taken me 72 years to learn that lesson. I was so lucky because that could have easily been the beginning and end of my retirement. I am also very thankful I didn’t hurt anyone else that day. That was not, unfortunately, the only bad event we would suffer on our move to sunny Florida. The very next day while Kathy was retrieving something from the car  she slipped and fell in the driveway. After a visit to the local ER we discovered she had broken her ankle and a couple of ribs. Was someone trying to tell us this might not be a good move for us to come to Florida?

          The next few months were uneventful, thank God, but I really was becoming quite bored. At first I enjoyed getting up when I felt like it and only doing what I wanted to do instead of what I had to do. However, that quickly became very boring. My wife said during those first few months I looked like a lost puppy. I also felt like one just wandering around looking for something to do. I checked with the local hospitals if they needed a part time Gynecologist but nothing was available. I tried to find a part time job in a pharmacy but again nothing worked out. Then one day while watching TV I saw the shooting of several police officers in Dallas, Texas. I felt so upset for those families so I decided that I could no longer just sit at home doing nothing. I needed to do something and that event gave me the incentive I needed. The next day I went to the Sebastian Police Department Office and asked a police officer there if there was anything I could do to help them. He said that they have a volunteer group which was looking for new members. After an interview and a background check I became a volunteer police officer. How’s that for a career change?

         My role as a volunteer police officer with the Sebastian Police Department rescued me from my retirement boredom. Although a part time job consisting of just two mornings a week, it provides me with somewhat of a schedule back in my life and something to look forward to. Many police departments across the country do not have volunteer units but it works well for the small town of Sebastian. We have 20 volunteers in addition to the 33 regular police officers and it is estimated that we save the town approximately $500,000 a year. The most important thing is that we free up the regular police officers to do the important things needed to protect the  citizens of Sebastian. We wear uniforms but are not armed. We drive police cars which helps to extend a police presence in our town. Our volunteers range in age from 60 to 80 years of age but none of them really look their age and all are remarkably healthy. They are ordinary citizens who just want to help others. From the Chief on down, we are thanked on a daily basis for the help we provide the department and community. Chief Morris, one of the few female police chiefs in the state, cannot thank us enough. She knows most of us by our first names and has publicly stated that we are the backbone of the department and wishes she had 20 more of us. Because we are not armed we do not do any confrontational police work but we assist in the more mundane work that does not require a regular officer. This includes transportation of vehicles, house watches of citizens on vacation, delivery of important papers, providing escorts for funerals and traffic control at events and accidents. We also do ride-alongs with regular police officers providing another set of eyes as a back up. Besides our two mornings a week, many of us give extra time including being called out at night or on weekends for emergencies. I liken the volunteer group to a good old boys club. We are from diverse backgrounds like ex-police officers, retired military, insurance agents, teachers, and me being the only doctor. We have a good time together relating many stories from our former careers and it gives a sense of purpose to our retired lifestyles. Volunteering to help others is a very rewarding experience and we are thanked regularly by members of the community for our service. As volunteers we are not paid but an occasional thank you is all the reward we want or need. I am so glad I found something like this to do with my spare time.

         The other important thing in my retired life is that I am an FAA designated aviation medical examiner or AME. I had been doing this for several years prior to my retirement. As an examiner I am responsible for evaluating, examining, and issuing medical certificates to private, commercial and airline pilots. After our move to Florida I asked the FAA if there was a spot in Florida where I could continue to do this work. As luck would have it about two years after our move I was notified by the FAA that a position had become available in St. Lucie County. Since our move I had been traveling to New Jersey once a month to keep myself current. My first step was to find an office so I looked up the airports in St. Lucie County and found the most prominent to be the Treasure Coast International Airport, formerly called St. Lucie County International Airport in Fort Pierce. One Saturday morning I drove the 30-minute trip to check the airport out. The very first thing I saw was a building which housed Aviator College. It offers a 2-year associates program which provides training and certification for private, commercial, instrument and airline transport licenses. My son, the pilot, informed me that the school has a very good reputation for providing qualified pilots to the airline industry. Again as luck would have it I ran into on that initial day the chief pilot of the school. We had a mutual interest in each other from the beginning because they were looking for a local examiner to take care of their 400+ students who needed regular exams and I needed a place to work. We talked for a while and he explained that he was a former fighter pilot with the French Navy. We hit it off from the beginning and after a tour of the college he showed me an office that was available to rent. Again how lucky was I to walk into the right building at the right time and meet with the right person who could help me. After a meeting with the college’s president who agreed to offer me the space for my office I next notified the Southern Regional FAA Flight Surgeon’s Office in Atlanta, Georgia that I had found an office to practice in. The school provides instruction to many future pilots from around the world. So far after only one month I have done exams on pilots from Vietnam, Singapore, England, Italy, Taiwan as well as those from the United States. Hannah, one of the school’s administrators, acts as my scheduler and makes my work so much easier by making sure everyone is properly prepared for their exam. I have been welcomed with open arms by the school and my two days a week there are an absolute pleasure.

          So as you can see by now my initial lack of any plan for my life after retirement has resulted in finding two very rewarding positions. I feel very fortunate to have found things to do which I love and find most interesting. How fortunate I have been. As I head into the closing chapters of my life I have had the time through this book to look back and see how fortunate I have been to meet the right people at the right time in my life. All of them have helped to contribute to my career as a physician and I cannot thank them enough. No matter what amount of time I have left on this earth I can say without a doubt that I have truly enjoyed my life to the fullest. I have had the immense pleasure of helping others in need and it  has rewarded me in so many ways. 

Lastly, thank you for sharing this trip with me and I hope you have enjoyed it as much as I have enjoyed reliving it with you. Thank you again to all who have helped me along the way and I hope I have passed on the knowledge I have gained over the years in the same spirit and manner in which it was given to me. This is the basic philosophy of the medical profession to not only help and heal others but to pass on our knowledge to the next generation of young physicians. That was an important part of  the Hippocratic Oath which I took back in June of 1970. I have tried to live up to that solemn Oath every day of my career. Besides passing on my knowledge to others it also cautioned  me to first do no harm.  I hope that I have done a good job in that respect  and that those that I have helped and those that I have shared my knowledge with will give me a passing grade. If so I will consider my life and career to have been a success. I also hope this book will help you to see your physician in a different and more understanding light than you had before reading it. If so,  I will consider that I have done a good and useful job by writing it. In closing I wish you a long and healthy life.

Chapter 17: My Family

        How can I begin to tell you how important my family has been to me? They have endured the good and bad times in our lives with equal grace and have been my backbone throughout my career. We all need family to support our efforts in life and mine have been the best. There is no way I could have endured the rigors of my professional life without their help and support. My parents, wife, four sons, and my four grandchildren are the reasons why I have been able to give so much time to my profession and my patients. They have unselfishly allowed me to pass on to others the love, kindness and support that they have given to me. I am forever indebted to them for all they have done for me.

         First I must thank my parents for giving me the spark to be a physician and then through their hard work and sacrifices paying for my education. Thanks to them the day I graduated from medical school I was debt free. It was my mother who provided the initial spark for me to become a physician. Not that she pushed it on me but just the way she talked about caring for her patients made me appreciate how special those in the medical profession are. My mother was a great nurse and I had the good fortune to speak to several of her patients who told me so. She made me understand how special it is to care for someone in need. What a role model she was for me. My father knew very little of the medical profession. I can remember many discussions that I had with my parents at the dinner table about my experiences in medical school. Some of those discussions albeit very graphic literally made him physically sick and sent him to the bathroom. Many times he asked me to please have those conversations in private with my mother. But nonetheless he encouraged me to achieve my goal in his own non-medical way. He wanted his son to be successful at everything I did from my childhood to becoming a physician. He spent so many weekends with me at track meets in high school and college. He was always there to support and encourage me. I will always remember the day I graduated from medical school how proud they were of me. They were no small part of my becoming a physician and I was so glad to be able to give them the pleasure of sharing in that moment. How proud they were of me and how thankful I am for all they did for me. They both are gone now but I know I could not have succeeded without their love and support. Thank you Mom and Dad. I will forever wish I would have told you that more often when you were alive.

          The most important person in my life is the woman I married over 40 years ago. My wife Katherine has been my best friend, confidant and calming influence throughout our life together. For over 40 years she has stood beside me through all my ups and downs. Being a wife and mother is no small task as I’m sure many of you know. Well try doing it alone on many days, nights and weekends. As a nurse, she has shown me the tremendous kindness and caring spirit that she gives to her patients. Her uncompromising devotion to help others was what first attracted me to her. With unique unselfishness she cared for her dying mother who suffered from bone cancer at the very young age of 46 and both of my parents in the latter parts of their lives. She welcomed them into our home and cared for them both as if they were her own parents until the day they died. She would not allow them to be sent to a nursing home even though she very well could have declined to take them in.  That was quite a feat considering she had 4 little children to take care of also. They were both fortunate to have her by their side when they passed on. Kathy is also an excellent nurse and that has enabled her to be the perfect companion for me. She understands the demands put on me more than anyone else because she has seen it first-hand. We worked together during my Ob/Gyn training and she filled in as my office nurse on many occasions during my career. She continually reminded me that caring for others is such a noble calling and the example she gave me on a daily basis has helped and guided me to be a better person and physician. From the day I met her as a new graduate nurse until the present, she has allowed me to devote the time necessary to do my job without a complaint or jealousy knowing that often meant I would have to be with others instead of her and our children. She has never let my absence at birthdays, graduations, anniversaries and special occasions with friends and family ever become an issue of contention between us. There is no doubt I have been able to provide her and my children with a good life, but she alone knows at what price. Being married to a physician carries a lot of hidden baggage with it, but no one else could have handled it with any more grace or understanding. I knew how she cared for her dying mother that this was the person I wanted to spend the rest of my life with. It was the medical profession that brought us together and it is what has kept us together all these years. Thank you for all your love, kindness and support Kath. I love and need you so much.

          As for my children, they are the pride of my life. My sons have grown up to be the compassionate and productive men we had hoped they would each become. Each one has taken a particular virtue or passion from us and embellished it to the fullest. We are very proud of our teacher, police officer, aerospace engineer and airline pilot. None of my children have decided to become a physician and I think I understand that because they saw first-hand the sacrifices that the profession demands. One of them reminded me of that when he told me one day "Dad, very few people understand how hard you work.” While I would have been thrilled if one had decided to become a physician, I know now that it is not the profession that it used to be. I certainly have been able to provide my children with many of the good things in life but the compensation has diminished so much that I often question whether the rewards are worth the sacrifice anymore and that is a shame on our society. Money is not what should drive our children or anyone to be a physician, but due to the time commitment, the extreme cost of the education, the rewards must be commensurate with and compensate for the sacrifices involved. That used to be the case but is no longer the situation any more. Many of our brightest young men and women are not choosing to go to medical school. That to me is the biggest shame that our society is letting happen. We need to reward those who choose to help others, not quibble over how much they make for the sacrifices they endure. Let’s be honest who is more valuable to our society: a doctor, football, baseball, or basketball player? Who else is willing to leave their home at all hours of the day or night to care for someone else and yet some people are jealous or resent the amount of money they make?  How many times have I heard over my career that doctors make too much money? I have never and still don’t understand that mentality. Talk to a physician’s family and you will see at what price it takes to be a member of this profession.  I sincerely hope this book will help you to understand this better and see why I have written this book.

          One thing that has always given me great joy is when one of my sons meets someone that I have delivered and I can see the pride in their eyes that their dad helped to bring that person into the world. I have a special bond with my oldest son Pieter, not only because he shares my first name but also because I delivered his wife Karen. He always tells me when one of his students informs him that I was the one who delivered them. At the beginning of every new school year he always asks the students in his class to stand if you were delivered by my dad. It is his way of showing me and them how proud he is of his father. My sons have always made me so proud of them and I'm glad that I have been able to provide them with the opportunity to be proud of their dad. As with my wife, my sons have always been so understanding of the occasions when I had to miss something important in their lives. I have never heard one of them complain even though I know there must have been times when they were very disappointed I could not share an important event in their life. This is the price the medical profession demands of its members whether they be doctors or nurses. Each one of my children has taken a particular joy in my life and let it blossom into a career for them. I always enjoyed teaching and Pieter has chosen that as his profession. I have always had so much respect for those in law enforcement and my son William has become a decorated police officer. Patrick saw my love of aviation and it led him to become an aerospace engineer. My youngest son Kevin, like me, is a pilot. As an airline captain he has fulfilled another one of my many dreams that I had as a child. I have had the extreme pleasure of flying on an airplane he has commanded and it was such a thrill for me to tell the passenger next to me or one of the flight attendants that it was my son who was the one piloting the plane we were on.

          As for my grandchildren, they are so precious to me. I was fortunate to be nearby when each was born. As I know how thrilled my father was with my sons I am so happy my 2 grandsons will continue the Ketelaar name. My 2 granddaughters are so special to Kathy and I. It took 77 years for us to have a girl born again into my family after so many boys. We are so grateful to have these two young girls to love, care for and dress up that we never were able to do before.

          So to my family I want to tell them how much I love them and thank them for giving me the freedom and support I needed to devote the time I had to  give to my profession. Each one has unselfishly shared me with my patients and my profession. Without them and their understanding I would not have been able to fulfill all the demands of my professional life. But most of all thank you for bringing so much joy into my life. I treasure each and every one of you and I go to bed every night so thankful and happy you have been in my life. Thank you one and all. You are the best and I hope you know I love you all very much.

Chapter 16: The Annual Exam

        The dreaded “annual exam” that women must endure on a yearly basis involves a complete physical exam, pelvic exam and Pap smear. It is unique to women as there is nothing quite equivalent for men. While there are many jokes about the exam, it is extremely important for women to undergo this check-up on a regular basis. Many women joke to their male counterparts about having to endure taking off all your clothes and having your private parts probed and prodded. Young women especially can feel like their body is being violated. It begins for most women as a teenager, often seeking contraception, and continues yearly until well into their later years of life. It is the prime example of preventive medicine for women. Regular annual exams have resulted in decreased death rates from many diseases which occur in this area of the body. The exam can produce quite a bit of anxiety, however, and I have been told by several patients that they have not slept for days prior to it. While it is an extremely personal examination, I want everyone to know what is involved, why it is so important, and relate some of the interesting and even amusing statements I have heard over the almost 40 years I have been performing the exam. Most, if not all, Gynecologists understand the anxiety it creates and do their best especially with a patient undergoing the exam for the first time to allay their fears and debunk the myths surrounding it. I was taught this by one of my professors, Dr. Humbert Riva. He taught me many ways to put the patient at ease and to understand their fears. How fortunate I was to be taught early in my career by this wonderful teacher and physician. The exam that I do is modeled after the teachings that I learned from this giant of a man whom I could never thank enough for all he has taught me. My career has been shaped by him in so many ways. May he rest in peace knowing his teachings have remained with me and so many others for all these years. 

          To understand this important recurring event in a woman's life, I would first like to explain in detail what is involved in this examination. When I think of it, I am often reminded of the skit that the comedienne Joan Rivers used to do about it. In it she describes the anxiety that it creates beforehand. The fact that all your clothes must be removed and replaced with thin paper garments, the positioning on the exam table in stirrups and the “coup de grace” of the doctor inserting the notorious cold metal "clamp" into the patient's vagina. You can imagine the laughter the skit elicits and the many memories it stirs in women while they relive their own experiences with it. The fact that Ms. Rivers was the daughter of a Gynecologist I am sure made her privy to many jokes about the examination. The levity that can be created by the thought of the exam should in no way detract or lessen the importance of it. So many diseases in women are silent during their early stages and frequently do not lead to any symptoms until late in the course of the disease. It is heartbreaking for me to see a woman who has not had an exam in many years who finally comes in and, unfortunately, it is too late to cure her. So it is my goal to make sure you understand that, although it may be an unpleasant experience, it is extremely necessary because it can, and does, save lives.

          Some of my older patients are quite nervous and, I am sure, embarrassed to have a male physician do their annual exams. One day I was talking to one of my elderly patients in the hallway before she went into the exam room. I could tell she was very nervous as we chatted. Many of these women, I know, must  think about going through the exam for days or even weeks before they come in. I do my best to appreciate their anxiety and, over the years, I have tried my best to allay their fears and apprehension as much is possible. Despite their nervousness I am always amused at some of the comments they have. That lady was no exception but her comment as she headed for the exam room was priceless. "Doctor, can't we just do lunch instead today?" I almost fell on the floor laughing, but I understood her underlying apprehension. I replied “maybe next year, Mrs. B”. I’ve also heard many times the expression brought on by nerves “usually doctor a man buys me dinner before this”. I think you're beginning to understand how this exam affects women in so many ways.

         There is a very nice elderly lady that I take care of who was a former patient of one of my senior partners. She had been his patient for many years and, like most patients, was used to how he cared for her. Well, one day she came in and was told that he had retired and the nurses asked her if she would mind seeing the new young doctor, me. She said “it’s okay I’m sure I have nothing he hasn’t seen before.” My wife happened to be filling in for another nurse that day. She went into the exam room with the patient to help her get ready. The patient was there for a pessary check, which involves removing, cleaning and reinserting a rubber ring in the vagina to support a dropped bladder or uterus. My wife could tell the patient was very nervous about seeing the new young doctor. The patient, however, is quite a character and she began questioning my wife about me. “ So tell me honey, what's this new guy like, is he nice?" “Is he cute?” My wife said " yes he is nice and I think you will like him."  “How do you know" she asked? My wife proceeded to explain to her that I was her husband and I know you will find him kind and gentle. The patient later on told me she wanted to crawl under the table after she found out that the nurse was my wife. She also was very embarrassed at the questions she had asked her about me. We have had many laughs over the years about her first visit with me and I have subsequently cared for that lovely lady for many years. She always asks how my lovely wife is doing with a slight grin on her face.

          Now let’s talk about what is actually involved with the examination in detail and explain what is done and why it is so important. The history and  basic physical exam is pretty straightforward. Most women consider their Gynecologist to be their primary care physician. As such, we have a very important role in their access to the health care system. While most common medical problems are easily related to physicians, many women find it embarrassing to discuss some of their problems like sexual dysfunction, period problems and even abusive relationships. It is there where a good physician must be able to communicate with the patient and give them a sense of security and trust to allow them to freely discuss their problems. But it is the pelvic exam that women really picture in their minds about the annual exam. It is at that point that I frequently hear patients say "and now for the fun part." Rest assured, there is no fun involved for the patient or physician. It is a very personal exam and deserves as Dr. Riva taught me the utmost respect. It is these comments that frequently help the patient allay their anxiety. The exam begins with taking or updating the patient’s history. A general physical exam follows including a breast exam. Finally a pelvic exam begins with an examination of the area around the vaginal opening, known as the vulva. This area can be involved with various conditions from sexually transmitted diseases to cancer. The physician then carefully inserts a metal instrument, known as a speculum, into the vagina. Contrary to a common myth, the instrument is not kept in a refrigerator but on a heating pad. It enables the physician to directly examine the vagina and cervix, which is the part of the uterus that is in the vagina. It is also where the pap smear is taken from. The vagina is a frequent site of disease, the most common one being yeast infections. The cervix is the site of many premalignant conditions, known as dysplasia, and also cancer. After removing the instrument, the physician inserts their fingers into the vagina to do a manual examination palpating the uterus and ovaries. This is simultaneously done by pushing on the lower abdomen with the opposite hand. Then depending on the patient's age and symptoms, the exam may be concluded by doing a rectal exam also. So as you can imagine, it takes a lot of confidence by a woman in her physician to allow him or her to do that type of exam. It also explains why once a woman finds a Gynecologist that she likes and trusts, many times it becomes a lifelong relationship. I even have several patients who travel from out-of-state to see me for their annual exams. I also have two patients who come to see me regularly from England. They are both very displeased with the care they receive under the national health insurance system there. It also explains why I frequently see women who have not had an exam for many years because of a change in their insurance where their physician is no longer in their current plan or because of the retirement of their prior Gynecologist. I think you can see that it is a very unique relationship between patient and physician.

          Lastly, I would like to explain in detail about the Pap smear test. The name is the short version of the Papanicolaou Test named for its inventor, Dr. George Papanicolaou. It is a screening test for detecting abnormal cells, both premalignant and malignant, in the cervix and vagina. His famous paper called “Diagnosis of Uterine Cancer by the vaginal smear" was first published in 1943 and the procedure was subsequently named the Pap Test in his honor. He was a true giant in the annals of medicine and the test named after him has literally saved millions of lives. He is responsible for one of the major advances in medical care for women in the last century. While it is a valuable test, it is not infallible and false negatives do occur. Recently, the virus that causes cervical cancer has been identified. Human Papillomavirus, or HPV, can now be detected from the same specimen that the Pap smear is done from. The combination greatly enhances the detection of premalignant and malignant changes in the cervix. Young women can now be protected against acquiring this sexually transmitted virus by a vaccination called Gardasil or Cervarix. It is highly recommended that young women have this vaccination prior to becoming sexually active.

          Over the years I have found that the annual exam has enabled me to establish a close personal relationship with my patients. Seeing women year after year and caring for them as teenagers, managing their pregnancies, delivering their children, providing emotional support during divorces and the deaths of children or spouses and finally assisting them through their menopausal changes brings about a special bond between patient and physician. I have grown to know their children, husbands and the most personal details of their lives. In a single day, I may be called on to console a patient who has just lost a spouse, counsel a patient whose husband has been unfaithful, deliver a child, share the successes of children I have delivered or console a patient with a terminal disease. At this stage in my career, I have cared for many women for over 30 years. When I look at my schedule in the morning, I look forward to updating both their medical condition and hearing important details about their lives. It is a pleasure and a privilege that I value very much. Many of them I have laughed and cried with over the years I have cared for them. Many times patients will bring in pictures of the children I have delivered and I enjoy knowing that I was the one who assisted in bringing them into the world. I am very proud when I am introduced to children as the doctor who delivered them. Also because it is such an intimate exam and discussion of problems several times a patient of mine who becomes a good friend of mine outside of the office declines to have me continue as their Gynecologist. I understand this totally and never question the fact that they may switch physicians. 

          One of my patients recently wrote me a letter which I would like to share with you and let you see how special it made me feel when I read it. "Dear Doctor Ketelaar, this note of gratitude to you may be late in expression, but it is nonetheless heartfelt in its entirety. Thank you for all your kindnesses always, but most especially for discovering that I needed surgery for a large ovarian tumor. Without your knowledge and concern, I would certainly not be feeling as well as I currently do and my gratitude is total. Very often we take our physicians for granted and as part of life service. I have found that your concern and caring for detail is a wonderful part of your service and who you are. I was fortunate in choosing you when I moved into this area. Once again, thanks for being such a special doctor. I certainly appreciate it and I appreciate you."

          Whether it is receiving such a letter or receiving a heartfelt thanks from a patient, that is what makes my job so special and rewarding. Such is the nature of the job that I have been blessed to have. How much more personal could a relationship be? It gives me great satisfaction to continue to care for my patients as we both age together over the years. Many of them I consider to be good friends in addition to patients. That is what being a physician is all about and why I consider myself so lucky to be in this profession. Where else could I have so much personal satisfaction? So it is the annual exam that really brings it all together on a personal and professional level.

Chapter 15: Private Practice Potpourri

    This next chapter is kind of a hodgepodge of little stories about things that have occurred over the many years that I have been in private practice. First I would like to start with the people that I have worked most closely with and that is the nurses on labor and delivery. Believe me when I say I have spent more time with them than my family. We have developed a close relationship through the many hours we shared together both caring for patients and just sitting around talking to while away the hours. I know many of them like my own family. We know each other’s spouses, children and personal satisfactions and sufferings. We have lived together through weddings, divorces, births, deaths and God knows how many other personal events in our lives. Yet somehow we are all professional enough to know caring for a patient comes first despite all of our other personal  relationships. I have known some of these people for almost my entire professional career and I value their friendships and tremendous dedication to the profession very much. They are some of the most unique people I have been exposed to in my career and I have learned a lot from them. Several of them I have had the privilege to care for as patients and I truly consider that to be such an honor, that after working closely with me, they have chosen to have me as their physician. There are countless stories and incidents we have lived through together and at our reunions now we are able to laugh and relive many of these interesting, sad, funny or challenging incidents. One of the amusing stories I would like to relate is how the labor nurses would call home when there was a particularly loud, I really mean a screamer,  patient in labor. I am told they hoped that their daughters would listen to these patients and then maybe think twice about the consequences of having sex without some form of contraception. Now certainly not all patients scream during labor but they used the few that did to try and teach a lesson. I am told that the message got across very well in most instances. As the father of four boys, I always found it quite amusing, but I also understood where they were coming from in trying to impart some first-hand knowledge to their children. Of course I did consider it my duty to preach to my sons about this subject also. Nevertheless, I would always get a good laugh out of it when it occurred.  I want each and every one of them to know that I have enjoyed their friendship and respect so highly the work that they do.

         Of course there were some difficult cases that we shared caring for that we also would enjoy reliving. Some were very sad and painful, but many we enjoyed reliving knowing that we had helped someone who was in need and that is a wonderful thing to share over and over. It is also the reason that we all chose this profession. I always found it amazing how detailed their memories were of those incidents, like they had just happened and, many times, I would hear little side stories about them that I had never heard before. So to the dear ladies of labor and delivery thank you from the bottom of my heart for your friendship and for all the work you do to bring new life into the world. I could have never done my job to the level I wanted without their support and help.  At our reunions, I like to remind them that they are truly the real “guardians of the next generation”. I will miss them all very, very much when I retire.

         Naturally over the years I have received some interesting phone calls when I was on call. One night about 3 AM I received a phone call from a very nervous husband who proceeded to tell me that he was sure his wife was in labor with their first baby and he was going to rush her to the hospital immediately and then hung up. He didn’t give his name or phone number, nothing. So what do I do? Do I stay home and wait until she arrives at the hospital or do I go in and wait for them to arrive? Well, being the conservative person I am and besides the fact that I was now wide awake at 3 AM, I decided to go to the hospital right away. When I got there and told the nurses the story, one of them laughed and said “I bet she doesn’t show up doctor”. And how right she was! I waited over two hours and she never showed. And without a name or phone number, I could not even call to find out what happened to her. Was she ok? Did they go to another hospital? Were they in an accident? What had happened? We even called the other hospitals in the area to see if she was there. Needless to say I did not get any further sleep that night. Well, a few days later, I was seeing a patient in the office and she told me what happened. She apologized for the phone call and said her husband got so nervous he thought she said her pains were five minutes apart when in fact they were only five hours apart. Nonetheless, I told her next time make sure he gives us a name and phone number.

          Another interesting-but-annoying call I received at 5 AM one morning was from a pregnant patient who was going to see her dentist at 9 AM and she wanted to know what medications he could give her for her toothache. I had just fallen asleep after being up all night with a lady in labor and my temper was a little short, to say the least. I asked her if she knew what time it was and she said “well, what difference does that make? I have an important question for you.”  I informed her it was 5 AM and her question was not important and to tell her dentist to call me after he sees her, which I’m sure he would do anyway, and hung up. I fumed for hours after and was unable to go back to sleep.

         Another really-annoying-but-predictable phone call on weekends is from young patients to refill their birth control pills. Most women on pills are on Sunday start cycles, which means they start a new package on a Sunday. So, invariably on Sunday morning, they wake up and discover they are out of pills so it’s now time to call the doctor. We have an office policy that we don’t refill prescription medications on weekends for many good reasons. We probably don’t know the patient we are talking to and they often don’t know the medication they are taking and have thrown away the bottle already. We also have had several patients who always call on weekends to extend their prescriptions because they don’t want to come in for a check-up. Usually after telling the patient we don’t refill medications on weekends, the next phone call is from her mother with 5 excuses why little Mary forgot to call during the week. This is sometimes followed by “you don’t want her to get pregnant, do you?” How tempting it is to tell her maybe Mary should not have sex then. Or the best one was “well, how could she call she was on a cruise all week?” Sometimes I just bite my tongue to keep from going ballistic. Other more clever ones will have their pharmacist call and plead their case. I am amazed at how ingenious they are after they forgot to call before their prescription runs out. I am sure other doctors who are reading this are having a good laugh right now, but I can assure you it is annoying as heck.

         The next vignette revolves around delivering a set of triplets. I was on call one night and had just gone to bed after another delivery about 4am when the nurse called to tell me that the lady we had in the hospital with triplets was having contractions. This patient had been in the hospital because of high blood pressure. Almost all sets of triplets are delivered electively by cesarean section but there I was in the middle of the night all alone with the possibility of having to deliver them vaginally because they were coming so quickly. I took a deep breath and thought to myself what one of my old professors had said. “Don’t ever worry if they're coming that quickly you probably don't even need to be there.” But just in case phone calls were quickly made to my partners, anesthesiologists and pediatricians to come in and assist. Before anyone could arrive, the first baby was born spontaneously and because the second baby was breech I quickly grabbed it’s foot  and delivered that baby without any difficulty. But then when I reached up inside the uterus, I could not feel the third baby at first. I could feel my heart skip a beat. Where was the third baby? Well, it happened to be in a very unusual position, sideways, which left me with nothing to grab onto to help deliver the baby. Both its arms and legs were extended up and away from me. By then everyone had arrived and one of my partners whispered to me that delivering two out of three was no good and I had better get the other one out quickly. This did nothing to increase my confidence level. So immediately we set up for a cesarean section and the third baby was born without difficulty. What a night that was but that is what obstetrics is all about. One minute all is quiet and the next all hell is breaking loose. I am reminded of that delivery yearly as that woman is still a patient of mine and she kindly brings me a picture of the triplets every year for me to see how they have grown. Afterwards, my partner tried to explain what he was saying was that two for three was okay for a baseball player but not in our business. Unfortunately, I did not see the humor in it at the time. That is another former patient that I get chills when I see her remembering our experience together.

         The next patient I would like to discuss is a woman I admire tremendously. She is a lawyer by profession who unfortunately carries a chromosome mutation which leads to frequent miscarriages. After several miscarriages a detailed workup revealed the chromosome abnormality. She continued to become pregnant and finally delivered her first child successfully. I was so happy for her. She was so persistent in wanting a child so badly she was willing to undergo a lot of heartbreak and had finally achieved her goal. Miscarriages, although common, range between 15 to 20% all pregnancies and can be quite traumatic. Multiple ones to the same patient are even more devastating. I admire that patient tremendously for her fortitude and perseverance in going through all that she did. She never complained once. She always said “well, we will just have to try again.” She is another good example of how patients teach doctors lessons in courage and strength of spirit. Patients like her have given me so much more than I have been able to give them and I have been fortunate to know several such inspiring women over my career.

         Some of the most interesting stories about private practice occurred in my office. One day I was seeing a patient in one of the exam rooms with my nurse and, as I concluded my exam, the nurse left the room while I discussed the patient's problem with her. When I was done, I began to walk towards the door and the patient said "wait a minute doctor, I have another problem." She began to explain that she had been having a problem with one of her breasts and she wanted me to check. She was a particularly attractive woman and suddenly she removed her blouse over her head. She did not have a bra on and she was sitting on the exam table now completely nude. I said okay and quickly went to the door to switch on the light outside the room for the nurse to come back in. I prayed she would come back in quickly. It was only a minute before she arrived, but it seemed like an hour to me. As I turned to give the patient a sheet to cover herself, the nurse came back in. There I was standing next to this very attractive woman who was completely nude and she is holding her breast up towards me while saying “here it is”. My face must have been as red as an apple and I could see the nurse was quite amused. She had a slight grin on her face as she helped the patient cover herself while I tried to look elsewhere for a minute. After I checked the patient, the nurse and I walked out of the room together. As we got outside the room, she turned and said “gee doctor, I can't leave you alone for one minute can I?" It was one of the most embarrassing moments I have ever had with a patient. I don't know whether she was trying to be provocative or she just whipped her blouse off as a matter of fact. The nurse, however, will never let me live that incident down and reminded me of it for years afterwards. It is a fact that, very occasionally, patients seem to come on to their doctors and especially gynecologists have to be extremely careful that they always have a nurse attendant with them during exams. Especially if it's a male doctor.

         Another embarrassing incident happened to me one day as I was preparing to deliver a baby. We had just moved the labor and delivery area from Point Pleasant to Brick Hospital. We had brand-new labor rooms where we did the deliveries also. The bed the patient labored on quickly could convert to a delivery table so that the mother would not have to be moved into another room at the last minute for the delivery. Well, as you can imagine, there were a few bugs that needed to be worked out. As I prepared to deliver that lady’s baby, I scrubbed my hands and put on a surgical gown and gloves. I checked the patient and the baby was not quite ready to be born so I attempted to sit down on a stool to wait. In the previous hospital, those stools did not have wheels on the bottom and I presumed the same was true in the new hospital. Wrong! The stool, to my surprise, had wheels on the bottom and, as I went to sit down, it went  flying away and I proceeded to fall to the floor and hit my head against the wall. Fortunately, I was not hurt but my pride was damaged immensely. There I was, all neatly gowned and gloved lying on the floor with two nurses standing over me laughing their heads off. My thoughts, however, were for my patient. There she was ready to deliver and her doctor who was about to handle her precious new baby can't even do a simple thing like sit down on a chair without falling. I wondered momentarily if she thought I was drunk. I bet she thought “do I really want this guy to handle my child?" I quickly got up like nothing had happened and went about delivering her baby uneventfully, but it sure was another embarrassing moment for me.

         Sometimes, with the advent of natural childbirth, couples and, especially some husbands, tended to carry things too far. It is fine to limit the amount of medication that a mother uses in labor through various breathing techniques. But, occasionally, some of the husbands who were not in labor or having any pain themselves would decide for their wives when and if they needed pain medication.  Well, one day I was with a couple and I could see the mother was having a very difficult and painful labor. I tried to suggest to them that I thought a small amount of pain medication at that time would be very helpful and not hurt the baby. Her husband would have no part of it and informed me that she was doing fine. I wondered for a minute where his wealth of experience had come from seeing this was their first child. It always used to annoy me that when I talked to a patient the husband would answer for her. But I said fine and I would return in a little while. About an hour later as I returned to check her again, I could hear her screaming all the way out at the nurses station down the hall from her room. All the nurses were rolling their eyes about how unreasonable her husband was being. They also had tried to get him to let her have some medication but to no avail. I walked into the room and examined the patient and told them that she still had quite a while before the baby would be born and I really thought she should have some medication to relax a bit. Again the husband chimed in and said “no, she is doing fine." By then I was really irritated with him and told him what I was going to do. I told him I didn't think it was fair to his wife that she suffer and that I didn't think he understood how painful labor can be. But I said let's try this: every time your wife has a labor pain, I'm going to hit your hand with a hammer and you tell me when you need pain medicine and I’ll give it to her instead. I was just joking, of course, but he got the picture and finally let us give his wife medication and she relaxed and went ahead and delivered a nice healthy baby a few hours later. It is great for husbands to participate in their wife’s labor and delivery process but, sometimes, they think they know it all from taking a few classes and refuse to let professionals help. I think that young man learned his lesson and after his wife had delivered he came to me and apologized and said “I understand what you were trying to do and thank you.”

         And finally, I would be terribly remiss if I did not discuss the important role my office staff has played over my time in private practice. My office manager, Barbara Rose, who warmly welcomed me when I joined the practice, has been my right hand over these many years. She has made my life so much easier by the competent way in which she has handled the financial and mundane tasks necessary to keep our practice functioning. Thanks BR for all your hard work, loyalty and friendship. Our other office manager Janet is a woman I brought from the hospital because of her hard work ethic. A tremendous nurse, she organized the nursing staff and single-handedly does all the follow-up of patients with problems in what we call the “tickle file”. It was one of the best decisions that I ever made and I will miss her very much after she retires. Thanks Janet for your hard work these many years. To the girls in the front office who make appointments, answer the phones, and take messages, you are the face of Pinelands and a big part of why our practice has been so successful. Thank you Denise, Carol, Pat, Jodi and Nicole for your dedication and hard work. Many of those women have been with us for over 20 years and our patients have come to rely on them to convey their problems to the physicians. They are such an integral part of our practice and many of our patients have complimented them on how helpful they are compared to other offices. And finally to the nurses who have assisted us in taking care of our patients. Jeanette, Nicole, Suzanne and Kathy thanks for making my job so much easier. All of those women are what I refer to as the Pinelands’ Girls. They are more than employees, they are my best friends and I can't thank them enough for their hard work, dedication and friendship. Lastly it was not always easy to be the only male in the office with 12 women, but they have done their best to help me understand the female side of life. I have occasionally shared their hot flashes, irritability, mood swings and cattiness and have as a result come to understand probably more than most other men what the female gender is all about. I have learned that under these circumstances even men can have menstrual cycles lol! Thank you all from the bottom of my heart for all you have done for me over these many years.

         During my years in private practice I was fortunate enough to take care of a few very important people, well really celebrities. The first was the wife of Mookie Wilson, the talented center fielder for the New York  Mets in the 1980s. Rosa Wilson was one of the nicest patients and most grateful that I have ever taken care of. She was a very down-to-earth person and never demanded anything extra because of her celebrity husband. I happened to be on call the night she went into labor and assisted in the delivery of their first daughter. Mookie was a very attentive husband and an excellent coach for his wife in labor. I was a little nervous to say the least to care for this couple but they did their best to put me at ease. Their new daughter was perfectly healthy at birth and I felt very relieved that all had gone well.

         Later that year the Mets were playing terrific baseball and entered the playoffs with high hopes of going all the way to the World Series. In the National League Championship series in 1986 the Mets played the Houston Astros. The Mets had had a phenomenal year with a 108-54 won-loss record. So had the Houston Astros and after four games the series was tied at two and two. The next two games were historic with the Mets winning game five 2-1 in 12 innings and they won game six 7-6 in 16 innings. There are many who consider this to be one of the best playoff series ever. So now the Mets were in the World Series facing the Boston Red Sox. Mookie had arranged for me to have box seats behind home plate with the Mets wives for all the home games. Boston won the first two games and the Mets won games three and four. Boston went up three games to two by winning game five. With the Mets facing elimination they entered game six with their backs against the wall. No one was prepared for the miracle of game six. Tied in the bottom of the 10th inning with two outs, Mookie came to bat and hit a ground ball towards first base that slipped under the first baseman Bill Buckner’s glove and the Mets won a real thriller. The Mets went on to win game seven 8-5 in not as thrilling fashion as in game six. Mookie invited me into the locker room of the new World Champion New York Mets and I will never forget that thrilling day. To this day I have a sport jacket that I wore which was doused with champagne which I refuse to have cleaned. Mookie also introduced me to several of the players including their ace pitcher Dwight Gooden. He was  known as Dr. K for his numerous strikeouts. When Mookie introduced me to him he said “Dwight, I want you to meet the real Dr. K.” There is also a picture of me with Mookie, Rosa and their new baby that I had delivered in the Mets 1986 yearbook. What an exciting year that had been for me. I had always been an avid Mets fan, but that year was a dream come true for me and all Mets fans.   

         And now let's talk about the famous Buckner ball. A few weeks after the World Series my wife was running a benefit for our hospital. Mookie was kind enough to accept my wife's invitation for him to be the honored guest. He brought along many World Series memorabilia including bats, shoes, gloves and last but not least the Buckner ball. All of these were auctioned off to the highest bidder and were presented by Mookie himself to the winners. I happened to be the winner of the Buckner ball. I thought twice about keeping it but, in my mind, I thought it was something that Mookie himself should keep so I gave it back to him. Classy move but really dumb in reality. But at the time nobody could realize how valuable that ball would become. In his true unselfish way he gave it away at another auction. Where it is today is unknown to me, but I have heard that at one time it was owned by Kevin Costner, the actor. Besides being a tremendous baseball player, Mookie was a kind man and a beloved New York sports idol. To this day I consider him to be a real friend.

         Although many of my patients were not celebrities like Mookie Wilson, some had rather interesting backgrounds. One of my patients was a beautiful young woman who I thought could be a model. She came in on her first visit and asked that she be tested for STDs or sexually transmitted diseases. This was not an unheard of request by patients and I didn't think much of it at the time. When she returned one month later asking for the same testing I became a little suspicious. I asked her if she really wanted to be tested again so soon and she replied “in my business you cannot be too careful doctor.” It was becoming clearer in my naive mind she was not a model by trade. I also informed her that this testing is quite expensive and she replied “don't worry about it doctor, I can afford it.” She went on to explain that she was a call girl in New York City and she would continue to return for regular checkups and she did for the next few years. All the doctors in the office had interesting groups of patients that followed them in their practice. One doctor had a large following of teachers, another one had a group of  dwarfs and I had the hookers! By far I think my group was the most interesting.

         Some of the most rewarding patients in my practice came from the same family. There were several groups of women in which I cared for grandmother, mother and daughter. I considered it to be such an honor for these families to choose me as their doctor. There were also many patients that I cared for over 30 years. These women became more than patients to me they became true friends. But the most interesting groups that I cared for the ones that I had delivered who subsequently came to me to deliver their child. It also gave me pause to think that maybe it was time for me to retire. In all I delivered four children of women that I had previously delivered. I also had the pleasure of delivering a child who would later become my oldest sons’ wife. The relationships that I had with these women was more than just doctor-patient. They had faith in my ability to care for their families which gave me a great sense of pride. I looked forward to seeing many of these women year after year and watched many grow from mothers to grandmothers and children to adults. I took care of them through their childbearing years, then into menopause and some until the day they died. Whenever a patient of mine passed away I always tried to send a letter of condolences to the family. I tried to tell each family why I had enjoyed caring for their loved one. I hope you can now see in some small ways that I never really considered this to be a job. It was so much more than that for me. They say if you love what you do you will never work a day in your life. How true this has been for me.  These are the things I will miss the most when I retire.