Dr. John S. Monk, Jr.: What Will Chip Do Next?

"What can you do for me, you ask? You can do an operation to help me lose weight," the patient replied.

"Well, you know, I have heard of that,” the cautious doctor said, “and I think that is a worthwhile thing to consider. But I have never done that operation."

"I have talked to God, and God said you will do it."

"God helps us in many ways,” he offered. ”Let me see if God can help me get you an appointment at Hershey or Hopkins, where I know they do these things."

This was 1993. The patient’s insurance then was “pretty rotten” and the two universities did not accept it. She, however, was not ready to give up.

"I have faith in you. You can do it," she beseeched.

"There are parts of this surgery that I have done for other reasons, but I have never done it exactly," he said.

" I want you to do it for me."

John S. Monk, Jr., M.D.

So, Dr. John ‘Chip’ Monk agreed to try to help a desperate woman. The tedious first-time surgery took four and a half hours. Before the weight-loss procedure, the lady of faith had needed supplemental oxygen to help her breathe, took three medications for hypertension, and was a severe diabetic. 

A few months after the gastric bypass, not only had she lost substantial weight, she no longer needed to lug around her oxygen tank, she was on only one medication for hypertension, and, most remarkably, her diabetes was gone, completely.

Dr. Monk admitted that he was “hooked” by these spectacular results. Since then he has perfected his techniques and has performed thousands of so-called bariatric procedures for grateful individuals struggling with the complications of obesity, a worldwide epidemic now affecting 40% of the U.S. population. Mostly, he feels, due to the easy availability of lots of “cheap, tasty, high-caloric foods,” especially simple carbohydrates--i.e., mostly simple sugars, especially fructose.  

But let’s go back, and fill in Chip’s story.

How did ‘Chip’ become Dr. Monk?  His father was an obstetrician in York and young Chip watched as “hundreds of women” in town came up to his father and thanked him for delivering their babies. Seeing this was (as you might imagine) “a  positive thing.” The obvious path was set before him, but maybe he should try something different. 

So he studied biology at Middlebury College in Vermont with the idea of becoming a marine biologist “like Jacques Cousteau.” After a while, he changed his mind and decided on medicine. He went to Jefferson (and he found this easier than his very-demanding New England college).   

Middlebury College

Chip first thought about being a family doctor, taking care of patients throughout their lifespans, but he “fell in love” with surgery, especially orthopedics, after he worked with Dr. John Dowling in Philadelphia. In fact, the orthopedic residency program in Cincinnati wanted him to join them after graduating from medical school ( in 1982), but he didn’t “rank” them in the “match” since he had decided instead on his “safe” place for training, York Hospital.

General surgery was “more exciting” than he had thought it would be, and he enjoyed working with Dr. Nikhelish Agarwal, who was developing the new trauma program at York.

But two years into his residency he got sick. Dr.Monk had seen unusual blotches on his legs for a few weeks, and after a long and tiring 36-hour shift (when men were men) he came home and went to sleep with this on his mind. He awoke at two o’clock in the morning to pee and saw blood. This was not good. He quietly told his half-awake wife that he was “just going to run into the ER" to check on something and that he’d be right back.  Off he went.

He waited anxiously for several hours for simple blood test results that didn’t arrive. The hematologist, Dr. Miodrag Kukrika, came to the hospital first thing that morning. He looked at the blood smear and informed Dr. Monk that he had acute promyelocytic leukemia and that this was a true life-threatening emergency, the most malignant acute leukemia. 

Helicopter pad at York Hospital

The doctor-turned-patient was helicoptered to the University of Maryland, and chemotherapy was started as he was being wheeled into the ICU.

He was given humongous doses of the drug ARA-C in an experimental protocol for a clinical trial. The resulting nausea and vomiting were horrible, and the sternal bone marrow biopsies were harrowing. After the first round of treatment, his marrow was “totally filled with promyelocytes.” He was told that either what they are doing was not working, or that the intense chemo killed all of the abnormal cells.

This was a very dark and “rough” day for a young husband and father of two, and it tested his faith. As it turned out, the bone marrow was packed with normal immature cells, and the leukemic cells were never to be found following that.  But Dr. Monk still needed eight more cycles of grueling chemotherapy. (Targeted therapy with monoclonal antibodies and vitamin A is the treatment now.)

After that terrible year of being sick (1984-1985) he simply wanted to resume his surgical residency, and to cherish his wife and children. He was too weakened to take call every three or four nights, and in place of that task, the hospital gave him a job as an educator of residents for a year. Dr. Monk did that and then did three more years to finish his training.

He “really enjoyed teaching” and after his residency he took a chance and asked for a position as assistant program director, working with Dr. Jonathan Rhoads. His bold request was granted and Dr. Monk took the job. He also did trauma and critical care and had a small private practice.

(Could a doctor-in-training be helped in this way today, thirty years later? Are our new giant health systems responsive to the needs of their physicians? Do these questions push me to tell doctors’ stories? Maybe.)

Anyway, so how did bariatric surgery become Dr. Monk’s special interest, his life’s work?

One year early in his practice, he went to one of the huge American College of Surgeons meetings (with nearly 18,000 attendees!) and as he was milling around he peeked into one of the darkened side rooms where they happened to be discussing gastric bypass for obesity. He walked in.  He had thought that weight loss operations were risky, and the results poor, but the talk changed his view. He came away from the lecture thinking that the surgery was not only safe, but that there could be amazing results.

So the request by the lady he met in the clinic in 1993 and whom he later operated on fell upon the ears of a man already primed for the challenge.

Dr. Monk followed her surgery with a few more similar cases over the next couple of years. But four hours was a long time to spend in the OR. Could he do better? He (as an assistant director) went to a meeting for directors of surgery departments. “One of the most famous weight-loss guys in the world” was at the meeting and Dr. Monk took another chance and summoned up the courage to ask if he could visit him at his hospital to see how he did things.

(Bold, but as someone once said to me in a similar vein, “What is the worst that could happen? He could say No.”)

Walter Pories, M.D.

Anyway, Dr. Walter Pories not only said that Dr. Monk could come to the hospital, but that he would arrange for him to get privileges so he could actually help in the surgery. The esteemed Dr. Pories would be happy to share his knowledge, not only of the surgical technique but of the importance of patient selection and critical follow-up treatment. This remarkable physician remains one of the “most favorite people” Chip has met, and Dr. Monk is still amazed by him and his generosity.

(I like a guy with chutzpah and gratitude at the same time.)

The excited protege returned to York, applied what he learned, and practiced. Some time passed. He remembered that Dr. Pories had told him about “a guy in Pittsburgh” doing surgery “through little holes” and suggested a visit, but he wasn’t ready then. Well, what do you know, one day, along comes an instrument salesman offering him the opportunity. Should Chip take him up on it?

A cartoon (one of many) by Dr. Pories

Next thing, he and his colleague, Dr. Paul Sipe, fly west for a lecture. After the short talk, the presenter abruptly leaves the hall and walks across the street to the OR. Transfixed, they watch the laparoscopic surgery “live” on the big TV screen. It takes only 90 minutes. "It was beautiful...it was beautiful,” gushed Dr. Monk. He signed up for the course and quickly grasped the details of the new technique.

Back in York, he shared the idea of the new less-invasive procedure with some of his patients. He told them carefully that he had not yet performed the surgery and, sure enough, one trusting soul jumped in and said, “Oh, you can do it. I’ll be your first!"

After three of four cases he was able to complete the surgery without resorting to opening the belly, and laparoscopic surgery has been the standard since then. The 30-day mortality rate for weight-loss surgery at the York Hospital is 0.1% (much safer than, for example, gallbladder surgery).

Surgery for weight loss can either restrict the size of the stomach (how much one can eat) or work by causing malabsorption (how much one absorbs through the small intestine), or do both. The most commonly performed procedure now is the gastric sleeve, essentially taking out 80% of the stomach, but not affecting nutrient absorption.

Various weight-loss procedures

However, the most effective treatment for weight loss is the so-called “modified duodenal switch.” A large part of the stomach is removed and the first part of the duodenum at the end of the stomach is then attached lower down into (nearly) the end of the small intestine so that food “bypasses” much of the surface where it can be absorbed by the body.    

“Banding” of the stomach was popular for a while but is rarely done now.

What are the results of bariatric surgery? Nearly 80% of patients will keep off 50% of their excess (that is, over the ideal) weight at five years. Dr. Monk said that “nothing else works like that. Not medication. Not diet. Not exercise.” After surgery type 2 diabetes (exceeding common in such patients) is almost always easier to control, usually without medication, and more than 50% have a completely normal A1C (the test for long-term blood sugar control) without any medicines.

And (this is very interesting) the improvement in diabetes occurs before the weight loss. Dr. Monk said this has something to do with food “not touching the duodenum.” There is a complex effect, “markedly elevating (the hormone) GLP-1, analogs of which improve diabetes and may help people lose weight.”  There are also changes in leptin (produced by fat cells to inhibit hunger and regulate long-term weight control) and ghrelin (which increases hunger). 

These two particular hormones act on the brain (at the hypothalamus, the base of the brain) to tightly regulate energy balance. In obesity there is resistance to the effect of leptin, blunting the feeling of satiety, of having eaten enough. “The adipose cells (then) trap excessive calories as fat and do not allow it to be used as energy for the rest of the body,” (Taubes p. 115).    

Hormonal regulation of hunger and satiety

“Obesity is a chronic disease that affects (nearly) every organ…(and) there are great benefits to weighing less,” said Dr. Monk. “Why do people see surgery for morbid obesity as an extreme option, when it’s the only option?”

Cutting back to his own story, his path in medicine, I wondered aloud about all of the people who looked after Chip, who helped him along the way.

"That's what I'm thinking,” he calmly said. “Some people would call it coincidence, but I have this spiritual thing. I'm probably doing what I am supposed to do in life." Somehow, he noted, he just “happened onto” what turned out to be a “nice and gratifying career.”

The future for Dr. Monk? For one thing, he has gone on church mission trips to Africa with Dr. Robert Davis. One time he visited his daughter who was in the Peace Corps and stationed there. He wanted to see one of the hospitals. While looking around with curiosity they asked him to do an emergency appendectomy. Needless to say, he obliged. He needs to do more of this giving-back, he feels. 

But he also wants to be “more than a doctor.” So, he is a member of the Chestnut Society, bringing back the American Chestnut tree.  He keeps bees and collects their honey. He goes camping with the Scouts. It’s “fun to learn,” he noted.

The American Chestnut

I can see Dr.Monk years from now. He will again be wandering around at some meeting, peering into a side room somewhere. But no doctors around, this time. He will cautiously step inside a room and look up at a 3-D display. Someone will notice him and call out, "Can I watch with you?" They will observe together, and Chip will say to his new buddy, "That's really beautiful. I want to learn to do that. And his friend will put his arm around him and say, "Sure."

Yes, I like a man with chutzpah and gratitude at the same time. (I'll have some honey with that.)

Chip's honey

Wait...

Chip and his real honey

Reference:

1. Taubes, G. 2016. The Case Against Sugar.  New York: Alfred A. Knopf.

By Anita Cherry 10/27/18