Can You Keep Up With Dr. Kukrika?

PROLOGUE: Unique; the only one.

Miodrag Kukrika, M.D.

On the website howmanyofme.com their “best estimate” is that there may be “1 or fewer” people in the U.S. named “Miodrag Kukrika.”  In fact, there is just one. He is a retired hematologist/oncologist in York; I asked him for his story.

Because of his accent, he said, people sometimes wonder where he's from. His mysterious reply? “I am from a country that no longer exists." 

ACT ONE: It is 1936 in the central Balkans. Adolph Hitler is spreading hateful xenophobic nationalism. Jesse Owens embarrasses him by taking four gold medals at the 1936 Olympic Games. The rest of the world watches.

“Mića” was born in 1936, in Belgrade, in the Kingdom of Yugoslavia. He was an innocent toddler when the war began in September 1939. The German invasion of April 6, 1941, ended 11 days later with surrender. The Axis occupation followed, and the country was partitioned along ancient ethnic and religious lines. The Croats, in a German puppet state, using the fascist Ustashe militia, brutally tortured and murdered between 300,000 and 500,000 Serbs who lived among them; 20,000 died in a concentration camp. (Thousands of Jews and Romanians were also targeted.)

The partitioning of Yugoslavia in 1941 (from US Holocaust Museum)

The fractured country was finally liberated from the Germans in October 1944 by the Soviet Red Army. Bringing Russian Communism with them, they “immediately” jailed Michim’s industrialist-father.  And "because there was something to be taken" his successful factory was confiscated.

Dr. Kukrika's dad was slated to be sent to "hard labor" for a year, but he was more useful as a machinist and was spared that. After a while, when things settled down, his father was freed, and he resumed his metal work and supported his family nicely. "He worked from five in the morning until ten at night until a week before he died," lamented Dr. Kukrika.

Though Michim and his younger sister could not clearly recall the swift German takeover he was old enough to remember bits of the Nazi occupation and then, several years later, how the Russians treated his father, and, especially, how he was filled with fear as the family was under threat.

[An aside: His hard-working father was born in Bosnia in 1905 and died at 79 in Serbia. Dr. Kukrika flew home to be with him in the ICU in Belgrade, where the nurses were "drinking coffee and smoking incessantly." The attending surgeon was puzzled by his father’s illness and did an exploratory laparotomy. He found "nothing."  His father "never came out of the anesthesia."] 

Dr. Kukrika said, with boyish enthusiasm, that he absolutely “loves” history and geography. So, for those who have forgotten (or never knew), here goes...

Yugoslavia, under various names and forms, existed from 1919 (as the Kingdom) until 1993 (as the Federal Republic of Yugoslavia) and cannot be found on a current map of the Balkans or anyplace on earth. Belgrade is now the capital of Serbia. The Serbian Kingdom, itself, was first recognized in 1217, went through several changes, and became part of Yugoslavia until after WWI. It is now The Republic of Serbia and is surrounded by, starting from the north and working clockwise, Hungary, Romania, Bulgaria, North Macedonia, Montenegro, Croatia, Bosnia, Herzegovina, and (the disputed) Kosovo. And where are the Balkans? To the right of Italy, across the Adriatic Sea. (See, that wasn’t so hard, was it?)

Dr. Kukrika said that “Bosnia is an unfortunate part of the former Yugoslavia because it has populations that hate each other.”  Hate, a strong word. The Serbs (on one side of the Dinaric Alps) are Eastern Orthodox while the Croats (to the other side) are Roman Catholic.  In the middle are descendants of a group that converted to Islam during the Ottoman Empire or Turkish conquests.  Dr. Kukrika is very disturbed by these long-standing ethnic hatreds, seemingly triggered in part by subtle religious differences, that have led to so much conflict and misery. Organized religion, he quickly determined, was not for him.

[An aside: My husband has told me more than once about Freud’s “narcissism of minor differences” where the most heated interpersonal conflicts are often between those who are pretty much alike and who come in close contact with one another.]

ACT TWO: The 1950s. Yugoslavia after Tito’s surprise break with Stalin. Our young man begins to find his way. He thinks about leaving home. Thinks about who he is.

Josip Broz Tito and Joseph Stalin

“How did you get into medicine? Were you, like others I have interviewed recently, ‘good in science and good in math?’” I asked. No answer. It seemed that this was the first time he had thought about this question.  But maybe I just spoke too softly, and I repeated it.

Pausing briefly, he proudly admitted that he was “good in everything, but, in nothing very good.” This was an interesting answer and, later on, I had to listen to my recording carefully to get it right.

As mentioned, as a student he loved history and geography, yet he could not see himself working as a research historian, with history “written by the victors.” A history that told, he knew, only one side of the story. He then thought about law, maybe criminal law. But his protective mother worried that someone would kill him, and she forbade it. His doting father wanted him to become an engineer. He was stuck. He couldn’t decide.

But two of his best friends announced that they were going into medicine, and he naively thought, “Why not? I will go too!” Since he had excellent marks at the ‘gymnasium’ (the 5th through 12th grades) he did not need to take the qualifying exam, and he went directly to the University of Belgrade Medical School. While there, he studied as an exchange student in Poland for six weeks, quickly learned the language well enough to pass for a native-speaker (he had already practiced English and Russian and liked the sound of Italian, from across the sea) and met and fell in love with his wife-to-be, Ewa, a pharmacist.

University of Belgrade 

After that, he did an (unpaid) internship for a year and then practiced as a GP for four years in two small picturesque country villages just north of Belgrade.

He wanted to practice internal medicine, and at one point he seemingly had the option, but there was a catch; he had to agree to be a member of the reigning Communist Party. Without hesitating to consider the consequences, he flatly refused; he would not compromise himself in that way. Becoming an internist in Yugoslavia was now “just a pipe dream.” From the age of 14, he had been geared to leave Yugoslavia, and it was time. Where to go?

He had several nice offers from Germany and Sweden. Possible, he thought, but not far enough away from a very unpleasant family situation. Dr. Kukrika confided in me that for some unfathomable reason his mother “absolutely despised” his wife (though his father adored her). But, even so, “God-forbid” he and Ewa didn’t visit his mother on his rare weekends off! “The farther we go, the better,” he said to himself sadly.  So, a different continent altogether, “the United States is just far enough.” 

(By the way, he said that  his wife was a person that could forgive almost anybody, anything, and she tried “everything” to bring his mother around, but never could.)

ACT THREE: The year was 1967. The "Early Years" of the Vietnam War. The Six Day War between Israel and its neighbors was fought. Rioting and looting in Detroit and other U.S. cities. The British brought us Twiggy and “Sgt. Pepper’s Lonely Hearts Club Band.” The Corporation for Public Broadcasting was formed. The world was again in turmoil as Dr. Kukrika arrived in a new land.

Vietnam war protest at Harvard in the late 1960s

“So how did you decide to go into hematology and oncology?” I asked.

“I came to this country (a beacon of freedom) in 1967 and did an internship at Frankford Hospital in Northeast Philadelphia,” he replied. During that year he became more fluent in American English and he became interested in cardiology. In fact, he read all of the EKGs at the hospital and was excited about the field. But when he looked around carefully he saw that he “might not be accepted as a foreigner” in that prized specialty. He needed another plan.

While in Yugoslavia he had spent time working with a hematologist and developed an interest in coagulation. A relatively obscure field (there was no specialty board then) might be a better choice, he reasoned. His stay at Frankford was followed by two years of an internal medicine residency at the Abington Hospital in the Philadelphia suburbs. He then took a two-year fellowship at the University of Michigan in Ann Arbor, and a further year in Rochester, New York.

[Aside: He had turned down--yes, turned down--a fellowship opportunity at the MD Anderson Hospital. “They didn’t read their own bone marrows” and left that critical task up to the pathologists; he thought that was wrong. A hematologist should read his own slides. To see for himself.)

Miodrag might have stayed in academics at the University of Rochester, but there was no position available at the time. So he decided on private practice. He did a year in Kalamazoo, but the partners were at war with each other and he was in the middle; he had to leave. He then interviewed at the well-regarded Marshfield Clinic in Wisconsin where they (are you ready for this?) liked and looked forward to the bitterly cold weather; he and his wife did not.

He came to south-central Pennsylvania in the spring of 1974 for a practice in Reading, and as he drove from Philadelphia he passed the gently rolling hills coming alive in the spring and he signed on for one year at St. Joseph’s Hospital where “the GPs ran the hospital.”

The inviting Pennsylvania landscape

While there, Dr. Ross Moquin reached out to Mike (his Americanized name) from the York Hospital and asked him to consider joining his own practice. The audition? Presenting Thursday’s Medical Grand Rounds on the rare (and then) almost always fatal blood disorder TTP, or thrombotic thrombocytopenic purpura. (This is now successfully treated with plasma exchange and specific monoclonal antibodies). The staff was impressed by his talk and he joined Dr. Moquin.

ACT FOUR: It is 1975.  Starting a practice of oncology and hematology in York. The Vietnam War is over (lost) as the Communists take over South Vietnam. The UK happily joins the EU. “Jaws” is the highest grossing movie of all time.

After working with Dr. Moquin for a year Dr. Kukrika decided to open his own independent practice. Dr. Eamonn Boyle joined him a few years later, and Cancer Care Associates grew and added more (international)  physicians and (dedicated) nurses. Chemotherapy for most cancers was dangerous and unpleasant, and generally not very effective early on. People often got sick, sometimes very sick, before they slowly recovered. The word ‘cancer’ itself provoked intense anxiety and fear, and truly effective therapies were few. Dr. Kukrika waited patiently for something better.

Things slowly improved and more successes eventually made his practice less grim. He was greatly heartened by the advances in his field by the time he retired in 2000, but he is absolutely awed by the “unbelievable and fantastic” understanding of the genetic aspects of cancer and the new targeted cancer treatments that have evolved over the past two decades. Though gene technology has spectacularly improved diagnosis and management of cancers and blood disorders old-fashioned skills should not be discarded:

It is 1984 and our doctor gets a frantic phone call in the early morning hours about a blood smear from a patient in the ER. It looks bad they say. Dr. Kukrika is worried. He tries to sneak out of bed and not bother his wife, but she is up already. He goes straight to the hospital lab, puts the prepared slide on the microscope and instantly sees the problem.

The patient’s blood is jam-packed with promyelocytes, immature blood cells. This is acute leukemia, and a rare version that may be rapidly fatal as a result of the accompanying bleeding disorder called DIC (disseminated intravascular coagulation). Dr. Chip Monk, a surgical resident, is the patient, and he is quickly flown to the University of Maryland. Serious bleeding is prevented, and his life is saved. A delay of even a few hours, waiting for someone else to read the pathology, could have resulted in a disastrous outcome.

[An aside: Where was I in early 1984 I thought?  My husband and I were in Baltimore finishing his fellowship. One of his colleagues, a neurology resident from Bogota, Colombia, Ernesto, and his wife, asked us to be stand-in godparents at the baptism of their son. We are Jewish, but they said it was okay. We watched intently as the priest performed the joyous ceremony and gently placed drops of holy water on the baby’s forehead.

Baptism ceremony

He then asked us, one at a time, if we believed in Christ. The quiet Catholic parents said nothing. Scott stayed quiet too. When it was my turn I confidently (as the good stand-in godmother) said, “Yes.” They all looked at me with raised (or was it furrowed) eyebrows. Anyway, after that, we went to a fancy Chinese restaurant down the street. While in the church I felt like I was an extra in a movie, one of my few long-time fantasies. Wait! I just realized I was (am) an extra...in this story.]

Speaking of Chinese, Dr. Kukrika said that in 1988 researchers in China found that treatment with vitamin A could cure promyelocytic leukemia, but this “natural” treatment wasn’t accepted here until after the French tried it a few years later. Dr. “K” (as he was sometimes affectionately called) is not very happy with the idea of “American exceptionalism.” 

Anyway, as I thought about Dr. Kukrika’s decades of intense and emotionally tiring work I wondered if he needed special social and personal skills to take care of people with cancer? Almost always helping anxious, frightened patients facing their mortality. Patients who turn to him for answers. Answers that he was often not able to provide.

His reply: ”Special skills? Not really.” Dr. Kukrika feels strongly that all doctors, by the very nature of their work, should be the ones able to hold the patient’s hand through difficult life-threatening illness, to guide, to be present. He feels that this most human of tasks cannot, and should not, be delegated to someone else. “You have to have a (strong) feeling for the person (to provide proper care),” he said, and continued, “If you don’t, I’m sorry.”

ACT FIVE: It is the 1990s. Bosnia secedes from Yugoslavia and Bosnian Serbs kill 100,000-200,000 Croats and Muslim Bosnians and displace 2,000,000 in “ethnic cleansing” of their region. Again, the world watches a genocide.

Dr. Kukrika continues to take care of patients as cancer doctors lead the way in bringing advances in genetics and "precision medicine" to the bedside.

ACT SIX: The year is 2000. Y2K fears of computer disasters did not materialize; nothing happened when the clock struck midnight. Yugoslavian president, and accused war criminal, Milosovic is overthrown in an uprising. The US Supreme Court stops the recount of the presidential vote in Florida; George Bush wins. It is time to move on.

Dr. Kukrika continued to practice his unique brand of cancer medicine until he retired in 2000. So, what has he been doing since then?  For one, he has been very involved in local and national politics, strongly supporting several Democratic candidates (and hearing from the public their desire for universal health insurance). He still keeps informed about his specialty and skims some of the medical journals, but the new information is mind-numbingly complex and doesn’t stick in his brain when it is not used daily in caring for patients. He visits his daughter Anna in North Carolina and his son Nicholas in London.

Finally, he and his wife had enjoyed going to New York for theater, and since losing her to pancreatic cancer in 2004 at age 65 he has continued to seek the stubbornly-hidden answers to life’s difficult questions from thoughtful playwrights and meticulous museum curators. And he has traveled to far away places with strange-sounding names, searching for home.

You see, the country of his birth no longer exists. 

CODA: From Beckett (a favorite author):

VLADIMIR  [to Estragon]: Let us not waste our time in idle discourse! (Pause. Vehemently.) Let us do something while we have a chance! It is not every day that we are needed. Not that we personally are needed...But at this place, at this moment of time, all mankind is us, whether we like it or not. Let us make the most of it before it is too late!...What do you say? (Estragon says nothing).

Samuel Beckett

(Beckett, Samuel.Waiting for Godot. Grove Press, 1954, p. 51.)

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