Dr. Michael B. Furman: It's a Beautiful Day

Michael B. Furman, M.D.

"This might be my last full day on Earth," the doctor thought to himself as he began his carefully-planned day, the day before scheduled surgery to repair an expanding aortic aneurysm and to replace his malformed aortic valve. He had put off the dual-operation for a while as he meticulously read and reread the literature on the procedures and the options.

He arrived at the JCC earlier than usual (and surprised his regular workout companions). He took a swim to loosen up his muscles and then did an intense (but not too intense) spin class. After this, he presented a lecture on his craft to his “fellows” in training and then did a few cases with them. He left the orthopedic practice a bit early to go home and watch a movie, Les Miserables, with his (fraternal) twin daughters. He then gently kissed his girls and told them to work hard, and to always be their best.

Following this, came the hour-long drive on Route 83 from York to Baltimore with his wife Esther for a nice dinner before checking in at the hotel near Johns Hopkins for surgery the next morning. Yes, a good carefully-thought-out logical day.

The following morning, with the IV stuck in his arm, the calm anesthesiologist told him to count backward from 100. After a few seconds he thought, “This stuff is not working...”  His next conscious memory was of simply awakening and seeing his wife’s worried eyes as if no time had passed at all:  “Nothing to it.”

Dr. Michael B. Furman, you see, doesn't stray far from his roots as an engineer. He needs to know exactly how something works, and when he finally figures it out he doesn’t stop; the goal is to improve, to get things better, to try to get them just right.

He grew up in “small town” (his words) Scranton where his grandfather owned “Furman’s Army-Navy” surplus store (established in 1911). As a young child he played in the store; later on, he worked there too. The family was close, and everybody got together on Thanksgiving. One year he vividly recalls seeing his uncle in a new light; though he had once been a strong military man he was now stuck in a wheelchair with multiple sclerosis.  His wife was the “nurse she had not expected to be.” This sad image of impaired mobility, limited function, and decline made a strong impression on the ever-curious youngster.

Cornell Engineering Motto

In high school, he was “good in the sciences” and  he “liked to think things through." He graduated in 1978 and went to the University of Pennsylvania as a pre-med student. But he soon decided to follow his natural inclination and transferred to the engineering school. After receiving a degree in chemical engineering from Penn he went to Cornell for a Masters in Science. His thesis was a graphics-based computer program simulating the movement of red blood cells through capillaries. He liked this kind of work. Yet, pondering his options, and with not-so-subtle encouragement from his friends, he felt the pull of medicine and concluded that he “would be happier as a doctor.” Yes...a doctor, that seemed right. But he would be one with the sensibility of an engineer.

At Temple Medical School in Philadelphia the grueling first year was “all memorizing,” not the “fun, and play, and problem-solving” our protagonist had expected and had experienced while in engineering.  It was time to rethink his plan.  He took a year off and did research; it was not quite what he wanted, and he returned to medicine with renewed zeal.

Dr. Nathaniel Mayer

During a summer job after the second year (with more memorizing) he had the good fortune of working with Dr. Nathaniel Mayer, a pioneer rehabilitation specialist who was then keenly interested in gait mechanics and movement, with the ultimate goal always of improving “function” for his patients.

In the third year, the beginning of the “clinical” years of actually seeing patients, the restless medical student discovered that he loved medicine and the chance to solve practical problems for people who were suffering. He was intrigued by the “up and coming” field of rehabilitation medicine where “function and medicine came together.” He wrote a computer program (“On cards,” he remarked, with some nostalgia) to explain to students how specific muscles “do different things” to move the human body through the environment.

The Physical Medicine and Rehabilitation (PM&R) professor (and chair of the department) was impressed by his work and asked him to present it at their annual Academy meeting. Dr. Furman was excited by the opportunity, and this introduced him to the politics of the specialty.  He took to this naturally and quickly saw that it could help his developing interests in teaching and clinical research.

Before starting his own PM&R training at Temple he did a so-called rotating internship at the York Hospital where he was exposed to various relevant specialties; he “loved” the year in York.

After he was back in Philadelphia he called an occupational therapist for a blind date. The careful young man suggested lunch and a hike. Lunch, yes, there would be less pressure if it didn’t work out. It did, however, and he asked the young woman if she would join him for dinner and a movie that very evening.  The rest, as they say, is history. Dr. Furman told me that one day at Esther’s apartment in Germantown she had her back to him at the sink washing dishes and he said, ”You know, we will probably wind up together.” She turned around, looked at him, and matter-of-factly replied, “Yes, I know.”  Less than ten months later they were wed, “on a beautiful day” (despite the rain).

"Blind" epidural technique

Anyway, after the three years of residency, he took a spine fellowship in Atlanta focusing on in “interventional pain management.” Among other things, he studied techniques of spinal injections of steroids. These procedures had mostly been done “blindly” (this is, without the benefit of imaging) by anesthesiologists who did nerve blocks for surgery. This was a relatively new idea for PM&R specialists as they searched for better ways to manage difficult spinal pain. Pain that sometimes prevented their patients from even taking part in physical therapy. 

The prime goal for the PM&R physiatrist is “to get people moving” and allow them “to get their lives back.” Dr. Furman envisioned the potential benefit of the spinal injections and concluded that precise and, most especially, safe, use of these techniques, when combined with various non-pharmacologic treatments, could ease patients along the path to wholeness again.

Engineer's Mind
 (from RoCkiNg EnGineRS)

It turned out that he so liked the feel of community medicine during his internship in York that he returned in 1995 (his parents and his wife’s parents lived in the Philadelphia area then; they would be not too far away) to practice with the orthopedic group. He was able to feed his interests in teaching, research, and medical politics in addition to doing clinical practice. He could use his critical insights and engineer’s mind to make things better. 

The far-sighted orthopedic surgeon Dr. Joseph Danyo saw this and encouraged him to start a fellowship (one of the first) in the field of image-guided intervention for pain. Dr. Furman did not hesitate, and the first fellow graduated from the program in 1998.

The program itself has remained successful despite lots of new competition, and there have been over 70 fellows over the past 20 years  (most still keep in touch and get together frequently). This success reflects the quality and passion of the teaching.

To that end, Dr. Furman is the lead author and creative force behind the standard textbook on the subject, and he has presented many well-received lectures (complete with “Furmanisms” as he calls them) to his interested colleagues around the country and internationally.

Dr. Furman's Textbook

In the words of David “DJ” Kennedy, M.D., now the PM&R Chairman at Vanderbilt, in his forward to the second edition of the text, the “Atlas of Image-Guided Spinal Procedures” transformed “multifaceted procedures into a series of simpler algorithmic tasks...offering clarity where only complexity existed.” The book is essential reading for anyone in the field.  

Dr. Furman enjoys teaching and takes this task very seriously. As he noted, "To teach is to learn twice” (echoing, it seems, the words of Joseph Joubert in the early 1800s). The Schwenck and Whitman (1987) version expends this: “To teach well is to learn twice as well, so that in the encounter the teacher learns more than the student.” This keeps clinician, sharp. Continuing their important thoughts on the subject: “Clinical teaching is essential in moving the profession of medicine forward.” Dr. Furman agrees, as does his professional society, as shown by their decision to recognize his efforts with their upcoming 2018 Legacy Award and Lectureship in October.

The Karate Kid and Mr. Miyagi
(Shu-Ha-Ri) 

(By the way, Dr. Furman has a deep and long-term interest in the martial arts and he told me about the important concept of “Shu-Ha-Ri.” That is, one first learns from the master by imitating his moves and understanding them (the Shu). The next step in the student-teacher process is to separate from the teacher with a higher degree of understanding, and to be able to break the rule when necessary (the Ha). The final step is to “become the rule” and to transcend it (the Ri). He followed this sequence as a student and now serves as the master. But I digress…)

Teaching is vitally important in management of patients. Teaching them how to deal better with pain, or teaching them how to cope with other orthopedic, skeletal, or neurologic limitations takes time and effort. Careful explanation of the planned intervention and providing expert guidance about reasonable “expectations” is critical for the best outcome, he notes.

Though Dr. Furman treats patients with a wide array of problems, with his special expertise in the interventional spinal procedures he sees many with chronic back pain, either with or without leg pain (sciatica). 

Though it is said that nearly 90% of acute back pain episodes resolve within six weeks, 70% reoccur, and as many as 7% will progress to chronic persistent back pain. Since acute spinal pain is so common (nearly universal), chronic pain, by extension, is an enormous problem for society. In fact, low back pain is felt to be the second-most-frequent reason for visits to a physician for a chronic condition.

Unfortunately, such pain is notoriously difficult to treat. Many individuals with chronic back pain are unable to continue working, cannot enjoy even simple pleasures of life, and feel that their lives are miserable. To make matters worse, the precise cause of their debilitating pain is often difficult or impossible to determine.

What, I wondered, about the “ruptured disk” people talk about?  Isn’t that the cause of a lot of back pain? A 2018 Medscape review (by Wheeler) notes that, “Although disk herniation has been popularized as a cause of spinal and radicular pain, asymptomatic disk

 herniations on computed tomography (CT) and magnetic resonance imaging (MRI) scans are common, (and) there is no clear relationship between the extent of disk protrusion and the degree of clinical symptoms.”

There are seemingly a few specific situations where surgery for chronic lower back pain is usually beneficial, such as when the spinal canal is severely narrowed, or when a part of the disk has broken off or fragmented, for example, but surgery is not needed for most patients. 

For them, a  “multidisciplinary” treatment program is more appropriate. The focus is on function (that word, again), utilizing a broad range of physical techniques in addition to analgesics, pain modifiers that change the pain signals traveling through the nervous system, and anti-inflammatory medicines. It is stressed that emotional, social, and work-related issues that may affect the patient’s recovery need to be identified and addressed. 

But when pain is too intense to allow participation in physical therapy, or when “conservative” (the non-surgical) therapies have been tried and failed and there is no clear-cut or urgent surgical condition an "interventionist" like Dr. Furman may be called in to help. With careful selection of patients, and the right image-guided technique for injecting the anti-

inflammatory steroid where it will provide the most benefit, there are very good results, often with sustained pain relief at six months or a year or more.  Relieved of the burden of pain, patients can enjoy life again.

So, Dr. Michael Furman--physician, engineer, educator, and author--and the scores of fellows he has trained over the past 20 years, can often intervene effectively and safely when stubborn disabling spinal pain gets in the way of recovery. And when chronic back pain is finally under control, is managed better, it can be “a beautiful day.”

Come to think of it, Dr. Furman’s planned “last full day on Earth” sounds pretty close to what he might like to do most days. 

Shu-Ha-Ri.

References:

Furman, Michael B., with Leland Berkowits, Isaac Cohen, Bradley S. Goodman, Jonathan S. Kirschner, Thomas S. Lee and Paul S. Lin. Atlas of Image-Guided Spinal Procedures. Elsevier, 2018.

Joseph Joubert.  Joubert: A Selection from His Thoughts.  1899.

Schwenck, Thomas, and Whitman, Neal. The Physician as Teacher. Williams and Wilkins, 1987.

Wheeler, Anthony. Low Back Pain and Sciatica. Medscape Jan 2, 2018 (emedicine.medscape.com/article/1144130)