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)

Dr. Tex Landis: The Importance of Being Earnest

 

Dr. Landis

The highlight of Tex’s day in college was peering through the small glass window of his box in the mailroom and finding a handwritten letter from his girlfriend back home, a thousand miles away. She wrote to him nearly daily; he replied about once a week. He was busy, and trying to find his way in the world. 

His father (William Landis) served as a flight surgeon in the military so the family moved around a lot. They were in Texas when he was born. Christened William, he immediately acquired the nickname “Little Tex.” The family can trace its roots in Lancaster County, Pennsylvania to the  1700s. So after spending time in Texas, they returned north to settle in a rural farming community outside of Marietta. Tex recalled that “you couldn’t see any neighbors” then. But there were streams to explore and plenty of interesting animals for a young boy with a curious mind to watch and “rescue.”   

He was happy. But when he was in the fifth grade someone had the nerve to build a house across their field, blocking his grand view of the natural world. How close was it you ask? It was nearly a quarter of a mile away; maybe within hollering distance, if the wind was just right. Tex was peeved.  

Lancaster County landscape (Credit: Wine-Searcher.com) 

But it wasn’t as bad as all that. You see, the man and his wife had two daughters and the younger became the letter-writer, and then Tex’s wife. So what seemed at first to be not so good became “one of the greatest blessings.”  Interesting lesson learned.  

Dr. William “Tex“ Landis told me he is very grateful for the people in his life, particularly his parents and his wife Desi (who sat next to him during our interview). His quietly stern father wanted his son to be bigger, tougher, and stronger than he was. His mother was unfailingly supportive. Together, they set safe boundaries for their four children (with four dogs) on the five-acre farm. 

As noted, Tex found particular pleasure in tending to wounded or abandoned animals he might come across. The list included a sparrow, a crow, a few rats, and even slithery snakes. His first job (at age 12 or 13, and for 25 cents an hour) was in a pet store. He liked the work and even thought he could have a career maintaining aquariums.

But it was not all nature. The house was full of books, and Tex would often pick out a Time-Life volume to read in bed. He did very well academically and dutifully learned to play the violin and (the ever-popular) clarinet. But he “lived” for sports, especially soccer and wrestling. He was pretty good at both, and they were formative; soccer taught him the importance of teamwork and wrestling gave him confidence and taught him to seize an opportunity (to make his “move”) when it is presented (since the steadily-ticking time clock might run out before he’s offered a second chance).

High School  

His 1975 Donegal High School wrestling team was undefeated and he lost only two matches. He is remembered (even 50 years later) for his quick recovery from a misstep that could have been terribly embarrassing. As he ran out to the center of the mat his foot caught the mat’s edge and he nearly fell face forward. But instantly, and without conscious thought, he did a flip and landed securely on his feet. Everybody watching was impressed; Tex was relieved.

A few "interesting" wrestling moves and holds-ouch! (Credit: scientificwrestling.com)

But let’s get back to Desi. Early on, young Tex wasn’t interested in either of the neighbor’s girls when they came over to skate on the Landis’s frozen pond or to swim in the pool. But by his junior year in high school, things looked different. At 16, in his underpowered 1951 Chevy pickup (that struggled to climb steep Chickies Hill Road by the Susquehanna River), he asked Desi for a date; would she go to the prom with him?  She accepted, of course, and their romantic relationship began. But it was soon time to decide on a college and a possible career.

At that point, Tex was still interested in pursuing marine/aquarium work and was still intensely sports-oriented. He realized that there were, as he said, some “dysfunctional” elements at home ( his successful family-physician father liked to drink) and he had to get away to grow. 

College

He decided to go to the Florida Institute of Technology (Florida Tech) in Melbourne. He would study biology. Maybe, he thought, he could even play soccer as a “walk-on.” 

Things were shaky at first. Tex drove down to the school in his Vega and briefly lived in the small car until he found a place to stay. The school’s admission policy was very liberal but the coursework (designed for nearby NASA scientists) was demanding and only 36 members of his freshman biology class of 300 graduated. As in high school, Tex was driven to excel, deciding not to settle for anything less than an A. He put his mind to it, worked hard, and finished at the top of the class. 

Olin Physical Sciences Center at Florida Tech (Credit: newsfit.edu)

(Why did he push himself? Tex innocently recalled that his drive to be the best “wasn’t discouraged” by his parents. His wife, as a somewhat more objective outsider, rather saw that it was “strongly encouraged.” Rashamon, once again.)

Questioning

Yet Tex craved more than worldly academic and athletic success. At 18, that critical time of questioning, he was thinking deeply about who he was, where he was going, and what might be his purpose in life. A key moment, perhaps “the key moment” in this quest occurred when a friend spoke passionately of the Bible and Christian Faith. This resonated with Tex and he eventually felt a strong need to “believe the Bible and to trust God.”  The beginnings of a maturing spiritual faith, the internal mandate that would guide his inner life.

As Tex studied the sacred texts, especially the succinct ethical sayings in the "wisdom" book of Proverbs, he realized that "serving God through serving others was a noble cause.” Actually “the cause.” How that might play out for Tex would take time; despite much success in college and finding the recognition he sought he still lacked a clear direction.  

As he made his way through his studies he began to feel that God was truly looking after him and protecting him. He liked “biology stuff” and his bio mentor asked if he ever thought about medical school. Tex reflected on his father’s work and saw that it was good. So he decided to pursue a medical career of his own. He took the few additional required courses and applied to medical school. He was accepted at the University of South Florida in Tampa while still in his junior year.

University of South Florida Medical School (Credit: health.usf.edu)

He proposed to Desi over Christmas during his senior year in college and they were married a week after graduation in June 1979. When Tex entered medical school ten days later, he and Desi “had nothing” (not even a kitchen table) but they were happy. She worked to support them while he studied and they had “enough to survive.” 

Medical School

During his intense three years of medical school (no summer breaks), Tex played intermural soccer for a while, but the rest of his time was “totally about study.” Again, he pushed himself and yet he was surprised when his friends told him that he, once more, graduated at the top of the class. He had enjoyed general hospital work and the challenges of the ICU and decided to pursue a career in internal medicine.

His advisor (who did not know him at all) didn’t like his plan to look at community as well as academic programs for a residency, and firmly recommended he stay at the University. Desi’s family was “relational” (Tex’s was not) and since both families resided in Pennsylvania Dr. Landis decided to leave Florida do his internal medicine training close to home.

As he looked at community programs in York and Reading, and at Geisinger, and the academic programs at Jefferson and Penn, he wanted to find “the best director.” By that time, Tex had learned that who he worked with became the most important factor in his education. The people were decisive.

Reading Hospital (the way it was) (Credit: Tower Health)

When he met with the illustrious, humane, and humble Dr. Eugene (Pat) Hildreth in Reading Tex knew he had found what he was looking for. Dr. Hildreth (as my husband, who was also trained in internal medicine in Reading before studying neurology, reminded me) surely had an unmistakable strong moral presence.

Residency and a Scare

So Tex began his General Internal Medicine residency in West Reading in 1982. He (like many other eager trainees) sought to emulate, to, in a sense, imitate, “The Chief” at first, but eventually (as others did before him) found his own style. Dr. Landis remarked that he was “extremely” influenced by Dr. Hildreth. And he liked the idea of being a general internist, treating the whole patient, rather than specializing in one organ system or discipline.

According to the American College of Physicians (of which Dr. Hildreth served as president, one of his many prestigious leadership roles): "Internal medicine physicians are trained to handle the broad and comprehensive spectrum of illnesses that affect adults, and are recognized as experts in diagnosis, in treatment of chronic illness, and in health promotion and disease prevention.”

In his third year of the residency, Desi (who already had a daughter) became pregnant again. But in the seventh month, she was at home when her water broke, the protective amniotic sac ruptured. At 32 weeks, it was a bit too early to deliver a baby safely since the so-called artificial surfactant that would help the immature lungs function better wasn’t available yet. Desi needed to be rushed sixty miles to Hershey Medical Center where they could do the delivery and take care of the fragile preemie.  

Hershey Medical Center (Credit: OnwardState.com)

Aware of the seriousness of the problem, Tex (who was working) left the Reading hospital and headed to Hershey to meet his wife for the birth. Losing the usually calm demeanor that he had when tending to critically ill patients, his heart pounded wildly as he imagined the worst, the potential future health issues. 

He drove as fast as was safe, but it wasn’t helpful; the baby came into the world in the ambulance on the Pennsylvania Turnpike. When he got to Hershey his newborn daughter was in the NICU on a ventilator. Things were quite rough for a while. But Tex found that simply talking with the neonatologist immediately calmed him. Another lesson; the anxiety and fear that inevitably accompany illness can be softened by compassionate empathic communication.

(Tex and his wife were reluctant about having a third child but their obstetrician in York, Dr. Leslie Robinson helped them work through their fears and all went well. However, his faith was severely tested–but sustained him–when, years later, his first grandchild died shortly after birth. This was, he said, “the saddest day” of his life.)  

Dr. Hildreth

Tex chose to stay in Reading for a fourth year as Chief Resident. The one-on-one mentoring relationship he enjoyed with Dr. Hildreth (whose patients he managed while Dr. Hildreth was away) greatly boosted his confidence in his abilities as a physician. And, foreshadowing things to come later in his career, his experience managing other physicians, learning what it meant to be a leader, was “rewarding and challenging.”

After that, Dr. Landis hoped to stay in Reading for practice but there were few good opportunities. While deciding what to do, he got a call from Dr. Ben Hoover in York. Would he like to interview for an unexpected opening for a partnership position with Brockie Internal Medicine? Tex was interested. He was suitably impressed by Dr. Hoover, liked the idea of becoming a partner rather than an employee, and joined the group. 

(Over the years, he learned a lot from Ben about taking care of patients as people, but also about the business of a thriving medical practice.)

Practice and Another Scare

With his Brockie partners, he did 75% inpatient work at the York Hospital (managing patients on the general floors and in the ICUs) and spent 25% of his time in outpatient practice (office, nursing home, and home visits). Dr. Landis cultivated an easy rapport with the busy ER physicians who called him in to admit patients. He was tireless and enjoyed the increasingly heavy and complex workload. Yes, he kept a positive attitude when his spirit could have easily been tested as the stresses of the ever-larger inpatient practice mounted.

But there was another more important test. When Desi was 37 she had a suspicious breast lesion. After it was biopsied, Tex reviewed the tissue slides with the pathologist. The lesion was a cancer. He came home prepared to tell his wife. As he hugged her tightly he could hear their hearts beating together; without words, she knew the ominous result. Tex had to devote more time to his family and a bit less to his career. The painful experience helped him become a more sympathetic (and empathic) physician. And a better husband, and father. 

New breast cancers by age; noting the need for earlier screening
(Credit: National Cancer Institute)

Back to the practice with Brockie. The inpatient demands were balanced by the less-stressful and more personal outpatient work. This part of the practice was emotionally rewarding for nearly 20 years as Dr. Landis developed warm friendships with his patients, and he and they experienced mutual abiding trust. But running back and forth from the office to the hospital (though it was only three traffic lights and less than a mile away) became cumbersome, especially as caring for the patients became more complex, highly technical, and increasingly time-consuming.  

Trust

Regarding the importance of trust in healthcare settings, Tex told a brief personal story in which it was abruptly lost. His wife had seen a specialist for heart problems. There was a significant abnormal finding on the CT scan. This was not addressed during the visit, even after direct questioning. No explanation for her symptoms was found and she was sent on her way. 

The official record of the encounter included a detailed physical exam, an exam that Tex knew was not done. Dr. Landis could no longer trust that physician with his wife’s health; he sought a second opinion for her problem. He is discouraged by the increasing lack of trust he sees within our health system. 

What are the elements of trust? In a 2023 article in The Hospitalist about building trust the writer notes that “trust consists of a belief that a person will behave in certain ways; an abstract attitude toward a proposition that someone is dependable; and a feeling of confidence, reliance, and security that the other person cares. And that to trust someone is to become vulnerable and dependent on the other person’s intentions and motivations.”  And that “as difficult as building trust can be, it comes down to two simple things—listening closely and caring about others.”

Hospitalists

By 1996, as an answer to the technical difficulty of tending to sicker and more complicated patients in the hospital while maintaining an efficient office practice in the era of so-called managed care (actually managed payment), the term “hospitalist” was coined. A general internist could decide to be a hospital-based specialist, with a full career devoted to doing complex inpatient medicine.  

The new idea caught on quickly in both community and academic centers. A ”large nationwide study of over 3,600 hospitals in 2005–2006 found that hospitals with hospitalists had higher quality of care in terms of diagnosis, management, and counseling/prevention for three common inpatient conditions: acute myocardial infarction, congestive heart failure, and pneumonia,” (Kulkarny and Wachter, 2024). 

Hospitalists have been active in teaching roles, in taking care of patients without housestaff, and in broad leadership positions developing diagnostic and therapeutic protocols and guidelines, and in enhancing communication among the increasing number of individuals involved in a patient’s care. Good communication, Tex emphasized, is vital, and a skill that can be learned; it requires sharply focused and sustained attention and awareness. And a commitment to getting it right, through practice.

As Dr. Landis foresaw the coming hospitalist movement he embraced it fully and became one of the first dedicated hospitalists at the York Hospital. The novel position was soon accepted by the general staff. In time, Dr. Landis took on more responsibilities. He served as the Medical Director of the WellSpan Hospitalists and in this “challenging” leadership position he managed 120 practitioners across several hospital sites. Expectations were high and could not always be met. But Tex has had an enduring belief in the still-evolving project.

Stepping Down 

By 2017, his full-time position (the highest clinical post in WellSpan) took a toll personally and professionally and (with a successor in place) he stepped down from his directorship. Tex has continued to fill in by doing strictly clinical work when it’s needed. As a result, he now has much more time to spend with his immediate and extended family.  And as he and Desi sat at the Thanksgiving table with ten members of their family Dr. Landis realized that “everything that was really important” for him was “right there, and the best thing” in his life. 

(Incidentally, before I send these tales out into the world the doctors profiled review them. My hope is that there is enough trust between us to allow the stories to be told faithfully and with compassion.)  

References and Selected Readings:

1. Collins, Thomas R. "Rebuilding Trust: A Top Priority for Hospitalists." The Hospitalist, November 14, 2023

2. Kulkarni, Shradha A., and Wachter, Robert M. "The Hospitalist Movement 25 Years Later." Annual Review of Medicine, Vol75; 381-390 2024.

3. Maxwell, John C. How Successful People Lead; Taking Your Influence to the Next Level. Center Street, New York, 2013. (Tex was influenced by Maxwell's popular teachings.)

4. Allport, Gordon W. The Individual and His Religion: A Psychological Interpretation. The Macmillan Company, New York, 1950. ("It is religion's peculiar secret that it brings to the individual a solemn assurance unlike anything else in life, an ever-present help in trouble, that makes next steps easier no matter what mesh of circumstances may entangle the life." p. 158)

By Anita Cherry 7/28/24

Toby (2010-2024)

Dr. Todd Butz Sometimes Gives His Sheep Animal Crackers with Their Grain

 You are here for a reason...  

                                                                102-year-old Holistic Physician Gladys McGarey, M.D.

Todd Butz, M.D.

Todd began life in a small rural town on the outskirts of the borough of Marietta in Lancaster County. The girl who would become his wife, Barb (seven years younger than him), lived about a mile away “as the crows fly.” His parents and her parents had purchased land from the same local farmer. And though one of his brothers was best friends with her brother, Todd didn’t meet Barb until he was already practicing medicine. 

This happened in 1994 at a 150th-anniversary banquet for their Catholic church. Todd’s mother had insisted that her four kids (including Todd’s two older brothers and his younger sister) attend, and  Barb was there. She and Todd married three years later.

 Dr. Todd Butz told me that he has been “fortunate, lucky, and blessed” as he had a lot of good people in his life and great parents. His father (in the family sign business) was of quiet, stoic German stock, while his mother (an R.N.) was an animated and passionate Italian.   

He believes that “creativity is what life is about” and early in his training he combined German technical insight and Italian passion with his family’s interest in sports to invent a unique exercise machine. It is worth telling this story in some detail.

You see, Todd was doing a Sports Medicine fellowship with Graduate Hospital in Philadelphia when he had a “crazy idea.”  He imagined a device to exercise “the torso” as he felt swimming did. Something to work the abdominal, hip flexor, and lower back muscles. Something that would allow for a prolonged session at a moderate aerobic intensity.  

He dreamed up a contraption that he called an ABDO-Cycle. You sat in it and it used a weighted flywheel with steady resistance to permit the user to perform repeated abdominal crunches and back extensions for minutes at a time. 

Barb on the ABDO-Cycle

Todd spent years (and a lot of money) on his idea. He tried to do the patent work himself but had to get an attorney (who charged him $10,000 to eventually use many of Todd’s own words). A friend’s father, an entrepreneur, helped him find an engineer to build a prototype. But the investor wanted substantial equity in the (proposed) company and Todd didn’t like that idea. 

Time passed, and after a prototype was finally fabricated, he decided to shop it around himself. A professional and talented graphic designer (it was Barb) produced a finely detailed brochure complete with a model (Barb, again) using the machine. The major fitness companies nibbled but didn’t bite. Dr. Butz said that he learned a lot about life from this experience. More than he learned, he noted, from college. 

(The model--the machine, not the girl–still resides in his attic. The girl is in the house proper.) 

It is not surprising that Todd’s creative drive would result in a piece of exercise equipment since he was part of a sports-oriented family. His dad had played football at the University of Florida and Todd and his brothers were in all the usual team sports from a young age. 

His mother (though not an athlete herself) was a fierce motivator (and a pretty good cook). He said that while she wouldn’t put direct pressure on him to do things, or to perform, she had her way. For example, he can still hear her saying (when he was away in medical school), “We have supper on Sunday and I made a lasagna and two dozen meatballs.” He knew what she really meant, and he could hardly fail to show up.

So after a childhood wrapped up in team sports and with no particular academic direction, Todd decided to go to the University of Delaware for football. While there, he first toyed with the idea of being an athletic trainer or a physical therapist. But when he watched the team doctor on the sidelines he decided to aim higher. 

University of Delaware football field (Credit: University of Delaware)

So he quietly squeezed in the needed premed courses. He didn’t tell anyone about his lofty goal until he was accepted to Hahneman and was on the wait list at Thomas Jefferson Medical College, both in downtown Philadelphia. 

Where should he go? He took advice from his knowledgeable football coach (who became a cardiologist). Todd waited a bit, got in to Jeff, and joined the coach, Joseph Bering, who was already there, two years ahead of him. 

He initially loved it in Philadelphia. But after two years of studying the basic sciences in the middle of a busy noisy city, he missed the peaceful countryside. So when he took a few clinical rotations at Geisinger Hospital in Danville in rural Northeast Pennsylvania, he was comforted by the calm environment, where he could see “cornfields and sunsets” again.

Sunset and cornfield (Credit: SimonSkafar)

During medical school, Todd’s evolving interests in sports, exercise, and preventive medicine led him to take an enlightening rotation with the famed Dr. Kenneth Cooper (who coined the term “aerobics” in 1968) at his clinic in Dallas. Dr. Cooper (who still works out five times a week at 93) was onto something that resonated with Todd.

Dr. Maddrey

Back in Philly, looking for a career path, Todd methodically crossed off one specialty after another (“Not this, not this…”). He finally settled on internal medicine, maybe cardiology. When it was time to look for a residency the Chairman of Medicine at Jefferson, the illustrious liver specialist Dr. Willis Maddrey, urged him to stay there for a life in academics. But Todd didn’t want that, he wanted to move back home.

In 1990, Lancaster (quite close to home) only had Family Medicine programs, so he ventured a bit farther away and looked at York Hospital’s Internal Medicine residency, York would be okay, still less than an hour’s drive from his home. 

As soon as he visited, he was impressed. He loved the congeniality as the doctors and nurses talked to one another face-to-face instead of communicating coldly on the patient’s chart, as they did in Philly.

Instantly comfortable in this atmosphere he thought, “This is where I want to be."

Todd had a happy experience as a resident. He believed he had outstanding training with a long list of wonderful physicians as he took specialty and general internal medicine rotations. (This was when almost all the attendings taught on a volunteer basis and gave freely of their time despite busy private practices.) 

After three years in York, Todd’s interests led him to the one-year Sports Medicine fellowship with a Graduate Hospital affiliate on the Main Line near Villanova. The staff at the large center served as the team doctors and therapists for the Phillies, Eagles, Flyers, and 76ers as well as Villanova athletes. They also did executive physicals, stress testing, and cancer screening. 

At the end of that year, Dr. Butz was again offered the option of staying in the Philadelphia area but chose to return home instead. (By the way, he had not yet met Barb.)  

Dr. Landis

What could he do? Thinking outside the box, he had an idea for a position in York. Over a steak dinner, he and Dr. William “Tex” Landis of the Brockie Internal Medicine group sketched the plan on a napkin. From his experience as a resident, he knew the practice and the physicians well. He proposed (that is, invented, created) a brilliant role for a single guy: he would admit and manage the Brockie patients (including new patients coming through the busy ER) at night. 

This would allow the overworked internists who were running back and forth from the office to the hospital and taking night-call to count on getting regular sleep. The idea was accepted, and Dr. Butz did this full-time for five years. And it was during this nocturnal phase of his career that he met and then married Barb.

But as the night schedule became too stressful to maintain, and thinking ahead, he had other plans. So in 1999, he went half-time with the enlarging WellSpan system and started a preventive medicine clinic across the river near Lancaster. At that time, before the Affordable Care Act changed things, preventive services, he noted, were generally not covered by insurance.

He did stress-testing and calculated VO2max (how much oxygen you can use during exercise) using Dr. Cooper’s data, and other stuff like that. Nearly 25 years ago, Dr. Butz counseled interested people on the importance of a balanced diet and regular exercise. He advised them to stop smoking, to get enough sleep, and to be better at managing life’s inevitable stresses. 

Todd thought that it was “crazy” that “we wait for people to get sick and then pump them with pills.” He knew that prevention of illness was a much saner approach to long-term health. Dr. Peter Attia, writing in his 2023 bestseller Outlive, calls this (not so new) idea “Medicine 3.0.” 

(In his book, Dr. Attia carefully explores the best science and emphasizes the age-old appeal of a personalized nutrition plan to prevent cardiovascular disease and diabetes and the complications thereof. He is especially enthusiastic about the remarkable ability of regular aerobic activity and strength training to delay the onset of a wide variety of diseases and to meaningfully extend our “healthspan,” not simply our lifespan. And he eventually recognizes that achieving emotional health often requires prevention.)  

While Dr. Butz was a resident, he had given a Grand Rounds presentation to the staff entitled (quoting a phrase often attributed to Hippocrates around 2,500 years ago) “Let Food be Your Medicine.” He is still keenly invested in this idea and feels that “we do best on fuels that our remote ancestors ate.”  

As we sat and talked, Todd mentioned the decades-long “Seven Countries Study” spearheaded by Ancel Keys. First published in 1978, the observational study of middle-aged men was started in 1958 near the height of the heart disease epidemic. Serum cholesterol, blood pressure, diabetes, and smoking were clearly seen as risk factors for coronary disease. And it suggested that certain dietary patterns played a role.

Location of cohorts (often in villages) in the 7-Countries Study

The nutritional aspect appeared to be the amount of saturated vs. unsaturated fat in the typical diet. The countries with a lot of saturated fat in the diet (e.g., Finland) tended to have way more heart disease than those with much less (i.e., Japan). Part of the war on heart disease became a war on saturated fat and cholesterol in the diet.

So as we became increasingly health-conscious and weight-conscious, we became fat-conscious. And in the 1980's the American food industry responded. Since saturated fat was “bad” they would use sugar to replace it in prepared foods and snacks to keep them tasty (and to keep us buying). 

We ate less fat. But a lot more sugar. Yes, a lot more sugar. And as we took more of our calories as “added sugar” (most often in surgary drinks) we ingested more calories overall. The prevalence of obesity and type 2 diabetes nearly doubled from 1980 to the early 2000s and has continued to rise. We became fatter and sicker, rather than thinner and healthier.  

The shocking increase in obesity from 1987 to 2021 (Credit: CDC)

What happened? Table sugar (sucrose) is 50% glucose and 50% fructose. Glucose is used immediately as fuel. Fructose is metabolized differently than glucose and if it is excessive it is stored as fat (to survive a cold winter with sparse food supplies). It is put away first in muscles, and then in the liver. Too much eventually leads to insulin resistance, diabetes, an increase in LDL and a decrease in HDL cholesterol (made in the liver), elevated triglycerides, and chronic inflammation.  

Part of the problem for us is that sugar is enticing and rewarding, and, therefore, potentially addicting. It produces momentary pleasure, a desire for more of it, and uncomfortable withdrawal symptoms when it is no longer available.  As Gary Taubes states in (probably rightly) calling sugar a drug of addiction: it makes children happy, at least for the period they’re consuming it…(but the) downside is that they “will come to expect another dose, perhaps to demand it on a regular basis.” (p. 31) We get hooked early.

(A childhood memory: Uncle Sol sold candy. I looked forward to his visits and I can recall the excitement at seeing the long thin red licorice “shoelaces” or “lariates” he brought with him. I twisted, braided, and knotted them in anticipation of their chewy sweet taste. The pleasant sugar high was soon followed by a disheartening letdown; I wanted more. I knew early on that sugar affected me strongly and I gave it up nearly altogether in my teens, in the early 1970’s.)

(Don't they look good?)

Dr. Butz said that the massive decades-long Keys study can be criticized for “cherry-picking” the data (leaving out countries that were initially to be included, 20 countries in total) and ignoring or downplaying the role of high sugar intake in heart disease. 

The truth, said Todd, is that no correlation could have been established between fat consumption and heart disease if the data from all 20 countries were used.  Nevertheless, Keys and his colleagues championed a diet low in saturated fat to combat heart disease (by lowering, it turns out, the all-important serum LDL cholesterol). The possible role of too much sugar and simple carbohydrates was ignored.  

Anyway, enough about sugar. Let’s get back to our main subject, Dr. Butz. He ran back and forth to his Lancaster clinic for three years until the commute became too much for his soon-to-be growing family. So, for their protection, he put his preventive medicine practice and the soaring ABDO-Cycle dream away and took a hospital position with good benefits.  

Dr. Van Wyck

As Todd returned to WellSpan full-time in the fall of 2002, he helped Dr. Rita Van Wyck do inpatient medical consults for the psychiatrists (where he learned a lot about mental health). And as the local family practices were one-by-one bought by the system he helped Dr. Douglas Rubelmann admit patients from the different groups. He also did some moonlighting for the Brockie physicians who had been greatly disappointed when he left his night-coverage position with them. 

Recounting this part of his journey, Dr. Butz told me, with a quick laugh, that he “seemed to do the things that other people didn’t want to do.” And he quickly added that he likes new challenges.

But over the years, the easy fellowship at the hospital that so impressed him began to erode. The expanding health systems became more corporate, industrialized, and impersonal. Todd said that doctors are, by nature, independent. So they were easy isolated targets, sitting ducks, as the art of medicine was lost to a business with multiple layers of managers setting and enforcing policy. Physicians gradually became “disengaged.”

Morale declined, so that simply walking through the hospital corridors became a gloomy experience. Dr. Butz recalled one of the corporate solutions: the 5/10 rule, a take on the “Ritz-Carlton 5/10 Way” designed to improve customer satisfaction. 

The idea is simple. If you are ten feet from someone in the hospital you make eye contact and greet them with a smile. If you are within five feet you smile and say hello. Mandated civility to improve the bottom line, sort of like a high-end hotel.

So Dr. Butz took on a new challenge in 2014 after Dr. Jonathan Whitney asked him to help with so-called case management as a physician advisor. In the late 1990s Medicare and private insurance companies, to reduce spending on healthcare overall, labeled some in-hospital services as “outpatient status.” They could reimburse the hospital much less for this than the same service deemed as “inpatient.” There had to be a clear justification for “inpatient status” or such additional payments would be denied. 

According to a 2016 Report on Medicare Compliance newsletter:

To comply with the two-midnight rule (for a justified admission), Todd Butz, physician adviser at WellSpan Health in York, Pa., is trying to get physicians on the same page, free of considerations that are beside the point. That means placing patients in observation or admitting them as inpatients because that’s the appropriate level of care, regardless of the impact on copays or skilled nursing facility admissions, or the hospital’s worries about revenue, patient-satisfaction scores or readmission penalties.

Dr. Whitney and Todd sometimes had to call out insurance companies when it was felt that their decisions about payment were wrong. Dr. Butz reviewed pediatric, obstetric, and surgical cases as well as internal medicine encounters, so he had to broaden his medical knowledge significantly, and he liked that challenge.

He did this for more than four years for WellSpan and then decided to work as a self-employed consultant for a hospital in Maine that sought his specialized expertise. Todd did this for another five years until Optum came to Maine and his services were no longer needed.  

So in May of last year (2023) as he felt “out of balance” he chose to take a break from the grind of working seven days a week. He needed to “unwind.”  At age 60, as “the next chapter has yet to be written,” Dr. Butz has been spending more effort on his farmette a few miles south of his home. He and his wife and their two teenage children can “unplug” in the peaceful environment that is like a “time machine.”

There is an 1850s log cabin with enough steeply banked ground to need a few sheep to keep the grass and weeds down. He stops by to feed the two ewes daily; they like Animal Crackers (this English delicacy was first made in the US at Stauffer’s in York in 1871, where they still turn out a million daily) along with their grain. 

The Butz's quiet rural retreat

He also has a good-sized and varied organic vegetable garden and he planted ten young fruit trees (already bearing fruit). He is paying careful attention to nutrition as he tries to adhere to a version of a low (starchy-) carbohydrate diet that includes beef from pasture-raised cattle and “lots of eggs” (scrambled, and always with onion) laid by happy free-range hens. He makes his own butter and yogurt, and he enjoys snacking on olives and tree nuts instead of chips (despite the fact that York County is the unofficial potato chip capital of the entire world).  

Returning to a regular exercise regimen, to routine physical activity, he often starts his day with a long meditative swim at the York JCC, where we sometimes cross paths and chat. 

What have we learned from Dr. Butz? Prevention of illness makes more sense than waiting to treat entrenched disease. We can start improving our food choices by cutting back on starchy carbohydrates, sugar, and calories. The Mediterranean diet is a good model, and buying fresh local produce or even growing some of our own vegetables is preferred to mindlessly consuming highly processed packaged food. Regular exercise is essential for good health; we need to keep moving and stay strong. So it might be time to brush off the old ABDO-Cycle, stationary bike, or treadmill collecting dust in the attic.  And we should, following Todd, not be afraid to take chances, to be creative, to try something new. And it is good to feel connected to the land.

Dr. Todd Butz and his family

Readings and References:

1. Anon. "Guided by Pocket Card, Doctors Are Coaxed To Keep it Simple With Two-Midnight Rule." Report on Medicare Compliance, Volume 25, Number 34, September 19, 2016. (Explaining Todd's foray from direct patient care.)

2. Attia, Peter, M.D. with Gifford, Bill. Outlive: The Science & Art of Longevity. Harmony Books, New York, 1993. (Synthesis of a lot of fascinating deep technical information, but quite readable and recommended highly.)    

3. McGarey, Gladys, M.D. The Well-Lived Life: A 102-year-old Doctor's Six Secrets to Health and Happiness at Every Age. Atria Books. New York, 2023. (The "mother" of holistic medicine in 1978 addressing the health of the brain, body, and, especially, spirit. You can watch her YouTube interview.) 

3. Nozowitz, Dan. "Why are So Dang Many Potato Chip Brands from Pennsylvania?" Atlas Obscura. October 24, 2017. (Is it the climate? The soil? The German ancestry?)

4. Taubes, Gary. The Case Against Sugar. Alfred A. Knopf. New York, 2016. (A strong argument that we need to pay attention to.)

By Anita Cherry  (04/21/24)

Soaring Hawk in Flight in Florida (Photo by SC)