This chapter is an invitation to read, view, and teach Primary Care, a play that explores moral dimensions of caring for a hospitalized woman who is blind and has advanced Alzheimer’s Disease.

Primary Care (complete script)

Introduction to Primary Care

Any play comes into being through collaboration. Writer(s), directors, actors, audiences, readers—all contribute to the mutual performances, the temporal experiences that collectively constitute the play. Compared to a poet or novelist, a playwright has considerably less authorial control. Edward Albee described his creative process to students when he taught playwrighting at the University of Houston.  He would take long walks, gradually composing dialogue and scenes in his mind and memory. Eventually he had a complete mental draft and would sit down to write. At that point, he would say, he could already anticipate the erosion of his role.

Soon enough there would be actors reading his lines, not exactly the way he had been hearing them, directors and set, lighting, and costume designers making and modifying meaning through their contributions, audience members coming with their own educations and expectations. For Albee, three-time winner of the Pulitzer Prize for Drama, these collaborations were painful necessities, while for others they become welcome enhancements.

Certainly Primary Care, from its inception, was through and through a collaborative making. I had written a dissertation closely examining several works by writers who were rather out of fashion because of their reliance on narrative as opposed to more respected modernist and postmodernist techniques. I was an assistant professor in the English Department and associate director of the University Honors Program at the University of Houston. As an untenured faculty member who was working twelve months a year in administration, I desperately needed time to do research, develop ideas, and write. I hoped to apply my personal and professional interests to medical humanities and was fortunate, on my second try, to be offered a Visiting Rockefeller Fellowship at the Institute for the Medical Humanities in Galveston, a division of the University of Texas Medical Branch (UTMB).  When my fellowship time in Galveston began, I met Dr. Thomas R. Cole, the Graduate Program Director of the Institute. Tom, a public historian and gerontologist, was often called in on patient cases to serve as an ethics consultant. One of those patients turned out to be Eldrewey Stearns, and eventually Tom wrote and published a book and co-produced a documentary entitled No Color is My Kind: The Life of Eldrewey Stearns and the Integration of Houston. 

Using qualitative research practices characterisitic of his field, Tom had collected oral histories from caregivers and a family member of Mrs. Greene, a patient with advanced Alzheimer’s Disease. Given my interest in narrative, Tom suggested that we collaborate on a novel about Mrs. Greene and her problematic situation. Her hands were strapped down to the bed, and she had been fed through a nasogastric tube for almost three years. Quite suddenly, the physician who had been managing her care died.  Without clear guidance—and not comfortable with the restraints—the health care team who inherited the case called on Tom to develop ethical, humanistic, and familial contexts needed to move forward with a responsible plan of care. Tom met and conversed with the only living family member as well as those who had been caring for Mrs. Greene and were familiar with her condition. With their permission, he recorded these conversations, and in the fall of 1989 he gave me access to them. This is a difficult, troubling situation, Tom said. In addition to an academic article[1] that eventually came out in 1995, Tom thought it important that the case be rendered as a story.

I was intrigued and hoped to be able to contribute. My own grandmother had caregivers during the day, but she had been staying with us at night, and as I listened to the cassettes driving back and forth the 52 miles between Houston and Galveston, in my mind Mrs. Greene became the aging person in failing health who belongs to us, or is us, all of us, sooner or later, one way or another.

Tom also arranged for me to meet and shadow a brilliant and boisterous chief resident and meet with him and the attending physician who had taken on the care of Mrs. Greene. Having “taken in” voices, photographs, details, and multiple perspectives, I was moved and had hopes that a narrative, perhaps a short novel, would begin to take shape. That didn’t happen. Reluctantly, I recorded a message one morning as I crossed the causeway onto the island. “Thank you very much for this opportunity, Tom, but I don’t think there is a novel here, at least not one that I can write.” And then, as an afterthought: “Maybe a play of some sort, but not a novel.”  Tom’s response was immediate and encouraging: no worries, make it a play.

Over the coming months, then, I began to draft dialogue and construct scenes. My grandmother passed away that January, and her loss made the writing more personal and intensified my emotional investment in the project. I created a character named Mrs. Brooks, a Black health care aid based in part on Vera Gipson, the woman who cared for my grandmother. I combined some of the attitude of the chief resident I had shadowed with the brilliance of a high school friend who had gone to Rice and then Baylor College of Medicine, and that character became Eliot “Stony” Marcher. My mother’s unsophisticated kindliness was incorporated into the speaking style of the niece from Beaumont, Margie Dunne. And as each character and scene developed, Tom Cole and other friends and colleagues at UTMB, the University of Houston, Baylor College of Medicine, and elsewhere, offered commentaries and critiques. One of those was an actor, originally from the Lower East Side of New York, who worked as the receptionist of the UH Honors Program. More than anyone else, Tanya Lunstroth, who as a young woman had played the lead role of Euripides’ Medea for the American Theatre Company in Paris, coached the material into a shape worthy of a public performance. Eventually she made the role of Margie Dunne her own, performing it on dozens of occasions over the years. Another essential contributor was Tanya’s friend Joyce Anastasia Murray, an Equity Actor who brought to life the part of Wynn Brooks, the aide who, for better or worse, maintains a personal relationship with the patient.

In early drafts, Stony was, well, stony. Dr. Mark Leifeste, a friend and psychiatrist in Boulder, read an early version and pointed out that Stony’s hardness was itself a symptom, that there was a person in his case as well.[2] I continued to convey the play to readers and continued to get constructive feedback. Albee himself thought it justified admission to a class he was teaching, a class that eventually provided helpful, if general, instruction in writing plays. For more specific feedback, Tom and I hired a screenwriting consultant who taught us about the necessity of beats and imbedded in us an unforgettable warning about “deadly exposition,” of which there was a great deal in early drafts. And there was the brief encouraging note from Gwendolyn Brooks, whose poems I loved and taught: “believable characters . . . realistic dialogue.” More than a decade later, there was the coaching of Megan Cole, a theater, film, and television actor who originated the role of Vivian Bearing in Wit. Among her many important suggestions: make it one act and get Stony back on stage for the curtain.

Over the years, then, with various contributions and collaborations, most in the course of rehearsals and performances, Primary Care continued to develop. Among the most important of those were readings and discussions arranged by Susan Cooley for a retreat sponsored by The University of Texas Houston School of Nursing and The Institute for Regligion and Health; a reading and discussion arranged by Warren Holleman for his “Compassion and the Art of Medicine” series at Baylor College of Medicine; and readers theater productions for the Conference on Critical Gerontology in the Strand Street Theater, one for a “Narrative in Art and Medicine” series sponsored by the University of Texas Health Science Center-Houston, and another for the McGovern Center for Humanities and Ethics starring Megan Cole and Brandon Hearnsberger. A full production at Cullen Performance Hall on the University of Houston campus was part of “Ebony and Ivory,” a production of two faculty plays, one by Dr. Elizabeth Brown-Guillory entitled Just a Little Mark and Primary Care. The interpretations of the script by actors and the creative approaches of various directors for these and other performances contributed to the shaping and development of Primary Care. We hope that those who encounter the play will not just read but also perform it. There is no better way to understand the heart and soul and situation of another.

Bill Monroe

December, 2022

Video of a Performance of Primary Care

[Insert Video here]

Primary Care

Images for Staging Primary Care

Discussion Questions for Teaching Primary Care

1. Dr. Marcher’s monologue is in the form of a direct address to an audience. Does it contain elements of “apology,” that is, of explanation or justification in the tradition of The Apology of Socrates? Stony knows what has already transpired, but the audience has not yet observed the action of the play. To what extent might Stony’s monologue be considered manipulative—why not let the audience members make up their own minds about what he calls “the Riegel case”? Could you make a case for Dr. Marcher’s position? What are the extenuating circumstances that he calls to our attention? (You may want to consult The House of God, an important novel by Samuel Shem.)
2. Mrs. Brooks is officially the primary caregiver for Mrs. Riegel. Is her personal relationship with the patient “unprofessional”? Consider the various ways that she demonstrates her resistance to other employees and her noncompliance with the rules of the hospital. Should there be a place for caregivers like Wynn Brooks in our health care system?
3. As part of the medical ethics curriculum for third-year medical students and the decision-making process at Jefferson Davis Hospital, Jo presents a patient case report, and Dr. LeMarque seems pleased with the presentation. What are the strengths and weaknesses of Jo’s report? Is anything left out? (You may want to take a look at “Is There a Person in This Case?” by Monroe., Holleman, and Holleman.)
4. Stony attempts to land a series of “rhetorical haymakers” on Dr. LeMarque, and later, Dr. LeMarque attempts to convince Mrs. Brooks in a similar fashion: “trust and abide by your procedures”; “she’s freelancing”; “wasting staff time and [scarce] resources”; “we must remember the burden on the patient”; “letting personal values affect your professional judgment.” Yet Mrs. Brooks seems unconvinced and unfazed. Can Mrs. Brooks’s approach to patient care be defended? If you had to explain her moral compass, what would you say to delineate it as convincingly as possible?
5. Mrs. Dunne, the only living relative of the patient, provides a rambling backstory about her aunt and brings with her some family photographs. Does her visit contribute anything important to the deciding process of the healthcare team?  What difference, if any, does her report make for the audience? If there is a discrepancy, do the differing “ways of seeing” raise important issues or questions?
6. Unpack the potential symbolism of the characters’ names. Begin by sounding them out. How do they enhance or complicate the conflicts depicted in the play? For stance, Eliot Marcher brings to mind attitudes and actions different from those suggested by Stony Marcher. Dr. Marcher prefers “Stony.” Why? And why does Ms. Winstone go by “Jo” rather than Jolanda, and what might her surname suggest about her inner conflicts? Consider possible homonyms for the proper names—words that sound the same but have different meanings. How might these names incite interest and suspense as the dramatic action develops?
7. Draft a verbal sketch of one or more characters. Consider what we learn about the character and from what sources the knowledge comes. How reliable are these sources? Consider the character’s name(s) as well as what they say, to whom, and in what context. Does the character change in any way over the course of the play? If so, how and why? Compare sketches and discuss differing descriptions and evaluations.