Retire And Go Fishing? Not For This Rural Florida Keys Doctor

In 1979, Surgeon Steven J. Smith set up practice in the Upper Keys of Florida because he wanted to be near a place where he could go fishing and boating. He'd stay there a year or two, he thought, and then move on.

"Little did I know I'd have to go fishing and boating elsewhere," he says. He'd be too busy performing surgeries, seeing patients in his office – and driving up and down Route 1 treating patients. If he tried to go fishing or boating near his home in Marathon, he'd always get called to come in, he says.

But he fell in love with the area and its people. And now, at age 61, he isn't even thinking of retiring or cutting back.

For many of those years, Smith was the only surgeon available for the entire stretch of the Upper Keys, and often he still is. That means he drives back and forth 43 miles on the narrow two-lane stretch of Route 1 to see and operate on patients in two hospitals, Fishermen's in Marathon, where he lives, and Mariners Hospital in Tavernier.

He keeps going from 6 or 7 a.m. to 10:30 p.m. often six days a week. For many years, he made the drive back and forth three times a day on some days, although these days he drives to Tavernier about twice a month. He makes house calls, and follow-up visits, and sees patients in offices he keeps in both towns.

The son of a surgeon, Smith often serves as the area's general practitioner too, treating hypertension and pregnancy-related issues when the area's other specialty providers aren't available. If a patient calls him with a cold and asks to be seen that day, the response is, "Come on in to the office."

He treats injuries from the simple to the acute and everything in between. Gunshot wounds, emergency appendectomies, ruptured ectopic pregnancies, endoscopies, even a procedure for pancreatic cancer called the Whipple–just about anything a general surgeon usually does. For many years, "I was pretty much the only person on call for Upper Keys hospital surgery," he says.

And he says, he's still the one doctor in the area most likely to be on call for surgery. Other doctors take time off from call on weekends, he says, but not him.

The upper stretch of the Keys has an estimated 25,000 to 30,000 residents, and qualifies as a most unusual rural areas. Vacationers pass through, or come to stay in Marathon, which normally has about 10,000-population year round. These days, many year-round residents are uninsured and poor.

But Smith treats them all. He receives payment for his surgeries based on hospital collections, so many of his procedures go uncompensated. But that doesn't matter, he says, "I don't even think about it."

According to his colleague, retired vascular surgeon Luis Sala, Smith allowed himself only one week off a year, plus another week for his continuing medical education. He kept that pace up until 2002 "when he had his first continuous two-week long reprieve ever," Sala says.

Medical capabilities at small rural hospitals like Fishermen's and Mariners, which now have 25-bed and 42-bed facilities, respectively, are limited. Often with traffic, fishing or boating accidents, or an occasional shark or barracuda bite, severe trauma patients must be transported to Miami for proper care. Smith is generally the one who makes sure they get there quickly.

"Before the rescue system existed with helicopters, he'd get in the ambulance and ride up with the patient to Jackson Memorial Medical Center in Miami," to stay with the patient in crisis, Sala recalls.

Lynn Mauck, Fishermen's chief nursing officer, has worked with Smith for most of those 31 years. He recalls that Smith worked so many long hours, his wife Barbara and children would travel with him on his rounds up and down Route 1 to Tavernier. "They would drive that commute with him just to get some family time," Mauck says.

The key for any surgeon, and especially one practicing in a transient area like the Florida Keys, is to prepare for the unexpected, and Smith excels at that. Once a woman driving on the seven-mile bridge ruptured her bladder and spleen, and there was a dangerous loss of blood that left her critically anemic. But she was a Jehovah Witness who refused a transfusion.

Smith removed her spleen and worked with her and her family to use TPN (total parenteral nutrition) and ordered certain medications to keep her alive until her anemia could be corrected.

Some wonder if Smith will ever retire, and if he does, how will the community find such a dedicated replacement.

Fishermen's Hospital Administrator Kim Bassett doesn't want to think about that. "He's going to be one of those physicians who will work until he can't do it any longer. I don't see him stopping; there are very few people like him left in the world," she says. "But if, for some reason, he can't continue at this pace or must cut back, it will take two surgeons and an internist to replace him."

And finding that many doctors for a small community like this is a tall order, especially physician specialists willing to work the long hours.

Smith agrees. "A lot of (doctors) who come out of training today don't have the work ethic of people who came out of training when I did. Their residency programs require them to work only a certain number of hours, and they have different priorities. Not that it's bad, but it's different," he says.

"They've tried in the past to offer doctors reasonably good salaries to work here. And they come, but they don't necessarily work very hard for their salaries. For someone to want to live in this area, they have to be willing to work a lot, and give up cultural aspects of life in the big city and entertainment," Smith says.

Smith recently was named the 2009 Country Doctor of the Year, the first surgeon to be named for an award traditionally given to family doctors by Staff Care, a physician staffing service. His prize: a two-week of respite with a paid locum tenens to cover his practice so he could take some well-earned time off.

But he didn't even consider it.

Instead, he asked that the amount of money they'd spend on the locum tenens–$5,000–be donated to a fund for indigent cancer patients. Then he matched it with another $5,000 for medical care for victims of the earthquake in Haiti.

"We paid it forward three times, and it worked out really neat," he says.

Smith has no intentions now of slowing down. The next day, he would get up at 7 a.m., drive to Tavernier for another full day of surgery and patient visits.

"I really enjoy what I'm doing, as long as my health holds up," Smith tells me. "I'm not sure what I'd do if I retired."