Meg Figdore, M.D.: It's a Family Affair

Little Meg at around 4 years old

"What do you want to be when you grow up?" the kind lady in church asked the quiet, blonde, pig-tailed five-year-old girl.

"I want to be a doctor," she replied, without hesitating.

The woman looked down at her with furrowed eyebrows and said, "No, you want to be a nurse, don't you?"

"No...I want to be a doctor."

The idea of being a nurse rather than a doctor was foreign to the little girl, now the grown woman, and obstetrician, Meg Figdore, M.D., of York. That brief conversation one Sunday morning took place in 1972 when only about 10% of U.S. medical school enrollment was comprised of women. Perhaps Dr. Figdore’s quick reaction as a precocious and determined child reflected her insider’s view of a life in medicine.

Meg Figdore, M.D.

Meg is the daughter of the late Dr. Galen Kistler. She noted that he was “a wonderful father” who practiced family medicine in Dover and in York. Early in his career, he was on-call every other night and every other weekend. Whenever his patients needed his help after hours he would gladly arrange to meet them in his office.

When Meg and her older sister and younger brother  (each two years apart) were in elementary school their father would “cart his children with him,” said Dr. Figdore. “We would be his assistants. He would tie sutures, and we would take turns as to who would cut off the ends.”

He instructed them carefully, "One-quarter inch, one-quarter inch…"  But Meg's eight-year-old brain would sometimes guide her (future-surgeon) hands to leave a half-inch, or sometimes considerably less than the requested quarter. She can still hear her father’s steady voice saying later, "Meg, I just took a lady's sutures out, and they were too short."

Sometimes the three tag-alongs helped with urine samples and learned to read the dipstick results, but when Meg looked intently down through her father’s microscope at the drop of urine she really had no idea what she was looking at. Reliving this, Dr. Figdore laughed softly, and admitted that she would just “pretend." She was playing the role of a doctor, and “it was great.”

I thought to myself, did this “family” doctoring scene occur in my lifetime?

Galen Kistler, M.D.

But it was not all for fun. The thoughtful Dr. Kistler needed his three children to know how lucky they were in life; that others were not so blessed. So he sometimes took them with him for brief glimpses into the lives of the less fortunate in the community.

For example, the kids were witness to the terrible loneliness in nursing homes. And yet, they saw that these often-forgotten people would “light up” when they visited. They saw the importance of warm human connection. Reflecting on this experience, Dr. Figdore recalled that the simple gift of a single young tomato plant in the spring that fruited in late summer showed that someone cared, and she saw that this act was very much appreciated. This was “eye-opening” for her, and left a “lasting impression.” 

(How is a lasting impression created?  Epigenetics may help with an answer as  environmental factors, including social input, turn specific genes on or off.)

But from where did her father’s humane sensibility originate? "My father learned from his dad, who was the town pastor, about being humble. To be grateful for what you have," Meg said quietly.

On the other side of the family, her maternal grandfather, the son of a physician,  was himself a general practitioner, and Meg and her family often traveled the two hours to visit him.

Mister Rogers

His practice was in his home. She reflected that, “It was neat that he would be playing with us and be ‘grandpop’ until someone would knock at the door.” Then, “like Mr. Rogers,” he would quickly take off his sweater, and slip on his jacket, go into the other room, and become Dr. Scholl. When he was finished seeing the patient he would come back to them, and put on his ‘grandpop' sweater again. "It was fascinating," Meg said.

(Between 1931 and 1974 the percentage of physicians describing themselves as general practitioners declined from 83% to 18%. It is certainly less than that now.)

Her maternal grandfather (‘grandpop’) had lost his own father when in college; he later went to Jefferson Medical College courtesy of his physician-uncle. He lived at home in Green Lane, PA, and took the train 90 minutes to and from Philadelphia daily. He served in WWII and he and his wife, a nurse, were his entire practice until he (very reluctantly) retired at 75.  

Looking even further back, Dr. Figdore can trace her extended family of healers, of doctors and nurses, into the 1800s.

Sadly, her father passed away before she dedicated herself to the pursuit of a medical career. He died when she was a student at Juniata College where she was initially cautious about declaring herself premed. Once she did, however, she excelled. She was accepted to several medical schools and she chose to go to Jefferson. Center City Philadelphia was “a culture shock” but “a good experience,” she noted.

Graduation from Jefferson
Harvey Scholl, Jr., M.D., Meg, Aaron Kistler, M.D., Harvey Scholl, Sr., M.D.

Along the way, she fell in love. She had first met her future husband (Chris) when she was in the seventh grade (he was in the eighth).  They were together in a class for gifted students. She remembers thinking that he was “very cute,”  but they did not get together until the summer after her first year at Jefferson. At that time she was the maid-of-honor at her sister’s wedding and Chris (get this) was the best man for his good friend.  

Her sister and brother-in-law saw something and prodded repeatedly; Meg and Chris eventually gave in. Dating a serious and dedicated medical student isn’t easy, and she said, ”We just made it work.”


For a while, Meg toyed with the idea of going into genetics, but during her third year at Jefferson she “fell in love” with obstetrics and gynecology, especially the obstetrics part. She loved being with the women, and loved delivering babies; there was nothing else that she wanted to do. She took an OB/GYN residency at Geisinger Medical Center.

Geisinger Medical Center, Danville, PA

Dr. Figdore and Chris got married in June of 1995, between the second and third years of her specialty training. He did CAD work in York and commuted the 90 minutes back and forth to Selinsgrove. That September, while wearing waders and fishing alone in the shallow Susquehanna, he heard a noise in his head, a noise “like a train.” He made his way out of the river to get help.

He walked, often staggering, about a mile into town. A  man stormed out of his house after an argument with his wife and saw Chris. Quickly figuring there was a problem, Meg was summoned, and the man called for an ambulance.

A devastating bleed

At Geisinger, 25 minutes away by ambulance, the CT scan revealed a bleed “in the center of his brain.” Dr. Figdore, knowing her husband’s “horrible” condition, felt that she was “going to be a widow that night.”  But an emergency VP shunt (draining fluid from the brain into the belly to reduce the critically-rising pressure inside his head) saved his life.

Through this, Meg “learned what it is like being on the other side (of the medical encounter).”  Weeks passed, and Chris made a remarkable and nearly-complete recovery. He was changed but remains “a wonderful person” who makes her laugh. 

After her residency, she joined The Women’s Healthcare Group in York and continues to greatly enjoy the varied practice. She is fulfilled as she cares for women and helps them deliver their babies safely.

"How does your early-life experience affect your practice today?" I inquired.

"My dad taught me the power of touch, and to be a good listener,” she said.  She uses these important lessons every single day. She shakes hands warmly when greeting the women, and hugs them (with permission) when appropriate. She listens closely to their stories to know what they need.   

But today, she noted, "there is a rush to see patients, and (required real-time) documentation on the computer interferes (with face-to-face contact).” Dr. Figdore works around these externally-imposed demands by gently tilting the computer screen away for a while. It takes more time but is certainly appreciated by the anxious mothers-to-be.

Has the practice of obstetrics changed much since her residency? While "the basic process of having a baby has not changed, people have,” she noted.

The worldwide obesity epidemic is one example. This has increased the incidence of pre-pregnancy type 2 diabetes and its associated problems during pregnancy and delivery.  For example, there are many more miscarriages in poorly-controlled diabetics, several times more birth defects (especially of the neural tube), and more babies who are “large for gestational age” (LGA).  Good early (and preconception) control of diabetes greatly reduces the risk of these problems.

Adult Obesity Rates in 2013

The excessive weight gain in the fetus in diabetics increases the risk of preterm delivery, mechanical complications of delivery (due to large shoulders and abdominal girth, not the size of the head), and the need for cesarean section.
Additionally, lung maturity is delayed in fetuses exposed to hyperglycemia in utero. And dangerous hypoglycemia may occur in newborns of diabetic mothers, resulting in brain damage, seizures, and death, if not recognized promptly.

Interestingly, the “metabolic syndrome” (obesity, hypertension, impaired glucose tolerance, and elevated lipids) is more common by age 10-16 in those who were LGA when born. The placental environment alters gene activity in a long-lasting way. 

Obesity itself, without diabetes, makes conceiving more difficult and complicates the monitoring of pregnancy. For example, obstetricians are now obliged to induce labor by 40 weeks if women are over a certain BMI to prevent stillbirths. Inducing labor, rather than letting it start on its own, increases the risk of prolonged labor and the need for a c-section. Wound infections are also more common. 

Yet there are also a few new bright spots in her practice. An infusion of magnesium sulfate, used for many years to treat pre-eclampsia (high blood pressure with a risk for seizures), when given for 12 hours to women at risk of delivering an early preterm baby is “neuroprotective,” she said. This reduces the chance of the baby having cerebral palsy.

Dr. Figdore also remarked that giving the hormone progesterone weekly from 18 to 36 weeks to women who have already had a preterm baby decreases the likelihood of another too-early delivery. This simple measure has resulted in a “really big difference” in her practice, as more babies enter the world at the right time.


Anticipating and preventing problems is vitally important. She spends the time, and she hopes that her careful advice about nutrition (and smoking and alcohol or drug use) during pregnancy is heeded. Too often it is not, and Dr. Figdore regrets that.

Percent of Births to Smoking Mothers 2013

She wants her patients to know how hard their doctors are working, and that they really want the best for them, and that it is frustrating when their counsel is not followed and there is a bad outcome. Good and consistent prenatal care, it must be stressed, greatly improves the chance of a safe pregnancy and smooth delivery.

Years ago, the five-year-old with the pigtails knew who she wanted to be, but only dimly knew why. Without being consciously aware of it, she was part of a genetic lineage with epigenetic tweaking along the way.

(Follow this carefully.)

When a woman is carrying a female fetus, the ovaries of that fetus (with more than six million eggs by the twentieth week of gestation) contain the ovum that will later be fertilized to become the woman’s grandchild.   


So, when Dr. Figdore’s maternal grandmother was pregnant with her own daughter (Meg’s mother), one special egg contained in the ovaries of the fetus was the egg that would be fertilized years later to eventually become Meg. And when she was carrying her daughter Meg was also carrying the ova that may someday develop into her own grandchildren. You see, one inside the other, inside the other…continuing the life journey.

Like nesting Russian dolls, or “Babushka” (i.e., grandmother) dolls.

Babushka Dolls: Fertility, Motherhood, Family

The egg that eventually led to us was formed inside of our mother while she was still a fetus in our grandmother's protective womb. And on and on it goes.

The seasoned obstetrician will be happy to assist in this ever-mysterious process.

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.)