Scott Cherry, M.D: "He Reads"

Scott Cherry, M.D.

Yes, I can see you as a neurologist, Scott,“ said his chief resident, stopping after softly tapping and slowly sweeping his red and white cane down the hallway. It was the late blind Dr. Francis Salerno whose words resonated with my husband and tipped the balance that I could not. 

Dr. Salerno (1946-2016)

The Reading Hospital program director, Dr. Eugene Hildreth, had watched helplessly as Dr. Salerno quickly lost his vision to diabetes. But he then made sure that Fran continued his own training, even while teaching the younger medical residents under his charge that vision could sometimes be clearer without relying on sight; careful attentive listening and a soft touch could be more telling. In fact, Fran was so adept at these skills that patients were shocked to find out later that he was completely blind! 

The general internal medicine program in Reading, PA was rigorous and strongly patient-focused. Dr. Cherry enjoyed most of the medical specialties, and, along the way, thought about doing a fellowship in several of them. But the quiet lure of neurology kept whispering to him. He was hesitant though, and not really sure what to do then.

Scott on the boardwalk (~1953)

Looking back, way back, the tiresome family story is that Scott uttered his first word standing on the wide Atlantic City boardwalk looking out in wonder over a crowded beach. That first word was...“People!” 

Well, years passed, he learned more words, and you probably know what comes next. Good in science, good in math, casual reader of the Encyclopedia Americana, etc.

He majored in psychology at F&M, and enjoyed anthropology, but he had no specific career goal during his freshman year. At the end of that year (the momentous 1969-1970, the culmination of the 60s-decade when society nearly fell apart) his father saw that Scott did okay and he offered “advice.” He calmly said, “Son, you can do whatever you want...after you go to medical school.” 

Scott trusted his wise father and listened. What did he see in him that Scott himself was blind to? Anyway, he then took the few required pre-med courses, slowly became disenchanted with psychology, applied to medical school, and went to Jefferson.    

But why was he interested in the (then somewhat) obscure field of neurology, even then? 

“As a senior in high school I took a few courses at Penn,” he said. “One evening the anthropology professor stopped, looked up to the back of the large stadium-style lecture hall, slapped his forehead, and told us, with absolute wonderment in his voice, that the human brain was the most complex bit of matter in the known universe. I can see and hear him now. That comment may have planted (or nourished) the seed, but I’m not sure.”

He went on, “At F&M I remember being in the bookstore looking for nothing in particular one day and tilting out a poetic translation of Lao Tzu by Witter Bynner. Later on, I picked up ‘I and Thou’ by Martin Buber. I then found ‘The Phenomenon of Man’ by Pierre Teilhard de Chardin.” Rereading all three recently, he noted that he still finds them challenging.

I found this in 1976

And, as his wife of more than 40 years, I know that he finds people interesting and often challenging, and worthy of whatever effort is needed to understand them and to figure out how to help them. He does this with unwavering steadiness and patience. “Where,” I ask, “did you learn to not give up on people?”’

“I would like to say that that it was a fully conscious decision, arrived at through careful thought about life, but it was not. Apart from my reading, I guess that I saw it in my father. It was never articulated overtly by him, but it was modeled, and “I” (Damasio's proto-self that lingers below awareness) knew that it was right.”

This early inclination to help, and general curiosity about who we are, was (unfortunately) not strengthened in medical school, which he found not as enlightening as he thought it should be. It was strengthened, though,  by his contact with Dr. Hildreth, a very strong and moral person (who co-wrote the American College of Physicians’ first document calling for universal access to medical care). 

Dr. Hildreth (1924-2018)

Dr. Hildreth had high expectations for his residents and helped them succeed. (The offer of the residency position at the academically-oriented community hospital in 1977 was sealed with a firm handshake, no written contract.) 

Scott said that Dr. Hildreth showed how to be with (and to sit with) a patient. He showed how to be completely on their side, that you were there only for them,  that your job was to do whatever was needed to help, and to relieve suffering, and that it was truly a sacred privilege, not to be taken lightly. And, most importantly, watching him, you realized that you did not give up until all reasonable hope was lost. 

Scott noted that after seeing a new problem the residents were encouraged to read in depth so they didn’t need to look things up a second time. Yes, I remember that his on-call room (he actually had his very own room for three years!)  was littered with copies of hundreds of articles strewn everywhere (I don't know how he found anything in that awful mess). 

(Can a quick glance at an article on Medscape or Up-to-Date substitute for deep study?)

Following up on the "reading thing" I ask, “Why are there so many crazy books piled on and under the nightstand on your side of the bed? And why do you always want to read something to me just as I’m starting to fall asleep?” 

“Following the thought process of someone who has spent time and effort to understand a difficult problem that intrigues me is quite enjoyable. I like that, and instantly have the urge to share a striking insight or the perfect phrase,” he said.

My husband and I met accidentally during his third year at Jefferson. The connection was instant when the man with the books sat down next to the (future) “If One Thing Isn’t Your

Thing Another Thing Will Be Your Thing” woman. We lived together during the last year of medical school when he took Jefferson’s first-ever neurosciences track program (run by the young Dr. Fred Lublin, now a prominent MS researcher). 

Scott had promised his parents that he would not get married until after finishing medical school, so we were patient and waited until two days after graduation. We took a four-day honeymoon in, get this, Atlantic City, and stayed at the once famed, but now faded, Marlborough-Blenheim hotel (just before it was demolished for a casino). The address of the hotel?  Monopoly’s pricey Boardwalk and Park Place. 

Marlborough-Blenheim Hotel (in its' heyday, not 1977)

Anyway, three years later, after finishing his internal medicine residency we moved to Syracuse for the first year of neurology training. After just one day in the hospital, he felt that the program was not rigorous enough for him and that we would have to move after a year. Okay, I agreed, we’ll move. 

Half-way through that snowy year, after the anesthesia wore off, I was informed that I just had a complete hysterectomy for stage 4 ovarian carcinoma. My belly was cut wide open and I was in pain and not prepared for that news, nor was my husband. 

Floating, and feeling unmoored in cold dark silence, as were the astronauts who ventured outside the mother-ship without a tether, without a lifeline, we decided at once, and simultaneously, not to look back. We would use our onboard battery reserves and thrusters to gently propel us in a different direction (yaw, roll, and pitch, and all that).  

Astronaut McCandless (1984)

Dr. Mayer (1929-2016)

We moved to Baltimore, and Scott finished his residency at the University of Maryland, followed by a one-year fellowship with Dr. Richard F. Mayer. The late Dr. Mayer was the epitome of the bow-tied clinician-scientist, and taught residents for 50 years, that’s right 50 years! Scott felt honored to be one of his fellows, and tries (though usually in vain, he notes) to “think like Dr. Mayer” when faced with a difficult diagnostic or therapeutic problem. 

Well, I completed treatment for the low-grade, but metastatic ovarian cancer, was seen at Hopkins, and, after a so-called second-look surgery, was declared to be cancer-free. We were very relieved, of course, and were ready to move on. 

We left Baltimore for a private community-based practice in York. The plan was to work with two other neurologists, Dr. Jeffrey Mosser, and Dr. Roger Weiss, but they wanted to keep the practices separate. They were “engaged” for a while, but never got “married” and the arrangement was called off a few years later. 

Solo practice with cross-coverage allowed each doctor to develop his own style. Office work, after-hours hospital consults, resident teaching, and a few brief (and unrewarding) committee stints, and keeping up with his reading kept Scott busy. He practiced general neurology.  

While he was occupied with seeing one patient at a time I taught children art, one child at a time, at the Montessori school. After a while, we relaxed and began to think seriously about adopting.  (And we were fortunate enough to do that a few years later.)

As the local health system grew over the next 15 years and employed more and more physicians two neurologists were hired to “work with” the volunteer staff. Before long other physicians were added, and the two remaining independent physicians were no longer needed to cross-cover. As the work in the hospital lessened Scott focused more on his outpatient practice. This eventually became his sole concern, and a source of great satisfaction as the interpersonal encounters, sometimes stretching over decades, enlarged his understanding of the human condition.

"The Tangled Wing"

Over the years he has become keenly aware of the always-present, but sometimes subtle and often hidden, interplay between the mind and body in neurologic disease, especially the fear and anxiety that intensify suffering. Scott notes that “Melvin Konner’s masterful analysis of how our evolutionary heritage results in ‘biologic constraints on the human spirit’ helps us begin to understand who we are, the greatest mystery.”    

Listening, I asked him: “What have been the most important advances in neurology over the past 40 years?”

Scott noted that when he was at the University of Maryland (1981-1984) Dr. Kenneth Johnson (1932-2011), the Neurology Chairman, was single-minded in his search for something to change the course of multiple sclerosis. He persisted and was instrumental in developing the protocols for the trials of Copaxone (then called copolymer-1 and developed by Israeli researchers to block experimental allergic encephalomyelitis, the animal model for MS) and Betaseron. These were the first two agents proven to be effective for MS and gave patients hope for the first time since Charcot initially described MS (as “sclerose en plaques”) in 1868. 

Betaseron was FDA-approved in 1995 and Copaxone in 1997, and since then there have been more than ten additional therapies for MS, each targeting a different part of the immune response. This has greatly improved the prognosis for patients with this unpredictable autoimmune disease. There is still no cure, but there is effective treatment.

Therapy for migraine, an often disabling and terribly misunderstood condition, has improved remarkably. Sumatriptan, approved in 1995, was the first drug shown to be specifically effective for acute migraines since ergotamine was introduced in...wait, you’ll really like this...1906. The so-called triptan was revolutionary and life-changing; other triptans followed. FDA-approved preventive therapies for migraine include propranolol and timolol (in 1977-8), the antiepileptic compounds Depakote (approved in 1996) and Topamax (in 2004), and Botox (in 2010). 

CGRP

As of this year, we have three monoclonal antibodies blocking the effect of the calcitonin gene receptor protein that is part of the migraine process. Scott has welcomed these advances for his struggling patients, having begun practice in 1984 when ergot was the only available migraine-specific medicine (it was relatively unsafe, and is no longer available).

Acute stroke treatment was revolutionized in 1996 with the approval of tPA to lyse (or “dissolve”) clots blocking blood flow to a part of the brain, but Scott said that it was slow to be accepted due to bleeding concerns and timing issues. Removing the clot mechanically was recently (2017) shown to be effective in reducing disability, even 24 hours after the acute stroke, and is available here. But better control of blood pressure and use of anticoagulants for atrial fibrillation has reduced the incidence of stroke by about 25% since 1980, and the more stringent blood-pressure guidelines should push that down further.           

There is also better treatment for Parkinson’s disease. Longer-acting forms of levodopa (replacing the deficient dopamine) and a new delivery system (infusion directly into the small intestine) allow for smoother functioning. Brain stimulation, with electrodes implanted into deep structures, can modulate the abnormal signaling responsible for the movement disorder. Special imaging can make diagnosis more accurate. There is more public awareness of this condition, and patients no longer have to hide their problem from others. Scott reminded me that patients often live full lives for many years after diagnosis. 

Dopamine transporter scans can help the diagnosis of PD

What about epilepsy? Removing a part of the brain may cure temporal lobe epilepsy (Dr. Joel Winer does this) and the newer anti-seizure medicines are easier to use and safer than the older drugs, though not that much more effective. There is still an unmet need for people with uncontrolled seizures, a not uncommon problem.  

But all is not rosy. Alzheimer’s disease, ALS, progressive muscular dystrophies, severe brain traumas, hereditary neuropathies and other hereditary or degenerative neurologic disorders are understood better but still have no effective therapies. Nevertheless, Scott notes that he has watched as patients and families often learn to adapt to these conditions remarkably well despite permanent or steadily advancing decline. Mankind is remarkably resilient, but sometimes those with such illnesses withdraw and become invisible to the outside world. 

What about cognitive neuroscience? What has happened there? Fluoxetine, the first selective serotonin reuptake inhibitor or SSRI was approved in 1987. There is debate about the long-term usefulness of SSRIs, but they revolutionized treatment of depression. So-called atypical antipsychotic drugs, often used as mood stabilizers, have also improved life for individuals with bipolar disease. Scott said that we are only beginning to understand how early life experiences affect the development of the brain's handling of stresses, and how that interaction with the environment shapes the connections of the deep, emotional, and "older" parts of the brain that can cause so much suffering.

Of course, there have been tremendous advances in understanding the mechanisms of disease, including molecular genetics, allowing for more precise diagnosis, even if not yet translating that into effective therapy.

Scott notes that there is still much that is completely unknown (and maybe ultimately unknowable) about how the human nervous system does what it does; how it can apprehend, represent, and manipulate the world; how the human brain endeavors to understand itself.

As the split-brain researcher Michael Gazzaniga has said, there are probably thousands and thousands of brain modules, built-up on top of each other and modified by evolution, working automatically, over a stupendous number of interconnections, doing their thing. And that much of what goes on in our brains is hidden from our awareness. Until things go awry. And when our left-brain interpreter that tries to make sense of it all doesn’t have the information it makes up the story. Maybe this is what keeps Dr. Cherry up at night, reading. 

Maybe we need to close our eyes a while like the Zen masters, or like Dr. Salerno, to get a fleeting glimpse of what’s really going on inside our braincase.

And Scott is always glad to recommend a book that might help.

My painting of Scott reading on our honeymoon (!).

Readings:

1. Buber, Martin. 1958. I and Thou. New York: Charles Scribner's Sons.

2. Bynner, Witter. 1944. The Way of Life According to Lao Tzu. New York: Capricorn Books.

3. de Chardin, Teilhard. 1961.The Phenomenon of Man. New York: HarperTorch books.

4. Damasio, Antonio. 1999. The Feeling of What Happens. New York: Harcourt, Inc.

5. Gazzaniga, Michael. 2008. Human: The Science Behind What Makes Us Unique. New York: HarperCollins.

6. Konner, Melvin. 2002. The Tangled Wing. Second Edition. New York: Henry Holt and Company.

7. Johnson, Kenneth. 2010. The Remarkable Story of Copaxone. Ney York. Diamedica. 
Publishing.

8. Salerno, Francis. Uncertain date. (Interview on Reach MD). Introduction to a Remarkable Career. (click link)