Dr. Ken Woerthwein's Medical Education and Practice

Dr. Woerthwein

When he was about 13 years old, his family began to ask Ken what he wanted to become; he had “no idea”.  But as he watched the 1950s documentary TV series “The Twentieth Century” (narrated by Walter Cronkite) and learned about “new and inventive” medical breakthroughs, he began to think about becoming a doctor.  

When he was a high school junior, Ken read “Arrowsmith” (as he recalls) published in 1925 by Sinclair Lewis; a story about the challenges faced by an idealistic physician-scientist.  From these two experiences, Ken then knew he wanted to be a doctor to serve others.

[A Wikipedia entry notes that the fictional Martin Arrowsmith of a hundred years ago was a bright young boy in a small mid-western town.  After spending time with a local general practitioner, he became aware of the “societal forces of ignorance, greed, and corruption that were as life-threatening as the plague.”]

[As an interesting aside, Sinclair Lewis famously said that “when fascism comes to America it will be wrapped in a flag carrying the cross.”]

After High School

From the suburbs of Chicago, Ken went to Princeton University in New Jersey.  While applying to colleges, he was naive about Eastern schools and asked others if such schools offered a good college education.  Ken told me that the elite Ivy League college was actively recruiting students from public schools to complement its traditional prep school applicants.  He was interviewed locally, was accepted, and went there “sight unseen”.

Beautiful Princeton Campus (Credit: depositphotos.com)

At Princeton, Ken majored in biochemistry.  He always loved sports and went out for the football team, but decided “it was too rough” at the college level.  He was well prepared academically by his high school education and did well in his freshman year.  In his sophomore year, he stumbled (like many premeds do) in organic chemistry.  He passed but did not do well in the course.  Ken moved on, enjoyed college and thrived in the other sciences and liberal arts courses. He did research and wrote his senior thesis on the regeneration of limbs in newts.

Introduction to Quakerism

Ken dated his late-wife, Wicky (Francine Willmore), in high school.  Wicky went to Beaver College (now Arcadia University) just north of Philadelphia.  Wicky was invited to attend a Quaker Meeting (The Religious Society of Friends) where she felt immediately at home with the form of worship, basic principles, and testimonies for daily living.  She introduced Ken to Quakerism, which slowly resonated with him.  They were married in a Friends ceremony at the Princeton Stony Brook Meeting House in November 1963, a week after President Kennedy’s assassination.

Stony Brook Meeting House (Credit: Princeton Friends Meeting)

[My experience, as a child, of sitting quietly on a hard wooden bench at the Frankford Friends School in Philadelphia during an hour-long worship Meeting left a lasting impression, as noted in my previous post.] 

After Princeton, back to Chicago

Ken was looking forward to going to medical school after graduating from Princeton in 1964, but he didn’t receive an acceptance letter, which he thought was due to his poor grade in organic chemistry.  A rabbi his wife knew thought Ken did not receive an acceptance letter because his last name may be Jewish.  (At that time, there was an unspoken quota of accepting Jews into medical schools.)  

When another opportunity opened, Ken returned to Chicago where he attended the University of Illinois in Chicago and studied for a Master’s degree in anatomy under Dr. Anthony Schmidt who also did research on the regeneration of limbs in newts.  (Ken’s Master’s degree included this research.)

Ken reapplied to medical school and was accepted in 1966 at the University of Illinois School of Medicine in Chicago.  Ken greatly enjoyed medical school where he rotated through three major hospitals in the area during his four years as a medical student.  One hospital was the Research and Education hospital of the medical school, another was the West Side VA and the third was Cook County Hospital, a government-run (free) hospital serving the poor (and mostly Black) community in the county.  Cook County Hospital is now called the John H. Stroger, Jr. Hospital of Cook County.

Cook County Hospital reborn as Hyatt House Chicago/University 
(adjacent to Stroger) (Credit: SOM)

It was at the Cook County Hospital that Ken had intense and formative exposure to low-income individuals. He was struck by the racial and class differences in health care, including patients placed in beds in large wards with little to no privacy.  As a student at this hospital, all the doctors, including him, were very busy, not only taking care of many patients but also doing lab work that could be performed on the patient's floor. (It is said that Cook County Hospital was the inspiration for the TV show “E.R.”)

Lead Poisoning

During his pediatric rotation at the pediatric building of the Cook County complex, he helped care for a young child who suffered brain damage from lead poisoning after eating chips of crumbling lead-based paint found in slum housing.  Ken and a fellow colleague (a Black student) encouraged the parents to go to the liberal newspaper, the “Chicago Sun-Times,” to tell their story.  They eventually did, and some initial efforts were then made to address the risks of lead poisoning in the inner city.  (It wasn’t until 1978 that use of lead-based paint was finally banned in the US. There is no safe level of exposure to this intense neurotoxin.)

There are many potential sources of lead poisoning

[In the 1960s, lead in paint was not the only source of the dangerous metal; the war in Vietnam, with millions of lead bullets fired from Soviet AK-47s and American M-16s, weighed heavily on our society, especially young men.  (We will get back to this later.)]

Project House and the AFSC                                           

Ken became a member of the Friends Meeting in Princeton in 1965 while living in Chicago.  Wicky was a social justice activist. She was invited to become the Young Adult representative to the board of the American Friends Service Committee’s (AFSC) regional office in Chicago. 

The AFSC owned a house in East Garfield Park called Project House from which many community programs were initiated. People from the community were the employed leadership.  (As Ken recalls, the first Tenants Rights Union was founded out of Project House.)

Project House in the 1960s (now an abandoned empty lot)
 (Credit: Jim Ralph)

Ken and Wicky took part in the AFSC’s PREP (preadolescent enrichment program) program out of Project House. After an assault of a Quaker by a member of the Southside Black Stone Rangers street gang, PREP was conceived as a way to break down racial barriers in the city by having white and Black families get to know one another through an experiential enrichment activities program for their young children.  On many weekends, the Woerthweins took mostly low-income, white and Black, elementary schoolgirls to a variety of new places and activities throughout the city.  

Ken recalled that a white girl from rural Kentucky lived with her family in a condemned building near Wrigley Field.  She was the poorest child in the group. This was eye-opening for everyone, including the rest of the children in the group.  The young girl had inadequate outerwear for the winters in Chicago; this needed protection was soon obtained for her.

The War on Poverty and the Chicago Riots 

During the summer before his junior year in medical school, Ken took part in the Student Summer Health Project (SSHP) funded by President Lyndon B. Johnson’s massive “War on Poverty” (that also created Medicare and Medicaid). 

Ken interacted with a Black teenage youth group in East Garfield Park who asked him to talk about sex education including anatomy, sexually-transmitted diseases, and contraceptive methods available at that time.  Through the SSHP, Ken became more informed about poverty, racism, and poor healthcare which led to the terrible living conditions in the Black ghettos in Chicago.

During the 1968 riots in Chicago, one of their PREP families was burned out of their apartment in East Garfield Park. The Woerthweins collected donated clothing and brought it to the family who had moved in with their grandmother in the North Lawndale section of Chicago (another poor Black neighborhood that had also suffered extensive burned-out residences and businesses during the riots).

Fires burning in the West Side of Chicago 1968 (Credit: Chicago Sun-Times)

[The urban riots are now referred to as "uprisings" by a York historian.]

These early experiences of social inequality and the effects of longstanding racism in the turbulent 1960s had lasting impacts on the young doctor-in-training. (Recall the sweeping Civil Rights Act of 1964 and the important Voting Rights Act of 1965.)

After Medical School

After four years of medical school, Ken was intrigued by the scientific basis of Internal Medicine and needed to find a residency. One of the students who graduated ahead of him from medical school (a friendly and jovial guy) went to York Hospital for training and touted its many values. Ken visited in September 1969, shortly after a second series of summer riots triggered by racial turmoil in the ongoing wake of the April 4, 1968 assassination of Dr. Martin Luther King Jr. (the day after his famous “I’ve Been to the Mountaintop" speech in Memphis).

Ken’s visit was extended for a few days when Wicky needed medical care.  As Ken met several York physicians (including Dr. Dave Jones), he was struck by the atmosphere of collegiality at the large comprehensive hospital. Impressed by what he experienced, Ken applied to the program, was accepted, and started his internship in July 1970.  Following that busy year, he began his formal residency, but he was emotionally exhausted by the many years of education he had completed and left the program early.  Ken knew he would be drafted.

[The first of two random draft lotteries for the Vietnam War was held in December 1969.  Men attending college were still exempt until 1971, but those studying medicine kept their protected status.]                                           

(As a junior in high school, Ken read the anti-war novel “All Quiet on the Western Front.”  It affected him deeply; he decided then that he did not want anything to do with war of any kind.)

While doing a rotation at the West Side VA Hospital, he helped care for a wounded Vietnam soldier who developed an infected, deep open wound, extending down to the bone of his lower leg. The soldier said that because his infection was so grotesque, his wife wanted nothing to do with him, and all he wanted as treatment was an amputation.  This experience further convinced Ken that he was not going to serve as a doctor in Vietnam if it meant caring for soldiers so that they could return to war.

West Side VA Hospital (Now the Jesse Brown Medical Center)
(Credit: Dept. of Veteran Affairs)

Since he was no longer in training, Dr. Woerthwein notified his local draft board of his eligibility and the decision he made, as a Quaker and a pacifist, that he wished to be considered a Conscientious Objector to war.  The board assigned him to two years of alternative service.  

As a physician, he could provide healthcare to an underserved population.  Where would he be assigned?

In the aftermath of the riots in York, to address the causes and other concerns, there was a week-long open community forum or public workshop called a Charrette.  According to a newspaper story years later, “The York Charrette explored the unleashed use of police dogs, lack of affordable and suitable housing, health care for the poor, and public transportation, among other community issues.”

One result of the Charrette was that in July 1970 the WE Group of the health committee (members from the community and health providers from various organizations) founded and incorporated the Community Health Center. It was staffed by volunteer healthcare and community providers.

Alternative Service

Since downtown York City was identified as a medically underserved area and was a “displacement” from Ken’s home environment in Chicago, the draft board felt it was a suitable option for Ken’s alternative service.  During this time, Ken discussed with Dr. Dave Jones at York Hospital his decision and desire. And in late July 1971 (through grant funding), he became the first full-time physician at the (free) Community Health Center (CHC) in York City.  

Dr. Piper

The initial medical facility was situated in the back of the VNA building at 218 East Market Street.  The York CHC was one of the first of the free health clinics in the US.  Some of the volunteer physicians were Drs. Pete Piper (1927-2013), Gary Ardison, John Trimmer, and many others, including interested York Hospital Residents.

As the CHC grew, it moved to 116 N. George St., a much larger facility remodeled in part by the staff and patients.  There were unmet healthcare needs for the poor beyond the city limits, as well.  With the help of the Community Progress Council, other make-shift offices were opened in rural Felton, Red Lion, and Dillsburg, and later on in Hanover and Lewisberry.  Ken saw patients at all of these centers. 

During one summer, Dr. Woerthwein saw patients at the Migrant Health Clinic run by the State Health Department. It was set up in the basement of Gettysburg Hospital. The patients were seasonal migrants who worked the vast apple orchards in Adams County. While there, they lived in poor housing.

Dr. Woerthwein greatly enjoyed the work at the various health centers and the people he worked with. He stayed on for an additional year beyond the two that satisfied his Selective Service requirement.

Switch to Family Medicine and Serving the Poor

While at the CHC, Dr. Piper saw that Ken’s nature was more attuned to family medicine than hospital-based internal medicine.  He urged him to do a family practice residency.  Dr. Woerthwein agreed.  He applied to and was accepted into the Family Practice residency program at York Hospital.  Through this residency, he broadened his medical education experience by being exposed to and caring for many patients with complex and common medical problems. 

During his residency, he was allowed to continue to care for his office patients at the CHC.  He said he owes a special debt of gratitude to general internist Dr. Jack Kline who guided him carefully and gave him appropriate responsibilities as he helped care for Dr. Kline’s patients in the hospital. 

Dr. Mulligan

After Ken finished his Family Practice residency in 1976, he returned to the Community Health Center where his future partner, Jim Mulligan (1944-2017) was now practicing.  (Jim completed his internship at York Hospital in 1970, followed by his Indian Health Service at an Indian Reservation in Washington, and then did a Family Practice residency in Rockford, Illinois.)  

About this time, the CHC needed additional funding sources.  The Board of the CHC sought federal funds to become a Federally Qualified Health Center.  As such, they were required to use National Health Service doctors from then on. The Community Health Center became today’s Family First Health.

Ken and Jim wanted to continue to serve low-income patients in York City so they rented an office on West Market Street for one or two years. They then purchased and remodeled a building at 462 W. Market Street, a former car dealership.  While at the CHC and at their office, they supplemented their income by serving as doctors at the old York County Prison (another eye-opening experience), the old Pleasant Acres Nursing Home, and for several years in the York Hospital inpatient alcohol and detox unit.  (Ken noted Dr. Dave Jones was a “silent partner” during this time to help find sites where they could earn additional income.)

[Dr. Woerthwein admitted openly to me that he was initially “prejudiced” against people with addictions, believing that addiction was a moral issue.  His time caring for such patients made him realize that addiction is a complex medical problem and not a question of moral weakness.]

Dr. McMillan

By the 1980s, Drs. Woerthwein and Mulligan decided that their practice should seek out employees “who reflected and looked like the patients they were serving.” They needed a diverse staff.  They hired additional front office staff and a nurse assistant. They later recruited Dr. Deborah McMillan (a York native working in North Carolina at the time), and Roland Williams (a physician’s assistant who trained at Hershey Medical Center).

In addition to their office practice, they took care of their patients when they were hospitalized and made home visits where they got first-hand experience of their patients and their living conditions.

Although their practice grew, the income lagged.  They decided to partner with an HMO (prepaid health plans designed to control cost) which began to move into the York area in the early 1980s.  This provided guaranteed monthly income, although their decision was not looked upon favorably by many of the other practicing doctors in York.

Healthcare continued to change.  In 1994, as large regional health systems were becoming the prevailing model, Ken’s and Jim’s group was the second family practice bought by the newly-named, Wellspan Health System.  The office was moved to West Bannister Street in West York.  (Dr. Mulligan left the practice in 1998 to do addiction medicine) 

Retirement from Practice 

Dr. Woerthwein continued to work at the Bannister Street office until he retired from clinical practice in 2009. He very much enjoyed working with his diverse and caring staff.  (He was employed by Wellspan for another 15 years doing insurance appeals. This work allowed him to stay in contact with the changing field of medicine.)

The practice that he and Jim started is still manned by a diverse staff adhering to the ideals and goals of the founders.  Poverty and the effects of systemic racism remain the most critical of the “social determinants of health” and well-being that Dr. Woerthwein confronted daily.  Ken told me, frankly, that he doesn’t believe there has been significant improvement in these issues over the years.

According to the American Academy of Family Physicians (AAFP) 2022:

The social determinants of health (SDoH) are the conditions under which people are born, grow, work, and age, and include factors such as socioeconomic status, education, employment, social support networks, and neighborhood characteristics. These social factors have a more significant collective impact on health and health outcomes than health behavior, health care, and the physical environment, SDoH, especially poverty, structural racism, and discrimination, are the primary drivers of health inequities (italics added).

Reflecting on the years he spent in medical education and his practice, Ken feels that so many things that happened to him were a matter of chance opportunities that occurred at just the right time.

(Ken and Wicky raised four children, three of whom were adopted. The children in the tri-racial family experienced personal and racial discrimination while growing up in the York area.  Wicky died in 2018.)

Reference and Suggested Readings:

1.  AAFP. "Poverty and Health-The Family Medicine Perspective" (Position Paper) AAFP, January 2022. (accessed at https://www.aafp.org/about/policies/all/poverty-health.html)

2. Kendi, Ibram X. Stamped from the Beginning: The Definitive History of Racist Ideas in America. Bold Type Books, New York, 2016. ( Detailed, heavily-referenced, timely, and chilling essential reading.)

3. Smith, Robert Lawrence. A Quaker Book of Wisdom: Life Lessons in Simplicity, Service, and Common Sense. William Morrow and Company, Inc., New York, 1998.  (An enjoyable reflection on the core Quaker values of simplicity, peace, integrity, community, and equality.  And that "there is that of Good in every man.")

Along the Old Field Trail at Richard Nixon Park and Nature Center (Photo by SC)

By Anita Cherry 1/30/25

So I had a Stroke...

I often wondered how I would feel if one of the stories I had worked on could not be posted online and shared. After more than fifty tales about local doctors, I found out. It did not feel good. I was deflated. But as I read the story again I realized that simply working through it was a gift. It brought back the warm childhood memory of sitting on a plain wooden bench in complete silence during an hour-long Quaker Meeting for Worship at the Frankford Friends School in Northeast Philadelphia.

The quiet meditative experience fit with who I wanted to be; that is, someone who tried to do good. And I recalled that the gathering for lunch after worship was special. It felt as if I was offered a seat at the United Nations as I (white and Jewish from a heavily Jewish neighborhood) shared a meal with Asian, Italian, and African-American kids from other parts of the city. 

I prefer to sit in silence in a synagogue, temple, church, or congregation service, and now I know why. (I simply ignore my husband when he points to the proper line in the prayer book.)

But there is more. While still working on the last bit of the (now-unpublished) story not quite two weeks ago I had a stroke. Earlier in the day I had trouble reading and had mild head pain. These vague symptoms passed, but I awoke in the middle of the night with a start. I had a severe headache, intense nausea, odd confusion, and trouble speaking. What came out of my mouth was pure gibberish, total nonsense. Naturally, my neurologist-husband quickly helped me dress. 

Within five minutes, and as light snow began to fall, we were off to the ER. The stat CT showed a round 2 cm left posterior brain hemorrhage.  Off to the ICU, an experience I don’t really recall (though they say I was a hoot). A transfer to Tower 3 was made in the late morning and over the next hours, a few words began to come out right. 

The follow-up CT late that evening was stable, my blood pressure finally came down by the next morning, and I left the hospital barely 29 hours after arrival. My speech miraculously returned to normal during the day and I was back to the gym the next day. I am still tired, but ready (and grateful) to be able to begin work on another story, with an interview tomorrow afternoon.

Anita 01/23/25

Rajesh Nallapati, MD, MBBS: You Must Know Yourself Before You Can Know Your Patient

  

Rajesh Nallapati

Rajesh was born in Guntur in Andhra Pradesh, forty miles west of the Bay of Bengal. The hot humid agricultural area in South India is an important site in the history of Buddhism.  It is felt to be where, nearly 2,500 years ago, the Buddha taught the never-ending cycles of existence. Buddhism flourished in India until about the 12th century when it was “absorbed” by the various strains of the folk religion that would later be called Hinduism.  

 His family moved 50 miles from Guntur when Raj was about four. His father was a primary care physician who would sometimes, for example, ride his bike from their small village to the tiny nearby hospital to deliver a baby using forceps. The two doctors in the town “did everything” said Raj, and his father became very “popular.” 

At the local school, Raj and his two younger siblings sat on the dirt floor under a thatched roof carefully holding their simple black slates; there were no books. They walked home for lunch and during monsoon season, their feet would be covered in thick mud. 

Indian children sitting outside at a school
during the COVID-19 pandemic
(Credit: Reuters/Prashant Waydande)

The Family Moves to Hyderabad

After six or seven years there, his father (then in his late 30s) decided to become a general surgeon so he moved the family to the ancient teeming city of Hyderabad for a residency. Young Raj got into “a horrible fight” on the first day of third grade at his new school, but he quickly adjusted. And as his father trained, his “amazing” mother took care of the household chores, including collecting scarce clean water between three and five in the morning, the only time it was made available.

The future Dr. Nallapati was a good student who was “always in the top two or three” in his classes. The textbooks were in Telugu, the local classical language.  English was introduced in the fifth grade, but only as a studied subject; Telugu remained the standard until the students were in the tenth grade.  Teeming India has 22 “official” languages and 121 major languages. (According to the BBC, Telugu is the fastest-growing language in the US.)

Official Indian Languages (Credit: Wikipedia)

When Raj was in the eighth grade the family needed more money than his dad was earning working for the government.  So his father took a more lucrative surgical post in Iran. By the time he returned, two years later, his son was thinking about a career. 

Medical School

In India, the 11th and 12th grades were comparable to junior college in the US. Raj had always looked up to his father, and after briefly considering a career in agriculture (he was “fascinated by plants”), he decided, instead, on medicine. 

There was intense competition for spots in medical school. Raj did well in the required testing and was accepted to the Siddhartha Medical College, about 30 miles from  Guntur. He said he loved the basic science and pathophysiology of “the disease process” and studied diligently. To advance his knowledge after medical school he hoped to go to the States to study internal medicine. 

Govt. Siddhartha Medical College, Vijaywada (Credit: MOKSH)

For some reason, Raj tarried and waited until his fourth year in medical school to complete the USMLE exam to be eligible to apply for a U.S. residency position. When he came home on weekends to study for the critical tests he holed up in the library at the Guntur Medical College. It was a fateful choice. You see, that’s where he first spotted the medical student who would (several years later) become his wife, Dr. Vatsala Parchuri (Guntur ‘96).  

Dr. Nallapati had to go to Singapore and Bangkok for the USMLE, and after passing the exams he was ready for America.  But since Raj did not enroll in the “match” system that pairs prospective residents with specific programs based on mutual interest, he had to “scramble” to find a spot.

New York and then York for Internal Medicine

Rajesh came here on a visa and stayed with his cousin in New York as he applied for a residency. He landed an interview with a hospital in New York but they didn’t take him.  Time passed. Looking slightly further afar, he saw that the York Hospital (in neighboring PA) needed someone to fill an open slot. 

When he met with York’s director of the internal medicine residency, Dr. Wolfe Blotzer, the meeting went well. (“I was so nerdy. Maybe he thought I was intelligent,” quipped Raj with a laugh.) It went so well, in fact, that when Dr. Nallapati returned to his room at the Yorktowne Hotel the small red light on the telephone was flashing. The message:  He was offered a position.  (He told me he was only the second foreign medical graduate in the medicine residency at York; many more would follow.)

The Yorktowne Hotel
(Credit: York County Economic Alliance)

A generous cousin lent him $2,000 for the first two months rent in York and he bought a ten-year-old car (a 1986) for about $1000, and he was on his way.

Dr. Nallapati started his three-year internal medicine studies with the idea of doing primary care. He had a few simple goals: How do you learn more? How do you get things done? How do you get things right? 

The training was mostly directed toward diagnosing and taking care of sick hospitalized patients.  Raj found that the science and application of medical knowledge in the hospital setting was relatively easy to master. But he and his fellow residents viewed their weekly four hours of dreary outpatient clinic (tending to people who weren’t acutely ill) as “painful, burdensome, and unnecessary.” 

(Incidentally, Dr. Nallapati and Dr. Parchuri were married in the second year of Raj’s residency and Vatsala joined him in York the following year for her own training.) 

Outpatient Practice

After he finished the three years, Raj found that the intense hospital-based work had not prepared him for the altogether different practice of outpatient primary care, the medical care that, in his words, “should be freely available, like water.”   

Fictional Walk-In Clinic/Hospital set in coastal southern India
(Credit: Fandom)

Everything (not really everything, but many things) he had learned “went out the window,” he said. Dr. Nallapati was faced with the daunting challenge of figuring out how to deal with human personalities, not just, for instance, falling blood pressure or poor cardiac output or sepsis. 

And that he had to learn this on his own as he encountered one suffering patient after another. It wasn’t long before he concluded that communication, the mysterious and remarkable coupling of brains, was the most important and most challenging part of his daily work. 

Communication and Kindness

The first step in communicating is listening. Dr. Nallapati gradually learned that by calming his anxieties and clearing his prejudices or preconceived notions, and by being more balanced, he could hear better. By listening closely (with true attention) without judgment, but with empathy and patience, the answers to problems would eventually come to him. 

And by being kind to the patient, yes, kind, he could know what they wanted, what they expected, what they needed.  He would intuitively know what to say to make them comfortable, how to counsel them, and how to engage them in self-care.  Trying to help people in this way he could focus on “basic human values.” 

We want to be listened to; we need to be heard. Developing effective listening skills was “an evolutionary process,” he said. The agenda during a visit, dictated partly by the health systems that require physicians to tick off a list of boxes, and partly by the doctor’s own biases, is not the patient’s. 

The truly effective clinician is mindful. According to Dr. Ronald Epstein (1999): 

The goals of mindful practice are to become more aware of one’s own mental processes, listen more attentively, become flexible, and recognize bias and judgments, and thereby act with principles and compassion.  Mindful practice involves a sense of unfinishedness, curiosity about the unknown and humility in having an imperfect understanding of another’s suffering. Mindfulness is the opposite of multitasking. Mindfulness is a quality of the physician as person, without boundaries between technical, cognitive, emotional, and spiritual aspects of practice.(p. 835)

And:

Self-knowledge is essential to the expression of core values in medicine, such as empathy, compassion, and altruism. To be empathic, I must witness and understand the patient’s suffering and my reactions to the patient’s suffering to distinguish the patient’s experience from my own. Then I can communicate my understanding and be compassionate, to use my presence to relieve suffering and to put the patient’s interests first. (p. 836)

To emphasize the importance of listening, Dr. Nallapati believes (and there is much evidence to show) that 80% of making a correct diagnosis comes from the history obtained from the patient. The physical exam may provide another 15% and only 5% is the result of testing. Get the story wrong and the correct diagnosis will be missed. 

Meditation and Self-Knowledge

Jayram

Raj said that meditating has helped him tremendously in this endeavor to get things right. Though he was “always” interested in meditation and read books on it, only in the last ten years has he practiced it regularly. He has been greatly helped by his friend and colleague, Dr. Jayram Thimmapuram, an accomplished meditator and calming instructor. Dr. Nallapati said that meditation is “the most important thing in life.” (Let that thought sink in for a minute.)

His daily practice of about thirty minutes of mindful meditating has given him invaluable insights into himself as he tries to see things more clearly, to become aware, he said, of “the smell of your own rotten tooth.” By understanding yourself, who you are, you can avoid the dangerous traps of preconceived ideas and biases that lead us astray. 

As a follower of Hinduism, Dr. Nallapati believes in reincarnation; that our soul, our true self, survives the death of the body. He feels that the reason you are born is to “clean up yourself and prejudices” to be a better human being, to live a virtuous ethical life, and to accumulate good karma. And that you will be reborn again and again until you become enlightened and realize that you are one with God, the all-encompassing reality. 

Raj mentioned a book by Brian Weiss, “Many Lives, Many Masters” where people under deep hypnosis recalled previous incarnations. What happened in one life affected future lives.  (Evolutionarily, we are the product of the distant past and the source of what will happen next.)   

Some Random Thoughts

Speaking of books, when he was younger, Raj (are you ready for this?) used to read a 300- or 400-page novel every day. Now, even with the meditator’s steady focus, he doesn’t have the patience to make it through a whole book. Instead, he watches movies. His daily dose of cinema leans heavily towards dramas, especially the classics.

Dr. Nallapati is also a thinker. Looking forward, what does he see? He said that while the “standard of care”  of American medicine is “great” the access is poor and the cost in our “for profit” system is “outrageous.”  Both problems need urgent solutions. 

He worries that the push for a brain-computer interface, as currently championed by Elon Musk, will be “the end of mankind” as it will (have the potential to) “completely control humanity.” Raj feels, instead, that the true promise of modern medical technology lies in tapping the regenerative capabilities of the stem cell. 

But what about now? Dr. Nallapati told me that the most important indicator of “health” is our fitness, not the presence or absence of disease. He is concerned about the worldwide obesity epidemic and he is a proponent of home cooking and of eating “real food.” He believes that intermittent fasting, with long periods of ketosis, has major health benefits (especially as nearly all cancer cells depend on a continuous supply of glucose and can’t use ketones).

As we travel along the cycle of life striving to live ethically according to our true nature as revealed by meditation, and by engaging with others through mindful listening and sharing, we can discover, among other insights, the importance of kindness.

"Kindness" (excerpted)

by Naomi Shihab Nye  

Before you know what kindness really is/ you must lose things,/ feel the future dissolve in a moment/ like salt in a weakened broth…

Before you know kindness as the deepest thing inside,/ you must know sorrow as the other deepest thing…
Then it is only kindness that makes sense anymore,/ only kindness that ties your shoes/ and sends you out into the day to gaze at bread,/ only kindness that raises its head/ from the crowd of the world to say

It is I you have been looking for,/ and then goes with you everywhere/ like a shadow or a friend.

Reference and Recommended Reading:

1. Epstein, Ronald. "Mindful Practice." JAMA 1999, 282(9): 833-839. 

2. Hahn, Tich Nat. The Art of Communication. HarperCollins, New York, 2014.  (A photo of my worn and marked-up copy is above.)

Reservoir Park in the fall (Photo by SC)

By Anita Cherry 11/22/24
 

R. Eric Mathews, M.D., Internist and Avid Tennis Player: Always change a losing game.

 

Dr. R. E. Mathews

Dr. Eric Mathews was born in Baltimore in the late 1950s. His father was a mechanical engineer employed by the government and his mom worked as a secretary. They were both introverted. They had no social contacts outside of work and “lived like hermits.” There was no public entertainment for the family, very rare vacations, and almost no church attendance. During the hot and humid summers, the air conditioner remained unused. They were isolated as they lived “in the sticks.” Why would people choose to live this way? 

Eric explained that the constricted lifestyle of his parents was based on a suffocating frugality, the urge to “save every penny.” With a touch of irony, he said that “it was an interesting childhood.” For example, he recalled that his father handed him a pail full of bent nails and Eric’s job was to straighten them so they could be used again.   

Unlike them, athletic Eric was a “pretty outgoing kid.”  Until the fifth grade, that is, when his front teeth were knocked out during a basketball game. It was “a formative moment.” As he was ridiculed and called “snaggle tooth” he became uncomfortable in social situations and turned inward. This went on for a good while. 

High School

By the time of the unfortunate dental mishap, the family had moved from their rural spot to more populous Timonium in Baltimore County, buying the house with cash. Eric attended Dulaney High School where he “didn’t try very hard” at first, as he would rather concentrate on basketball and tennis. (His tennis partner was voted class clown; Eric “came in second.”)

Artist's rendering of Dulaney High (Credit: designcollective.com)

But in his senior year, when he took a class in medical biology “something went off.” He knew at that exact moment that he wanted to be a doctor. Maybe a pediatrician, he thought. He quickly became “pretty nerdy” and subscribed to (get this)  the “Morbidity and Mortality Weekly Report” sent from the CDC (it was free). He “gobbled up all the medical stuff” he could.  His parents approved of this change in their son’s interests.

For his senior biology project on artificial parthenogenesis (triggered reproduction without sex; no male of the species is required) in sea urchins he “made up most of the data.” You see, he was mad at the teacher for withholding an A for his work despite an 89.9 average for half of the year. 

College and Medical School

After high school, Eric went to college at the University of Maryland Baltimore County campus (UMBC). It was so cheap  ($649 a year)  that he could pay the tuition by giving tennis lessons. And, saving money, he could live at home and commute. Eric did well academically, but still thought of himself mostly “as a jock.” 

Retrieiver Tennis Complex at UMBC (Credit: UMBC)

Yes, Dr. Mathews admitted that he “was always kind of a maverick” and has had trouble with authority figures, including his father. One day, his dad, who was paid by the hour, told him to spend four hours to till a quarter of their vegetable garden. After Eric finished the entire plot in two his father sent him back for another two. This didn’t make sense to an independent industrious child.

Eric played #1 on the tennis team through college. And as a senior, he was “Academic Athlete of the Year.” Though he didn’t join the premed society (he didn’t fit in) he worked toward his goal of becoming a physician and he gained acceptance to the (relatively inexpensive) University of Maryland Medical School. Again, he could minimize costs by living at home and commuting. 

Famous Davidge Hall at the University of Maryland
Medical School(Credit: Acroterion)

While there, he still enjoyed playing basketball and kept up his (quite accomplished) tennis skills (in the late 1980s he hit with Jenni Goodling and Laura Glitz, both of whom competed at the Wimbledon Championships). He didn’t find medical school “that hard,” as he “really liked it,” and studied from morning to night and on weekends. 

During his training, as he thought about his future, he crossed off surgery (his hands weren’t steady enough) and OB/GYN (it had no appeal). He briefly considered doing pediatrics (but that was too tricky). As he discovered that “thinking about things” was what he liked most, he decided to do internal medicine.  Where would he go for that?

Residency

Eric had dated a medical student from York (a straight shot 40 miles north of Timonium) who was a year ahead of him, and he took a few outside rotations at the York Hospital. His experience was so positive that he chose to return to York in 1985 for his three-year residency. 

From Timonium to York (From Google; where else?)

He enjoyed working with his thoughtful and dedicated attending physicians (he specifically mentioned Drs. Jack Kline, Jay Nicholson, and John Carson). He became close with his fellow residents, especially Bob Clinton, Eric’s Best Man at his wedding.  (Bob, an oncologist, sadly passed away suddenly at 49.)

Dr. Mathews moonlighted in the ER during his residency. He greatly enjoyed the work and took a job there after he completed his internal medicine training.  (You didn’t need to have done an ER residency back then to man the ER;  in fact, emergency medicine wasn’t even recognized as a specialty until 1979).   

Lisa Enters the Picture

And yet, the ER wasn’t quite enough for Dr. Mathews who “wanted to be a real doctor.” While he was looking into joining a practice in Lewes, Delaware, where he could work and still play a lot of tennis, fate stepped in. Or, shall we say, it was a girl.

Eric and a buddy went to a local nightclub, Zakies.  As they were coming in, he spotted a pretty girl on her way out. He managed to say something to her like: “I think I just fell in love with you.” She continued on her way.

Dr. Mathews was back at the same hang-out a month later, as was the girl. He spotted her, eventually walked over, and they “talked for a few hours.” She was in the medical field (as a radiation therapy tech) and she enjoyed sports (she played, of all things, both tennis and basketball).  Eric quickly knew that “she’s the one.” 

After their first date, the girl, on the other hand, wasn’t quite so sure; she heard (from her hospital sources) that he had a “reputation.” But her kind boss, radiation oncologist Dr. Greg Fortier, convinced her to agree to a second date. She did, and Eric and Lisa were married one year later (in 1990).

After the Residency

The relationship kept Dr. Mathews from moving away for the Delaware job. Instead, he decided to join Dr. Barb Shute in the Hanover Hospital ER. He worked nicely with her until 1993. By then, he and his wife Lisa had two sons (they would later have one more) and as he needed to provide for the growing family he took a better-paying position at a Level 2 ER in Indiana, Pennsylvania (birthplace of actor Jimmy Stewart). In the middle of nowhere, there was little backup for a cerebral internist with a deft backhand, but almost no surgical skills.  

Main Street in Indiana, PA (Credit: Wikimedia)

At the time, Dr. Mathews also manned a very busy urgent care unit (seeing 65 patients a day) in addition to shift work in the ER. He did all of this for a year,  but there was a nagging sense that he wasn’t fully qualified for the job (especially as many acute emergency patients were simply flown to a tertiary care center).

When a car carrying a family of five was hit by a coal truck he decided it was time to make another move. He left Indiana and returned to Hanover in 1994 to do internal medicine with Dr. Hy DePamphilis (though they each had their own patients). Dr. Mathews had a full office load, took care of patients in the hospital (as one of only four internists on staff), made nursing home visits, and did house calls. He was very very busy.

The Stress Gets to Him 

And by 2001 he was “pretty stressed out.” He was “always worrying about something” concerning his patients as he was essentially “on call 24/7.”  Eric developed more and more trouble sleeping as his mind was constantly going, and after “two weeks without sleep” no matter how he tried, he turned to sleeping pills.  

He began using the benzodiazepine Restoril regularly. It helped at first, but he soon needed increasingly higher doses. This went on for some time, and as Dr. Mathews continued to have painful insomnia despite that, he began taking Ambien (not a benzodiazepine, but still potentially addictive). He eventually overused this as well, and when he abruptly ran out of pills he had a withdrawal seizure. 

He got some help but continued to have sleep issues. He tried to solve the problem with a wide variety of non-addicting non-controlled medicines. But to no avail. And after a second seizure (this time a direct result of high-dose medication, not withdrawal), and a painful family intervention, he finally got the help he needed through the Pennsylvania Physicians Health Program (PHP).

The PHP is designed to rehabilitate (literally, "to make fit again") physicians with substance abuse, mental health, and/or behavioral concerns. Dr. Mathews willingly took part in the residential program and “came back a different person.” He told me that it was “life-changing.” He had always felt that “someone” was looking after him, and this experience cemented, solidified, that notion. After that, he no longer had sleep problems, and has no interest in taking pills. 

After Rehab

Thus, Eric was able to return to his patients. After staff members had left, his wife stepped in and helped run things. It “was fun” and “more profitable,” he said. For years, he had a stable “closed” practice of people he cared deeply about (and who cared about him), and he was content. 

But, in time, the use of a government-sanctioned electronic health record (EHR) was being pushed on physicians. The high cost of implementing one for a small office such as Eric’s seemed unreasonable, despite the incentives. So, after two decades in private practice, cost-conscious Dr. Mathews decided to give in to economic pressure and join a regional health system. 

Busy screens that demand attention (Credit: Britannica)

They took over his practice with about 6,000 patients who were his “buddies.” One of the rules was that you could not work with your spouse, so Lisa had to go. And Eric had to learn to use a clunky and buggy EHR system in a day or two.  

Flummoxed by the computer, Dr. Mathews relied on his paper charts when seeing the patients and tried his best to enter the stuff into the EHR when he got home at night. But the system was frequently down and he was often up until one in the morning getting the work done.

Six weeks into the practice, his invaluable paper charts were sent away to be scanned; he would have to make do with a few bits of information clumsily abstracted from his carefully organized records. 

A Quick Decision

When he was to see a man with a routine cold he was allotted five minutes for the visit. The (temporarily uninsured) patient (who adamantly refused to go to the hospital) had type 1 diabetes and was in florid ketoacidosis, a complex acute medical emergency. It required time and skill to address as an outpatient. The office manager soon knocked on the exam room door, peeked in, and told Dr. Mathews he was spending too much time with the patient.

His response? (In tennis, Eric’s game, you keep your eye on the ball, quickly size up your opponent, and always change a losing game.) “Here’s what I’m going to do. I’m going to finish this week, and then I’m done. If this is what medicine is nowadays, I’m done. I quit. I’ll be here until the end of the week” So Dr. Mathews left the practice less than two months into his contract. 

The agreement with the system included a “restrictive covenant.”  So, to provide for his family, Eric was forced to leave his long-term patients (his “tribe,” added his wife) and find a place to work that was more than 32 miles from his former (but brief) employer. 

Patient First and Family First Practices

He bent the rules somewhat and found a suitable job at a free-standing walk-in facility in East York, Patient First Primary and Urgent Care. It was “kind of fun” for five years. And, importantly, staying in the York-Hanover area allowed his three sons to finish high school and go off to college.

The distinctive green Patient First office in York (Credit: Patient First)

At that point, Eric’s father and his wife‘s dad were both in assisted living facilities and were (in his wife’s words) “miserable.”  So Eric stopped working and he and Lisa took their fathers into their home and cared for them for about a year and a half. After his dad passed away and her father needed skilled nursing care, Dr. Mathews would resume his winding career.

By then, he told Lisa that he wanted to go to an Indian Reservation to get away from administrative work and to help people who needed him. His wife convinced him that he could give back locally. She suggested he look into Family First Health, a well-established federally qualified health clinic she often drove by on her way to work. 

He did and saw that they were looking for physicians. They had several practice locations and Dr. Mathews told them he would “go anywhere except Hanover.” They (of course) sent him to Hanover. 

Family First Health (Credit: FFH)

Working there turned out to be an “awesome” and “rewarding” experience. However, their somewhat haphazard charting “didn’t make a lick of sense” and Eric spent a lot of time fixing that problem.  

As he listened to many harrowing stories from his often disadvantaged patients he saw that these poor and traumatized people were just “trying to make it.” He realized that taking care of “disasters” who were (in his wife’s words) “broken” was what he did best, and was the reason he was here.  He felt fulfilled, and he worked there until he retired recently. 

(Lisa added that Eric had the support he needed to be able to practice medicine his way.)

Retirement

Since Dr. Mathews and his wife liked to go “everywhere” to learn about different cultures and meet new people, and more travel was the plan on his retirement. But their needy dog Max (whom my husband and I met as they walked him through Reservoir Park one hot afternoon) has made that a little tricky. In addition, Lisa’s “as needed” work became almost full-time (since they were understaffed).

Early morning at Reservoir Park (Photo by SC)

As Eric and his wife traveled as a family they tried to show their three sons “the world outside of York,” the real world. And they limited the time the boys spent with technology. Eric would sometimes say, “You guys are on the computer too much; here’s a ball, take it outside and throw it back and forth to one another!” Indeed, the whole family carefully avoids the insidious trap of so-called “social” media. 

Dr. Mathews, among other things, still plays high-level tennis, reads (he just started a translation of the Bhagavad Gita), and enjoys birdwatching (when I sent him a first draft of this for his review he and Lisa were in Maryland doing just that). 

Concerns

In this highly tech-influenced world, Dr. Mathews is very concerned about the future of medicine. In fact, he (not one to mince his words) thinks it’s “terrible.” He is worried about the quality of the training of physicians, and he worries as he sees doctors being replaced by Physician’s Assistants and Nurse Practitioners who are often left all alone, unsupervised. He believes having the computer in the exam room “completely ruined the doctor-patient relationship.” And he witnessed what he considered avoidable “mistake after mistake” (for which there are many sources) in urgent care settings.   

Causes for unsafe acts, including errors
(From rushem.org)

For example: His 97-year-old mother (who walks five miles a day!) called him one morning about six months ago because she "couldn’t feel" her left side. He took her to the hospital and she stayed overnight.  Nothing was found. When Eric showed up to take her home, as planned, he discovered that she had been discharged. There was apparently no attempt to notify him.

Another example: His wife’s mother (on hemodialysis)  went to the ER recently with Covid-19. Dr. Mathews was appalled by the perfunctory fragmented care she received while there ("Do you have a cough? I will send you for an x-ray,").  He had to intervene (with leading questions) to prevent misuse of an inappropriate antiviral.

And he is shocked and dismayed by the cavalier and uniquely American direct-to-consumer advertising of medicines, especially for the latest targeted cancer treatments: ”Ask your oncologist about…” He is troubled that primary care often seems to have come down to “What organ is involved?” and “Who do you send the patient to?”

And in The End...

Looking back, after years of experience in various forms of medical practice, it was with Family First that Dr. Mathews felt that “this” was what he was put here to do, that “this” was what he was supposed to do. Sometimes it was “train wreck after train wreck,” but he tried to figure things out. He was struck by the remarkable resilience of people who had suffered so. 

And it was during the year and a half that Eric left medical practice to take care of his ailing father that he was finally able to be close to him; growing up, his stern father was not ” touchy-feely.”  When with his dad at the end, there was no complex computer screen competing for attention and no mandatory guidelines to mindlessly follow. There were just two men together, trying to do the best they could. 

Thank you, Eric, for showing me the way. Set and match.

Suggested Readings:

1. Easwaran, Enkath (trans). The Bhagavad Gita (second edition). Nilgiri Press, Tomales, California, 2007.("At the beginning, mankind and the obligation of selfless service were created together." 3:10, p. 105.)

2. Murthy, Vivek N., M.D. M.B.A., "Healthcare Worker Burnout and Well-Being." New England Journal of Medicine 2022, 387: 577-579. ("Burnout manifests in individuals but it's fundamentally rooted in systems...Causes include inadequate support, escalating workloads and administrative burdens...and moral injury from being unable to provide the care patients need.") 

3. Saddicha, Sahoo. "Diagnosis and treatment of chronic insomnia." Ann Indian Acad Neurol 2010;13:94-102.(Behavioral measures are much preferred to using pills, but are not always enough.)

4. Tilden, William T. (Champion of the World). The Art of Lawn Tennis (second edition). Methuen & Co. Limited. 36 Essex Street, W.C., London, 1921. ("Fully 80 percent of all errors are caused by taking the eye from the ball in the last one-fifth of a second." And: "One can only control one's mental processes after carefully studying them; pp.8 and 48.)

By Anita Cherry 9/22/24

Watchful Great Blue Heron
Clearwater Beach 2019 (Photo by SC)