Dr. KimberLee Mudge: Surgeon With a Vision

KimberLee Mudge, M.D.

Looking out over her farm’s pasture after a long day of breast surgery is “just good for my soul,” said Dr. KimberLee Mudge.  And on weekends, “the labor of mucking stalls is cleansing and rewarding.” Sometimes her 15-year-old son Peter is with her, sharing the vision and the chores. She noted that “there is something to be said for doing what our ancestors did every day” and that “it feels good to be connected to the earth” and to “try to be sustainable.”

Thinking about my own Eastern European shtetl-living and likely mutant-tumor suppressor gene-carrying forebears I quickly respond: “I’m not exactly sure what my ancestors did, but I know they did not do that.”  We laughed together, and so began a relaxed and far-ranging interview.

“So, you have a farm?” I asked.

“When I finished my residency at York I bought this little 1881 house and worked to restore it. It was on three acres. I planted an orchard, and that evolved into a woodland hobby farm. I grow sour cherries, apples, rhubarb, potatoes, squash, and blueberries. Also, I have chickens, and a few beehives.”

“Are you getting ready for the apocalypse?”

“That is what my partners Tommy (Dr. Thomas Nicholson) and “Iggy” (Dr. Ignacio Prats) joke about. When something happens, they say, they are coming directly to the compound.”

Not one to sit still, Dr. Mudge has expanded her vision and is now working on an old log farmhouse on the part of her property where she has already set up a “fiber farm.”  She raises alpacas, llamas, and sheep (the males are rams and the females, ewes, I was kindly reminded later), and she has a few miniature donkeys (the male is a jack and the female is a jenny, for those interested in such things). She hopes to grow this into an educational tool, as “a way of giving back,” she told me.

Freshly-shorn llamas and alpacas in Dr. Mudge's pasture

“How in the world do you have the time to do all this and practice medicine too?”
“My days never stop. I have zero downtime. But I think it keeps me good,” she said. Her son (she is a single parent) does his chores on the farm before and after school. He was adopted from Siberia, she told me.

(Did she say Siberia?) “Did you have to go there to get him?” I asked.

“Yes, he was almost a year old and institutionalized.”  The abandoned children (most are not really orphans) have very limited physical contact and nurturing. “You read about this,” she said, “but until you see it, it is something else. For the first couple of years, Peter did not know how to look into people’s eyes. He smiled on his own terms, but not (in a) reactionary (way).”

“They didn’t hold him or comfort him enough?”

“Not really.”

“Did you know the situation of the orphanages in Russia before you went?”

“I used Bethany Christian (adoption services), out of Lancaster, and they had never gone to Siberia before." (She paused...reflecting...) "Usually, when I am given an opportunity, I think of it as a sign, and that I need to take it. So I did.”

“Go on.”

“It was a nightmare situation,” said Dr. Mudge. But “he was in relatively good health” compared to the other institutionalized kids she saw when she got to the embassy where they and Peter were eventually sworn in as U.S. citizens.

“Did you have times when you wanted to back out?” I wondered.

“No, but the Communist environment was straining,” she replied. “After the first trip, Peter did not come home with me. On the second, they needed a redo of the paperwork that they had already received. This was followed by an appeal, and (I had to) stand before the court, and the sit-in judge was not happy about my request.”  Though her attorney pleaded with the judge Dr. Mudge feared that they were going to decline the adoption; she sensed that the process was being “driven by (the quest for) the American dollar.” 

Russian Orphans (from Ekaterina Loushnokova)

But (and here is a crucial point) Dr. Mudge is not one to give up when the goal is vitally important to her; she admitted that she “is a bit of a fighter.” So she persisted, stood up against the formidable Russian bureaucracy, and was able to rescue her son from what would likely have been a sad life.  “It was horrible, but I have no regrets,” she said.

Two years after finding Peter she started the process of adopting a little girl from China. The Beijing Summer Olympics were approaching, and TV images of children leaving the country would not be good PR.  (Remember when we all watched the same three or four networks, remember when the news was a shared experience?) The Chinese government changed the rules again and again and Dr. Mudge was disheartened as her hard work failed, and she reluctantly withdrew her request.

Moving on: “How did you decide to become a doctor?” I asked.

“Everyone in my family (in north-central Pennsylvania) was a school teacher and education was important. It’s weird, as a youth I was terrified of death, but, somehow, I wanted to be a physician. My passion was for science. I wanted to be my own boss. I wanted to make a difference. I thought that in medicine I would have autonomy.”

Unspoiled farmland in north-central Pennsylvania

“Tell me more.”

“I have always tried to push the envelope as a woman,” said Dr. Mudge. “I went to college on a basketball scholarship from Marshall University in Huntington, West Virginia. They also had a young medical school there” (making it especially attractive to her). Before medical school, she got a master’s degree in biology. Altogether, she lived in Huntington for ten years. At that point, family, friends, and her “hometown folk” thought she should be a pediatrician or a family doctor.

But KimberLee the medical student needed “action” and, as a visual learner, surgery was the best fit; the days flew by during her surgical rotations and she was excited by what she saw and wanted to share that.

She graduated from medical school in 1991. When looking for a residency she longed to come back to her roots. She wanted to be close to family, but in a somewhat less rural setting than where she was raised. While a fourth-year medical student, she did a surgical rotation in York with Drs. Steve Pandelidis, Tom Scott, Samuel Laucks, Gil Rothrock, and Vasudevan Tiruchelvam.  As she reflected on that formative experience,  York seemed to be the ideal setting; she loved the “family feeling” of the York Hospital where everybody seemed to know each other, and where they worked together.

An old postcard of the stately-looking York Hospital

Surgery in the 1990s was shifting, and as a young surgeon, she went through her five-year residency she sensed the push towards subspecialization.  Dr. Mudge decided to focus on women’s health and she reached out to one of her valued medical school attendings. She asked if she knew of anyone specializing in breast surgery.  Her professor did, and KimberLee contacted Dr. Claire Carman in Norfolk, Virginia.

She spent six months (“with essentially no pay”) shadowing Dr. Carman and learning everything she could, came back to York,  and began her practice of breast surgery. “This has been a good fit,” she said. It filled a void, as there were no (local) women physicians dedicated solely to women’s health.  And, as an added bonus, “it just felt right” and it was who she was.

Claire Carman, M.D.

“What changes in surgery of the breast  have you seen over the past 21 years of practice?” I asked.

Dr. Mudge recalled that when she came to York in 1991 she would scrub in for cases where the woman was about to undergo general anesthesia for a breast biopsy. The consent form included the wording that she would agree to an immediate mastectomy if cancer was found during the procedure. Standing by the draped and prepped patient in the cold OR, and realizing that she was the only person in the room that the patient knew was humbling. Dr. Mudge felt that these women were the strongest people she had ever met, knowing, as they did, that they might wake up missing a breast. Thankfully, that doesn’t happen now, as women almost always know beforehand what to expect.

In fact, by the time she started practice, the simple removal of just the tumor itself, the so-called lumpectomy, was already becoming the standard of surgical care. Routine Identification of what is known as the sentinel lymph node in the axilla (the armpit) allowed for easier staging without the development of the feared permanently swollen arm of lymphedema. The disfiguring radical mastectomy was gone and even the less severe modified mastectomy was fading. Breast conservation was much preferred. But things don’t stay the same.

Modified radical mastectomy (from the National Cancer Institute)

Since the mid-1990s there have been remarkable advancements in genetic assessment of cancer risk and genomic evaluation of the tumor tissue. Since identifying a number of mutated genes that increase the risk of developing breast cancer, most notably some of the many variants (perhaps a thousand!) of mutated BRCA-1 and BRCA-2 (tumor suppressor) genes located on chromosomes 17 and 13, respectively (discovered by Mary-Claire King, Ph.D.), women are becoming more “empowered” according to Dr. Mudge.

For example, even knowing, as carriers of certain mutations, that their chance of having breast cancer by the age of 80 may be as high as 70%, many of these high-risk women are choosing to have close surveillance and breast-conserving procedures rather than a prophylactic mastectomy. The women will, however, often have their ovaries removed to eliminate the also-heightened risk of ovarian cancer, since monitoring for that isn’t very good, and while treatment options are improving, they are still poor.

(Note to the men who have gotten this far: Males of the species harboring the genetic BRCA2 mutations have about an 8% lifetime risk of breast cancer and a nearly 25% risk of prostate cancer. This genetic information, you see, is not just for women.)

While genetic testing can identify women with an increased risk for cancer, “genomic” testing of the tumor itself can help direct treatment.  For example, with a commercial 21-gene assay, a low “score” predicts a 2% rate of distant recurrence at 10 years that is unlikely to be improved by adjuvant chemotherapy (that can, therefore, be withheld). A high score, on the other hand, predicts benefit from chemotherapy. This “preventive” chemotherapy may reduce cancer deaths by up to 70%. Endocrine therapy is now often recommended first for women with hormone-sensitive (so-called estrogen- or progesterone-positive) tumors. Other markers such as HER2 must also be taken into consideration as various new treatments are developed.

Women's risk of breast cancer by age and BRCA status

Curiously, despite the many advances and options, young women with one-centimeter localized cancerous lesions that are not associated with known genetic mutations are often choosing to have a (simple) mastectomy and breast reconstruction. They don’t want to have the fear of another cancer hanging over their heads for decades. “They want to get on with their lives,” noted Dr. Mudge, as they consider “lifestyle” issues to be paramount.

Decisions, decisions. Education gives women the tremendous advantage of a fully-informed choice. So Dr. Mudge and members of her team spend a lot of time and effort to be sure that adequate information is provided to every woman, and that the women fully understand their options. The management of diseases of the breast is now exceedingly complex; there are benign but suspicious breast masses, clearly precancerous growths, sharply localized cancers, cancer that has spread to regional lymph nodes, and even cancer that has spread distally at the time of initial diagnosis. Patients need time and help to take it in.

One algorithm for breast cancer (from Onkopedia)
(BCS=Breast conservation surgery)

“Handling the intense emotions that accompany a breast cancer diagnosis must be difficult for you,” I say.

While there is a little bit of hand-holding, a softening, Dr. Mudge tries her best to be “a straight shooter” and she doesn’t “sugarcoat” things. After the anxiously awaited biopsy is completed the fear and anxiety continue. She knows this and makes sure to call with the pathology results as soon as they are available. Dr. Mudge notes that at the time of this phone conversation the women “are on their own territory” and they can react “on their own terms.” They may “cry or throw things,” but this happens in private. KimberLee then arranges for an office visit within 24-48 hours to work out a plan.

She writes everything down and gives them their reports. They need to be fully informed. And with that information, they are more empowered and, hopefully, less victimized. Dr. Mudge reviews everything, and the woman gets to know her surgeon and the support staff. They need to develop mutual trust and a true partnership.

Some patients have told Dr. Mudge that cancer is “the best thing that has ever happened” to them. She said that “many come out on the other side stronger and more confident.” They have “conquered the beast.” She said that “it is quite remarkable” as some move on, maybe from a spouse that was not right, or gone on to college and become nurses. It is courageous to work through suffering.

Not really knowing why, I ask if she is optimistic about the future of her still-independent practice.

When she came to the York Hospital she was pleased that there was a feeling of family throughout the community. But over the last 20 years, the health systems grew and spread. It seemed to her that “respect for the clinicians” was being slowly eroded, and that physicians were gradually becoming “expendable commodities.”

Countering this trend, Dr. Mudge said, is that her surgical practice has remained unique. She and her partners  “have all subspecialized” but collectively they “function as one general surgeon.” And it has been ingrained in them that they have a sacred responsibility to the patient, who always “comes first.”

As the continued autonomy of her practice, “Leader Surgical Services,”  is threatened by the large health conglomerates that control patient flow Dr. KimberLee Mudge has needed to expand her vision of the future.

What does she see?

Maybe a bright new facility dedicated to the comprehensive management of diseases of the breast.  A place where patients and staff work together seamlessly. Where there is a focus on early diagnosis when suspicious lesions are still small and easily removed. Where the surgical procedure is carefully fitted to the specific needs of the woman. Where postoperative and late follow-up care occur in a peaceful nourishing setting.

Where this setting is dotted by plantings of lavender and sunflowers. And vegetable patches.  And fruit trees. Where honeybees flit from blossom to blossom. Where patients and staff can walk on lovely winding paths together. Where there is mindfulness of the needs of future generations. Where sustainability is a guiding principle. Where everything is connected. Where there is family.

That would be a nice vision. Squinting, I can almost see it forming in the distance...

Dr. Mudge's animals are watching us...

Suggested additional readings (from my husband's bookshelf):

1.  Capra, Fritjof. The Web of Life. Anchor Books, New York, 1996.

2.  Mukherjee, Siddhartha. The Gene: An Intimate History. Scribner, New York, 2016.

3.  Wilson, Edward O. The Future of Life. Vintage Books, New York, 2002. 

By Anita Cherry 6/27/19

Dr. Ed Rogers: Holistic Medicine

Ed Rogers, M.D.

Find a comfortable position. Take a slow full breath through your nose. Hold this in-breath for five seconds. Then slowly exhale. Repeat. And again. Did you, perhaps, note an interaction between the mind and your body? Did you begin to feel a subtle change? I sat down with York internist Dr. Ed Rogers who focused much of his energy on bringing the mind and body together in his medical practice. How did he get there?

“I grew up Catholic and went to parochial school till the sixth grade,” he said. “What the nuns did really well, what I took away from them was this: the sense that everything about Life and God was a mystery with a capital M.  Even as a young boy he knew that there was something out there “greater than us.” And he wanted to mingle with that Mystery.

Born in Baltimore, Dr. Rogers grew up in Pasadena, between Baltimore and Annapolis.  He and his two brothers often played by the Chesapeake Bay. (Sadly, his younger brother has passed away.) They had fun in nature. When it was time, his father, an architect, told his son that he needed “a reason” for going to college.

Ed thought of following his father’s fine example, but being left-handed, his father warned him, would be a huge disadvantage (before computer-aided drafting made that irrelevant). He should probably look elsewhere. Ed listened. He wanted to find something that was valuable in itself and he was drawn to the idea of medicine.     

He majored in zoology (actually biology) at Duke, but was careful to take courses outside of the hard sciences to broaden his perspective on life. Being a premed was tough, and he worked hard. So hard, in fact, that he missed two Grateful Dead concerts and a campus appearance by Bruce Springsteen. But he liked being on the water and he joined the Duke sailing club and enjoyed a few special trips through the Bahamas. Ed graduated from college in 1978.

Duke Chapel (from KEnZPhotography)

He worked in a virology lab for six months and then taught white-water canoeing before going to medical school at the University of Maryland. The study of medicine was hard and, as a “mere mortal” he was tested, he reflected.

At the end of his "exciting, exhausting, and humbling" freshman year of basic science, he took a one-month rotation with a Dr. Greg Pinkerton in Eglon, West Virginia. This young idealistic doctor had only finished his internship, and yet he was the town physician. Ed had a formative experience;  Dr. Pinkerton was a good teacher and kind to all. “Hey! This might be something I could do,” he thought to himself, excitedly.

That was his first mentor, but the infectious disease specialist Dr. Frank Calia and rheumatologist Dr. Wolfe Blotzer “made us better than we believed ourselves to be. He helped us to develop confidence,” noted Dr. Rogers. His first encounter with Dr. Blotzer was at an hour-long clinical-correlation lecture where Wolfe lamented that the average student remembers only the first five minutes of a talk.

The evidence of that? Well, Ed said, with a laugh, that he recalled Dr. Blotzer’s introductory remarks, but that he had “no idea what he said after that.” An hour really is too long, and maybe the TED Talk rule of no more than 18 minutes makes sense. Attention wanders after even ten minutes.  (I can sense that you are beginning to lose focus already, your thoughts are probably headed somewhere else. Please pay attention. Try to stay in the present moment.)

J. Wolfe Blotzer, M.D.

But after a talk people do remember how they felt; the primitive emotional limbic system is slow to forget.

Anyway, Dr.Blotzer popped up again teaching him physical diagnosis during the second year. He demonstrated how to take a “patient-focused” history that “asked about the person” and “how the illness affected their life.” This mantra was repeated over and over; it eventually sunk in.

Through medical school, Ed didn’t especially take kindly to surgery or obstetrics, but he enjoyed everything else. He decided to go into the broad field of internal medicine. When the time came for residency Wolfe showed up again and advised Ed to take a look at the York Hospital program. He did that and was quite impressed by the strong medical staff; they liked him, and he “matched.” He came to York in 1983.

“Did you bring something different (than your peers) to the practice of medicine here?” I asked.

Pausing briefly, and thinking carefully, he said Yes. He felt that he brought himself. "I thought I was a good listener," he said, "and I felt strongly about the importance of self-care and lifestyle changes as being fundamental to one's health and well-being." And his desire to get to know his patients through ongoing relationships over time, to take the long and holistic view of good health, not simply illness, as was the focus in medical school.

After finishing his residency he did a fourth year as Chief Resident.  Dr. Rogers then joined the private practice with Drs. Fred Kephart and Steve Kreiger in 1987. He quickly saw that the medicine he was taught in school did not always address the patient’s real needs. 

Many (if not most) of the people a doctor sees have chronic conditions and vague symptoms that can’t be cured or alleviated by specific medicines or surgical techniques. Anxiety and fear about illness, and about life’s struggles, make things worse. It is said that a caring compassionate doctor can help alleviate suffering just by his or her presence. The placebo (“placebo” means “I will please”) response in the effective medical encounter is powerful and is accompanied by changes in brain chemistry and neural activity (as I am told by my husband).     

In his mid- to late-thirties Dr. Rogers tried mindfulness meditation to help him connect with the mysteries that still tugged at him. He took up a regular practice of this, and it helped. It then occurred to him that he could bring this gift of self-awareness to his patients as part of a holistic approach to health. This would also include informed self-care, balanced healthful nutrition, regular physical exercise (including yoga), other relaxation techniques, and restful sleep. But he did not know how to proceed.

He found a three-day workshop for the teaching of stress-reduction to cancer patients. Someone advised him to “check out Herbert Benson,”  the Harvard cardiologist who described “The Relaxation Response.” This idea was based on meditation traditions but stripped of their overtly spiritual or religious features. It was geared to help his heart patients cope with the stress that affected their cardiovascular system. The stress that delayed recovery from acute events and it often worsened the underlying disease.   

Dr. Jon Kabat-Zinn with Dr. Herbert Benson

Dr. Rogers took up the challenge. He did three intensive retreats with Dr. Benson’s group, and he was energized. He then was fortunate to meet Dr. Jon Kabat-Zinn, developer of Mindfulness-Based Stress Reduction (MBSR), and did two stimulating workshops with him. Good scientific research into the emotional and physical effects of meditating and yoga was just beginning to be available, making these “new age” or “alternative” practices slightly more acceptable to an ever wary medical establishment.

(Several decades ago “someone” handed me a book, The 28-Day Yoga Exercise Plan, to help me give up my seemingly-harmless “social” smoking. The slim woman in the stark black-and-white photos wore a pale leotard and matching tights; the now-ubiquitous patterned and colorful yoga pants had not been invented. I managed to do some of the positions and easily stopped smoking. Did the yoga itself help me stop, or did the giving of the book? Or were both needed?)

"I can't breathe, I can't breathe..."

The meditation and breathing techniques Dr. Rogers learned from the masters helped him cope with his own stress of raising two daughters (with his ever-supportive wife) and “working too many hours a day” in a busy primary care office. With this experience, he was ready to share his knowledge; he knew he had something. 

One day he cornered one of the York Hospital administrators, and, with his usual zerizut (see below), he said that running a stress reduction program and teaching meditation would be a great idea for the community. But York was not quite ready. 

Undeterred, Dr. Rogers said to himself that he and his patients were ready.

He started slowly with his office staff (practicing on them), and they mediated together during lunch break. (I hope no one was so relaxed that they fell sound asleep and couldn't get back to work.) He then cautiously offered simple guided meditation exercises to a few of his patients. After a while, he developed the confidence that he “could teach this.”

A year after his idea of an innovative program for stress reduction was nixed such things had caught on elsewhere, and the York Health System was more open to it and the broad field of complementary medicine including acupuncture, massage, yoga, tai chi, and nutrition. The mind-body interaction was integral to a holistic approach to well-being.

So, along with psychologist Jere (Kottkamp) Howell, Dr. Rogers started the program with eight-week stress reduction sessions modeled after Dr. Benson’s approach. His co-leader unexpectedly left the area the following year (2000) and he then ran the comprehensive Mind-Body Center himself (and worked full-time in his regular practice) until 2014. He was very happy to see the successes (and that mindfulness itself was rapidly becoming mainstream and part of our culture). 

He enjoyed the challenge of spreading the word and the practice of mindful attending to the present moment.

Over the years Ed kept up his personal practice of meditation and mindfulness. He learned to take a few deep breaths as a “sacred pause” and to feel his feet firmly planted on the floor before opening the exam room door to warmly greet the next patient. He learned to “focus” intently, to listen closely with compassion, and to give his patients “the time they need.” 

What are the effects of non-judgmental conscious awareness of the present moment?  The practice of mindfulness meditation, often focusing intently on the breath and letting intruding thoughts pass without judgment, can induce the so-called “relaxation response” described by Dr. Benson. This voluntary activity engages the parasympathetic limb of the autonomic nervous system, the system of “rest and digest.” Blood pressure, pulse, and muscle tension decrease, and markers of inflammation (like CRP and interleukin-6) diminish, as stress hormones of “fight or flight” (such as adrenaline and cortisol) fall. This sympathetic/parasympathetic balance is tipped and the effects are widespread. 

Functions of the autonomic nervous system

Brain structure is also affected. One study of new meditators showed that as little as an eight-week course in Kabat-Zinn’s MBSR resulted in increased gray matter in brain areas associated with learning, memory, and control of emotion including the hippocampus. There was a decrease in the density of neuronal gray matter in the amygdala, the key site of the fight or flight responses of fear and anxiety (Marchant, p. 170). 

Hotzel, BK Psych. Res. 2011; 191(1): 36-43

Dr. Rogers told me about studies on telomeres. (I had absolutely no idea what he was talking about but my husband helped, once again.) Telomeres are structures at the ends of strands of DNA, and the longer the telomere the longer the life of the cell it is in.  The enzyme telomerase slows the age-related shortening of the telomeres. Studies have shown that meditation may lead to increased telomerase activity, and may slow the aging process (Goleman and Davidson, p. 177).

Experienced meditators and veteran yoga practitioners likely have long-lasting changes in brain structure and connectivity, and there are new enduring "traits" not simply passing "states." There is much to learn about how mindfulness and other forms of meditation modify the brain and affect the autonomic nervous system (and the endocrine and immune systems), but there has been little doubt for thousands of years that what happens is beneficial. 

How the practice (and some type of meditation is seen in all religious traditions) affects the soul and informs ethical (social) behavior may be even more important, and a more profound mystery.     

Three months into “the very edge of retirement,” Dr. Rogers feels that “in the long run” he did what he “set out to do.” He rediscovered some wonderful ancient tools to help himself in his own spiritual journey and tools to help his patients cope with illnesses and suffering to bring about well-being. He doesn’t know what the future holds as he and his wife move to Vermont (one daughter is in Boston and the other lives in Upstate New York) but, as Ed says, “that’s exciting.”

There is a Vipassana, or Insight, Meditation Center a few minutes from where they are moving to, and Dr. Rogers plans to check it out.



Sitting quietly,
Doing nothing,
And the grass grows by itself

(Matsuo Basho 1644-1694)

Photo by S.C.

Readings:

1. Benson, Herbert, M.D. Beyond the Relaxation Response. New York: Berkley Books, 1984. (Still relevant.)

2. Golman, Daniel and Davidson, Richard J. Altered Traits: Science Reveals How Meditation Changes Your Mind, Brain, and Body.  New York: Avery, 2017. (The best review of the science.)

3. Hittelman, Richard. richard hittleman's Yoga 28-day exercise plan. New York: Workman Publishing Company, 1969. (For the pictures.)

4.  Marchant, Jo. Cure: A Journey into the Science of Mind Over Matter. New York: Broadway Books, 2017. (Highly recommended.)

A Definition:

Zerizut: A Hebrew word that is often translated as “zeal,” “alacrity” or “promptness.” Zerizut is the spark that catalyzes us to quickly and effectively do the things that need to be done. However, according to Alan Morinis, it may more accurately mean clear, deliberate, single-mindedness. This may be achieved, of course, through a meditative practice (see article).