Sharon Scott, M.D.: Fearless Compassion

Sharon Scott, M.D.

Her mother delivered a fourth child, a boy. Melvin seemed perfectly normal at birth, and everyone was happy as his early development progressed as expected. He crawled, and he learned to sit. But at six months of age he began to have minor seizures followed by repeated violent convulsions. While the family watched, Melvin lost motor control, lost the ability to sit; his behavior steadily deteriorated. As a result of the unnamed neurological disorder he failed to develop. He was unable to feed himself, unable to walk, unable to gesture, unable to speak; he could not communicate at all.

The neurologist in Montreal, ten hours away, told her mother that while all of her children will have worries and stresses in life, “this child will always be happy in his own world.” Those generous healing words stuck with, and sustained, the family.

Of Melvin’s three siblings, the eldest, by virtue of her position in the family, stepped in to help her mother take care of him. Untrained in medicine, and living in a small town far north of Montreal, her mother was forced to teach herself nursing and doctoring to care for her fragile son. As she lovingly treated him, her daughter watched closely. 

Dr. Sharon Scott is that daughter and sister whose childhood was not what one would have expected, and who "got up at six o'clock in the morning and took great pride in helping Mum with Melvin, and got two hours of housework done before going to school." She noted that her younger siblings, Gary and Lynn, played their roles as well, and Dr. Scott remains close to them.

Noranda Copper Mine, Murdochville
(c/o Bob Anderson)

In Murdochville, a far-eastern Quebec copper-mining town of 4,000 then, the frigid winters lasted until April. Not everybody went to university then, and “nobody” (yes, really, nobody) went on to study medicine. While her mother raised the family her father “worked from morning to night.”  He was “driven and highly-motivated, and taught himself everything. He built a construction company, and did very well," Dr. Scott said, with obvious respect.

She did well enough, herself, in school, and enjoyed sports and student council, but had “trepidation” about going to college, about leaving her family, leaving her mother and her brother. She was attached to him. Choices. What to do? 

Dr. Scott noted that “in the early 1970s women were teachers or nurses.”  She applied to nursing school at John Abbott College in Montreal. She went there, and graduated. ”This totally changed me," she said, as she, for the first time, “became interested in studying and learning.”

The new Manitouwadge Hospital

She was now 21, and good local nursing jobs were hard to come by. She moved to another small mining town, this time north of Lake Superior in northern Ontario. She worked and learned at the tiny Manitouwadge General Hospital. When on night shift there were no doctors around and she was the only nurse in the hospital as she and an aide were on their own.  Reflecting on that experience, she said, "Looking at the moon as I drove to work, I would pray to God that the night would go well. I was utterly terrified. I wondered if I had the skills to take care of the patients by myself.” 

At night she managed deliveries by herself. She watched babies die with SIDS. She administered CPR. Some patients lived, and some died. She washed the bodies of the deceased, dressed them in burial shrouds, and placed the “toe tags,” before slowly sliding the morgue drawers closed. At times, she was “absolutely petrified.” 

When she later on accepted the position as public health nurse (a job for which she, of course, had not been specifically trained) she had to travel to the nearby “Indian reservation,” and she needed an armed police escort; there was a lot of abuse in this poor under-served native community, she explained, and it  could be dangerous.

As I heard these words, I wondered, “Who would choose to continue to do nursing under those conditions?” Her calm reply: ”You did what you had to do.” Yes, you did what you had to do.

But she needed to know more, and she dreamed of getting a university degree. So she took a few correspondence courses before moving to Hamilton, Ontario, to attend McMaster University for a B.S. in nursing. While there, she studied International Health with Dr. Susan Smith (“an amazing woman”). She enjoyed the difficult work and was encouraged to do an elective rotation at Aga-Khan University (in partnership with McMaster) in Karachi, Pakistan.

Headline from Islamabad Newspaper 

Dr. Scott was getting ready to leave for Pakistan when President Zia Ul-Haq’s plane crashed under "suspicious circumstances" (on August 17, 1988). She went anyway. She was 30. Her parents were strong, and they encouraged her “to explore the world.”
(Landing in Karachi, she was shocked to see armed soldiers on the tarmac, their  Kalashnikovs ready for firing. Flashback to words of wisdom before her departure: “If shelling has started, and you are on the tarmac, lie down and pretend you are dead.”) 

And now, in 2018, would she provide the same encouragement to her 13-year-old daughter Lily, the daughter for whom she had waited so long? Without hesitating a second, Dr. Scott, now in the role of the protective mother, said, ”I tell you, it would not be the same."

Back to 1988. So the plane arrived safely in Karachi, and “it's wild.” Millions of people, rickshaws, wandering animals, more people, teeming with people, and...lumbering elephants. It's hot, dirty, smelly. Overwhelming. “You can feel it in the back of your throat,” she said, as she briefly relived the experience. The smell of open sewers, the swarming mosquitoes, and human waste. “It burns." Did she turn and run? Did she seek safety? Why, of course not! Sharon dug in. 

Aga-Khan University Hospital 

She stayed at the residences at the Aga-Khan University where there were “lots of (American and Canadian) expats,” including professors from McMaster that she knew fairly well. And the intrepid student-nurse adapted quickly. For her research project she looked into the nutritional status of the local pregnant women. Unfortunately, there were a lot of superstitions and rigid customs about what foods could be eaten, and which could not. As a result, “there was a huge problem with malnutrition.”

She went around with an Urdu interpreter, and had to wear proper traditional dress (a long tunic) and a head-covering. She said, “We would ride ‘shotgun’ in the van to the outlying villages, and there was always killing.”  

“That must have been terrifying,” I noted. 

She replied, “Just doing what I’m doing.” As if there is no danger at all, or that the obvious danger must be pushed into the background to get the needed-work done.

“It was a time for the first free elections in Pakistan but ‘free elections’ in Karachi meant that they had army tanks sitting outside the polling booths telling people what they could or couldn’t do,” she told me.

She did the maternal nutrition research for two months and she “really liked it.” The professors liked her, too (she received a national Canadian award for the work), and they asked her to come back and join the joint faculty. She quickly accepted, and on her return to Pakistan after receiving her degree she taught public health.

She realized, however, that she was still doing “a lot on the fly” and that she “would really like to have skills” to take care of her patients better. She “would love” to study medicine in more depth. How? She discovered that in Karachi she could  go into a “little shop” or “tiny cafe” and purchase illegal photocopies of standard American medical textbooks “for a dollar or two.”  

For ten dollars, the future Dr. Scott could collect all the books she needed to study medicine. “What a great thing!” she thought. She could, like her father, teach herself anything. So...medicine it was.

Let’s go back to 1986, before Pakistan. She was cajoled by friends to take a much-needed vacation break on her own, and she picked a family resort in the Caribbean. On the first day they sat her at a table with a gentle man and his two adult daughters.

The famous St. Lucia Pitons

"Hello, I’m John Mathai from York, Pennsylvania, and I’m a heart surgeon,” he opened.

"Well, I am Sharon Scott, and I’m a nurse from Toronto," she replied.

Reflecting on this now, she noted, “This is such a cheesy story.” Anyway, they spent a lot of time together that week, and got to know each other. At one of the last dinners they came down the steps together and the official resort photographer took a picture of them under a trestle of flowers. She thought, “This is what people do when they get married."  Perhaps this same fleeting image occurred to the recently-divorced Dr. Mathai (not so fast buddy boy...) and before leaving for home he gave her a copy of that photo with his office phone number written on the back. 

They reconnected later, and he visited her in Toronto “once or twice,” but it was not the right time for a serious relationship.

Nurse Scott went off to Pakistan and did her thing for a year. She shared a flat with Tina, a Fulbright scholar, and related her story about the humble man she met a few years before. Tina, noticing her interest, said, “Why don’t you call him?” Sharon got up her courage, and called. Dr. Mathai quickly rearranged his schedule so he could meet her in Toronto on her return.

Afghan Girl
(c/o "National Geographic")

But just before leaving Pakistan she and two of her women-friends flew to Islamabad and hired a driver to trek up to the Afghan border since (get this) “the Afghan war with Russia was over.” At the border they met the security guards. Dr. Scott and her comrades wore the full burqa covering and (hold onto your seats) they learned to shoot the previously-mentioned Kalashnikov (aka the AK47). Dr. Scott noted that despite the seeming hopelessness of their situation, the inner beauty of the Afghan people was striking, and she is unable to forget the look in the eyes of the lovely shepherdesses.   

After this she returned to Toronto for her dreaded medical school interview at the super-competitive McMaster (4,000 applicants for 100 spots) and Dr. Mathai met her there (in Toronto, not at the actual interview). Though the prospective medical student had not seen him in three years it was as if they had been together the day before. She decided that if she did not get into medical school she would go back to Karachi and continue with her life there without him, but if she did, they could see each other.

She was accepted, of course, in 1989, and medical school itself “was easy, and it was fun” and she went “straight through” and graduated in 1992. During the three years of study she and Dr. Mathai met either in Toronto or York every other weekend, and they decided to stay together. That worn photo of them under the trestle of flowers was displayed at their wedding and read, “The Island of St. Lucia, the summer of '86;” someone knew something we did not.” 

Her direction in medicine? Dr. Scott’s experience taught her that it was critical to treat “the whole patient,” and she applied to internal medicine programs, including the coveted Johns Hopkins. She was accepted there, but (are you ready for this?) she turned them down in favor of the community-based York Hospital residency. She felt that there were “excellent teachers” in York and that it was a “strong program.” She did not want to travel back and forth to Baltimore and she “didn’t need the paper” from a prestigious institution to let her know who she was. She felt “very proud and privileged” to be a physician.

At York she completed the three-year program in 1995 as Chief Resident. She then practiced and taught general internal medicine, both inpatient and outpatient, through the Internal Medicine program for 15 years. Dr. Scott has spent the last eight years as a hospitalist, and was recently appointed as the Site-Director for the Academic Hospitalists with WellSpan. She focuses exclusively on the inpatient service, and the task of teaching the art of medicine to students and residents. 

Sir William Osler c. 1912

Her own most important mentor? The nearly-legendary Dr. Wolfe Blotzer. She noted that he was the former program director (her director) who, like Sir William Osler (another Canadian, by the way), was “a master of medical knowledge” and the consummate clinician.  He shared his knowledge with Dr. Scott, and shared her love of medical quotes. Quotes such as Osler’s: “To study the phenomena of disease without books is to sail an uncharted sea, while to study books without patients is not to go to sea at all" (Osler, p. 210).

The nurse-doctor, student-turned-teacher, tries to pass on to her own students what she learned working alongside Dr. Blotzer, and what she had learned from her patients. She models close compassionate listening to arrive at a correct diagnosis and, more importantly, to understand the patient’s full needs. Listen carefully, and the patients will tell you the diagnosis (there's Osler, again); listen, and they will tell you what they need.  

She sees that while the students and residents can use phone apps expertly to find information in seconds, they often struggle with the interactive and communication skills. To help them (especially, with difficult patients) she employs role-playing before asking them to enter the patient’s room for that ever-critical history-taking and confirmatory physical exam. 

"The Lost Art of Healing":

Dr. Scott strives to engage her patients on a level field as she and they work things out together. The effective physician, in addition to mastering the science of medicine and the knowing the limits of diagnostic testing, must get to understand her patient’s full range of needs, the physical, emotional, and social. She must know where the patient wants to go from where they are, and how that journey may affect her loved ones. Dr. Scott says, “Let’s work together. How we can help you?”

Cardiologist Dr. Bernard Lown writes, “If there is a partnership in medicine, the senior partner has to be the patient, who must not be deflected from having the decisive word” (Lown, p. 77).

For her efforts with students, Dr. Scott felt honored this year when she went to Philadelphia to receive Drexel University’s “Dean’s Special Award for Teaching” at the medical school graduation ceremony.  

(Although her career goal was always to pursue studies at a higher level, as she certainly has, her dream was to have a child. Lily Scott Mathai, her daughter, is that dream, who “came home” from Guatemala at the age of three-and-a-half.  Simple words cannot convey the depth of Dr. Scott’s gratitude for that “gift from above.” Family, you see, means everything.)

A true clinician, in the words of the renowned Dr. Philip Tumulty, of Hopkins, is “one whose prime function is to manage a sick person with the purpose of alleviating most effectively the total impact of the illness upon that person” (Tumulty, 1970).   

To that, Dr. Scott adds that she hopes “to give people the strength and the resources that they need to help themselves.” She strives to treat them “with respect and humility,” just as she would want done for her own family. While this is not be something you can teach through a lecture, it is something you can model, and is something that others can seek to emulate. 

Dr. Scott watched her mother care for Melvin. She watched her father teach himself what he needed to know to support his family. She watched her physician-mentors. She watched and learned. The next generation watches her.

"In these days of aggressive self-assertion, 

when the stress of competition is so keen

 and the desire to make the most of oneself so universal,

 it may seem old-fashioned to preach the necessity of the virtue

 of humility for its own sake,

 and for the sake of what it brings,
and that a due humility should take the place of honor...
amongst the influences which make for a good student, and a good physician."

Sir William Osler, to medical students at the University of Minnesota, 1892 (Osler, p.38)

References:

1.  Lown, Bernard, M.D. The Lost Art of Healing: Practicing Compassion in Medicine.  Ballantine Books. New York 1996. (Recommended reading.)

2.  Osler, Sir William. Aequanimitas: With other Addresses to Medical Students, Nurses and Practitioners of Medicine. P. Blakiston's Son & Co. Inc. Philadelphia, 1932.

3. Tumulty, Philip, M.D. "What Is a Clinician and What Does He Do?" NEJM 1970; 283: 20-24. (Essential.)

Joel Winer, M.D.:The Practice of Neurosurgery

Joel Winer, M.D.

Just before Dr. Winer was to start medical school his then-brother-in-law “fell off a cliff” and was severely brain-injured. After the “dominant-hemisphere” injury he was hospitalized for a year and was non-communicative. I struggled to listen as the doctor quietly told me this sad family story. "It was a long drawn-out process,” he said, “and he ended up being institutionally supported for the remainder of his days, which was until, maybe, five years ago.”  Dr. Winer admitted that "subconsciously" this may have influenced his career choice...but he's not sure.

Dr. Joel Winer is an ever-so-slightly-graying but still boyish neurosurgeon who has served the York community for nearly 27 years. I asked him how the serious and often life- and personhood-threatening problems he sees nearly every day affect him. Does he, say, discover that he is more grateful for what he has?

After a short pause, he answered, "Neurosurgery is a microcosm of life. There are ups and downs, and you have to celebrate the ups a little more. That works for me. You complain less about the little things. A flat tire becomes less important." 

A Hospital in Honduras

Continuing his thoughts, "The privilege of being a part of medical missions in Honduras for a number of years also gave me a good perspective about what we take for granted and what we should be more grateful for. We wander through the day, not realizing that tomorrow may be the day we have a problem." 

"Life hangs by a thread," I offer.

"It's fragile. We all have these elements. When someone comes in with a brain tumor diagnosis (for example) they are losing direction. We all have a piece of that, because of the uncertainty of life. So, if we can help one another, instead of (following) Western hemisphere competitiveness, it could be better," he softly explained. He went on, "Growing older, we learn a lighter footstep than when we were younger. We try to do the best we can."

"But it seems that many parts of your practice could be so depressing," I say.

A quote from Viktor Frankl

"I think that," he noted wryly, "depending on your existential perspective, life can be depressing. For me, neurosurgery is life. The basis of humanity is that we can make a good thing happen. Sometimes (when things are dark) it's hard to see that humanity is going to win out. At base we have to be good, otherwise, we are not going to continue to exist...(and) we do better together than individually." 

As we talked further I was moved by his clear and balanced optimism about life despite what he has seen and what he does. "You might be one of the happiest doctors I’ve met," I blurt out, without thinking. 

"Maybe I am just a happy person," he responded, with a smile, and a laugh.   

Location of Niskayuna, NY

Dr. Winer is originally from a little town in upstate New York just east of Schenectady called Niskayuna (the Mohawk word for "extensive corn flats").  

[Wikipedia notes that William Edelstein, one of the key developers of MRI, the technology that has changed neurosurgery forever, lived in Niskayuna, too. But more on that later.]

His dad, a retired optometrist, who will be 90 in July, was the only member of his family who went to college. He is "one of the nicest men on the planet," according to Dr. Winer, and when his patients couldn't pay for their care he understood, and just let it go. 

When his father became “bankrupt” he joined another optometrist, this time as an employee. After one of their patients complained that their eyelashes were hitting their new glasses the guy he was working for said "close your eyes" and simply trimmed the offending curved hairs. Shocked, Dr. Winer’s father said to himself, "I'm out of here," and he left. He then opened a practice of his own in the small textile-manufacturing town of Cohoes (Mohawk for "place of the falling canoe"). 

Dr. Winer's mother is 88 and is a "wonderful" wife and mother who, after raising her three sons, did real estate and was a school guidance counselor. His older brother is an accountant and his younger brother is an electrical engineer.

The happy youngster wanted to be a doctor, even in high school, and Dr. Winer left New York to begin his studies. After receiving his undergraduate degree in nuclear chemistry from the University of Maryland at College Park he went further south to Tulane for medical school. He then came back north again and did a grueling neurosurgical residency at Temple in Philadelphia under Dr. William Buchheit, "a terrifically tough fellow."  

National Hospital for Neurology and
Neurosurgery, Queen Square

He then went east (really east) and did a classic neurology rotation at the National Queen Square Hospital in London. This was followed by a trip north (far north) for a fellowship in seizure surgery at the Montreal Neurological Institute with the epilepsy pioneers Drs. Andre Olivier and Theodore Brown Rasmussen. 

He considered academic medicine, focusing on surgery for epilepsy (he was signed up to do a fellowship in Connecticut and at the last minute changed his mind), but decided that such a practice was not for him. He was better suited, he thought, to be a general neurosurgeon, and to be able to make it to his kids' soccer games. After this hard decision was made he “never looked back.”

So, how did Dr. Winer then go a little bit west to wind up in York in 1991? Well, one of his now-retired partner's sons was a medical student (now also a neurosurgeon--go figure) who rotated on the Neurosurgical Service at Temple. It was about time to look for a practice and Dr. Ron Paul's son said, "Why don't you come and look at my dad's place in York."  

York? He would consider the idea. Since his wife is from Palmyra, just outside of Hershey, he toured the practice and liked what he saw. Despite his previous travels, he noted that "We always (aim to) settle within, you know, 100 miles of our in-laws." So he joined the group and has stayed here since.

Russian Cossacks on the March
(Carl Ernst Hess c.1800) 

Speaking of his wife, Dr. Winer admitted that when they were younger she used to refer to him as “the rebel.” He explained to me that this trait “may be cultural." His grandparents were from Odessa, Kiev, and Warsaw. They were Eastern European immigrants who “survived because they fought.” Sometimes his grandmother wondered "why we were not rioting in the streets." Dr. Winer reassured her that she was safe, that “the Cossacks are not coming over the Urals.” 

I wondered if he recalled any particularly moving or memorable patients that he’s taken care of over the years.

Memorable patients? He thought for only a few seconds before he said, “One who just got married.”  Dr. Winer had met the newlywed from Honduras in 2010 when the patient had a “dorsal midbrain lesion” (at the back of the all-important brainstem) and was referred here for treatment. Dr. Winer had arranged for all of his intricate coordinated care to be donated. 

The young patient did "terribly well," but years later had a “shunt malfunction” and returned to York. The “rebel” surgeon and Dr. Robert Schlegel (one of his partners then) "agonized" for several days over what to do. Could they help the man again without doing harm? They struggled, and finally operated. “The patient came through it...mercifully.” And “it was probably more than me at hand,” he believed.

Another especially memorable patient had a glioblastoma, the most malignant of brain tumors, with an unusually prolonged remission. For reasons he admitted he didn’t understand, “the darling fellow went 11 years (without disease) before his tumor came back.” He then added, ”When we have that rare long-term survivor we don't know why, and we celebrate when they come in.”  

He feels that medical science often progresses by serendipity and that  the answer for glioblastoma “will come in a very left-field way." While there have been advancements in supportive care for these patients such as more precise surgery for non-dominant hemisphere lesions, effective adjuvant chemotherapy, and advanced radiation protocols, “we still don't (fully) understand the biology.” But we are getting closer. 

“What major technical advances have you seen in the past 30 years?” I asked.

(Time for a few tidbits of neurosurgery and brain imaging history.)

Trepanning  c.1350 (Getty Images)

[There is good evidence that holes were drilled in skulls more than 5,000 years ago (and that at least some individuals survived this so-called trepanning to, maybe, release the evil spirits), but operating on the brain was dicey until modern neurosurgery began with Dr. Harvey Cushing at Johns Hopkins at the turn of the 20th century. However, they were still “in the dark.” Without any way to image what was going on in the brain before sawing open the skull, the surgeon made a preliminary diagnosis based entirely on a meticulous clinical history and a detailed physical examination. 

This usually allowed him to “localize” the lesion and make an informed guess about the cause of the problem, but he could be surprised and the actual lesion could only be confirmed by seeing it.  X-ray (though in use since 1895) was of no help with the “soft tissue” of the brain and spinal cord.

So in 1919, Dr. Walter Dandy at Hopkins came up with (dare I say) a “dandy” solution; the spinal fluid was drained and replaced by air. This allowed better contrast between the brain tissue and surrounding or internal structures by plain x-rays. The patient was immobilized strapped to a chair and twirled around into different positions to get the pictures. It was, needless to say, not well tolerated, and it was “indirect.” This pneumoencephalogram, as it was called, was still used into the 1970s! 


Another indirect way to see what was occurring in the brain was devised in 1927 by the Portuguese neurologist Edgar Moniz. He injected dye straight into the carotid artery (ouch) and took a rapid series of x-ray pictures of the blood vessels. This “angiogram” showed displacement of normal landmarks, and any abnormalities of the vessels themselves, but not the actual tumors or other masses. Again, it was partly a guessing game for the brain surgeon. 

Left carotid angiogram (from NeuroradialAccess)

The breakthrough came in the early 1970s with the CT scan, invented by Godfrey Hounsfield in 1967 at the EMI lab in England. The science evolved rapidly and the first MRI images of a human were published in 1977 (the scan took five hours). Since the late 1970s both CT and MRI have improved spectacularly.]
(Back to Dr. Winer.)

"I can't imagine practicing surgery in the 1950s when the giants in neurosurgery were laying the foundation. We stand now on their shoulders." Dr. Winer said.

MRI Spectroscopy of 2 tumors (From Franklyn Howe)

He notes that MRI and MRI “subsets” such as MR angiography (to be able to see arteries without the danger of catheters), MR venography (to visualize the draining veins of the brain), MR spectroscopy (to image metabolic activity to distinguish tumor from an abscess, for example), and cine-flow (to watch the flow of spinal fluid) have revolutionized his beloved specialty and have made tricky brain and spinal operations much safer and remarkably more precise. 

In addition, there have also been key advancements in neuroanesthesia, and there is the emerging technique of “computer-directed surgery.”  With the electronic health record “they can read my (poor) handwriting,” he noted, “(and) my history and orders are accurate and immediately available (across the health system).”

Site of temporal lobectomy
(From Mayfield Clinic)

What procedures does he especially like to do? Temporal lobe resection for uncontrolled epilepsy is particularly rewarding, as seizures often stop occurring or are more easily controlled. He is also happy to be able to alleviate back and leg pain by doing a discectomy and lumbar fusion, or to relieve neck and arm pain or spinal cord compression by cervical disc surgery. Removing a benign and superficial “convexity” meningioma is also very rewarding. Implanting electrodes for so-called “deep brain stimulation” for Parkinson’s disease relieves tremor and other abnormal movements but, regrettably, he noted, does not stop the progression of this debilitating disorder. 

With the “interventional” vascular expertise of one of Dr. Winer’s new partners, aneurysms and vascular malformations can be treated definitively without craniotomy, without exposing the brain to the air. And the damage caused by a clot blocking a major artery can be reduced by removing the thrombus, even 24 hours after the onset of the stroke.

So, what do we see in the future? Tomorrow's neurosurgeons need to integrate information technology with the evolving advances in imaging, molecular biology, and genetics. Surgery itself will become even more focused on minimally invasive techniques and will increasingly use digital technology. True team efforts will be more important than ever. Today’s intractable problems will be less so. 

Hyper-SCOT Decision-Making Navigational 
System (Okamoto in Biomedical Engineering 2017)

Hours after the interview ended, later that evening, my husband pointed me to an article on Medscape: “The Inexplicable Irony of a Future Neurosurgeon Losing His Father To Brain Cancer," by David Kurland, M.D., Ph.D. 

My eyes took in the faces in the photo beneath the title. A mother, a father, and a son smiling together on their porch. I wanted to stay with this image. I did not want to read the story, but I did. A just-graduated medical student had received the “match” for his longed-for seven-year neurosurgical training. Soon after, he learned that his father had a deep-seated aggressive and, therefore, non-surgical brain tumor. Sadly, there was nothing to do, and his father died several weeks later. 

Surrounded by friends and family he put his father to rest. Shortly thereafter, as had been planned, he celebrated by marrying his beautiful fiancé. 

Celebrate the ups. Celebrate life. Because, yes, it really can change in a moment.

An update on a possible treatment for glioblastoma (from MedLinx 7/26/19):

Neurosurgeons at Massachusetts General Hospital crafted a CAR-T cell that can be delivered into the cerebrospinal fluid. When it gets into the brain, the CAR-T then secretes a second type of immunotherapy, called a bi-specific T-cell engager, or "BiTE." This" can have a local tumor effect by targeting the second tumor antigen. In an animal model of glioblastoma, they found that the modified BiTE-secreting CAR-Ts eliminated about 80% of the tumors. The technique holds promise for treating other solid tumors as well, says lead author Bryan D. Choi, MD." 

(Read the most recent story here.)

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)