Dr. John S. Monk, Jr.: What Will Chip Do Next?

"What can you do for me, you ask? You can do an operation to help me lose weight," the patient replied.

"Well, you know, I have heard of that,” the cautious doctor said, “and I think that is a worthwhile thing to consider. But I have never done that operation."

"I have talked to God, and God said you will do it."

"God helps us in many ways,” he offered. ”Let me see if God can help me get you an appointment at Hershey or Hopkins, where I know they do these things."

This was 1993. The patient’s insurance then was “pretty rotten” and the two universities did not accept it. She, however, was not ready to give up.

"I have faith in you. You can do it," she beseeched.

"There are parts of this surgery that I have done for other reasons, but I have never done it exactly," he said.

" I want you to do it for me."

John S. Monk, Jr., M.D.

So, Dr. John ‘Chip’ Monk agreed to try to help a desperate woman. The tedious first-time surgery took four and a half hours. Before the weight-loss procedure, the lady of faith had needed supplemental oxygen to help her breathe, took three medications for hypertension, and was a severe diabetic. 

A few months after the gastric bypass, not only had she lost substantial weight, she no longer needed to lug around her oxygen tank, she was on only one medication for hypertension, and, most remarkably, her diabetes was gone, completely.

Dr. Monk admitted that he was “hooked” by these spectacular results. Since then he has perfected his techniques and has performed thousands of so-called bariatric procedures for grateful individuals struggling with the complications of obesity, a worldwide epidemic now affecting 40% of the U.S. population. Mostly, he feels, due to the easy availability of lots of “cheap, tasty, high-caloric foods,” especially simple carbohydrates--i.e., mostly simple sugars, especially fructose.  

But let’s go back, and fill in Chip’s story.

How did ‘Chip’ become Dr. Monk?  His father was an obstetrician in York and young Chip watched as “hundreds of women” in town came up to his father and thanked him for delivering their babies. Seeing this was (as you might imagine) “a  positive thing.” The obvious path was set before him, but maybe he should try something different. 

So he studied biology at Middlebury College in Vermont with the idea of becoming a marine biologist “like Jacques Cousteau.” After a while, he changed his mind and decided on medicine. He went to Jefferson (and he found this easier than his very-demanding New England college).   

Middlebury College

Chip first thought about being a family doctor, taking care of patients throughout their lifespans, but he “fell in love” with surgery, especially orthopedics, after he worked with Dr. John Dowling in Philadelphia. In fact, the orthopedic residency program in Cincinnati wanted him to join them after graduating from medical school ( in 1982), but he didn’t “rank” them in the “match” since he had decided instead on his “safe” place for training, York Hospital.

General surgery was “more exciting” than he had thought it would be, and he enjoyed working with Dr. Nikhelish Agarwal, who was developing the new trauma program at York.

But two years into his residency he got sick. Dr.Monk had seen unusual blotches on his legs for a few weeks, and after a long and tiring 36-hour shift (when men were men) he came home and went to sleep with this on his mind. He awoke at two o’clock in the morning to pee and saw blood. This was not good. He quietly told his half-awake wife that he was “just going to run into the ER" to check on something and that he’d be right back.  Off he went.

He waited anxiously for several hours for simple blood test results that didn’t arrive. The hematologist, Dr. Miodrag Kukrika, came to the hospital first thing that morning. He looked at the blood smear and informed Dr. Monk that he had acute promyelocytic leukemia and that this was a true life-threatening emergency, the most malignant acute leukemia. 

Helicopter pad at York Hospital

The doctor-turned-patient was helicoptered to the University of Maryland, and chemotherapy was started as he was being wheeled into the ICU.

He was given humongous doses of the drug ARA-C in an experimental protocol for a clinical trial. The resulting nausea and vomiting were horrible, and the sternal bone marrow biopsies were harrowing. After the first round of treatment, his marrow was “totally filled with promyelocytes.” He was told that either what they are doing was not working, or that the intense chemo killed all of the abnormal cells.

This was a very dark and “rough” day for a young husband and father of two, and it tested his faith. As it turned out, the bone marrow was packed with normal immature cells, and the leukemic cells were never to be found following that.  But Dr. Monk still needed eight more cycles of grueling chemotherapy. (Targeted therapy with monoclonal antibodies and vitamin A is the treatment now.)

After that terrible year of being sick (1984-1985) he simply wanted to resume his surgical residency, and to cherish his wife and children. He was too weakened to take call every three or four nights, and in place of that task, the hospital gave him a job as an educator of residents for a year. Dr. Monk did that and then did three more years to finish his training.

He “really enjoyed teaching” and after his residency he took a chance and asked for a position as assistant program director, working with Dr. Jonathan Rhoads. His bold request was granted and Dr. Monk took the job. He also did trauma and critical care and had a small private practice.

(Could a doctor-in-training be helped in this way today, thirty years later? Are our new giant health systems responsive to the needs of their physicians? Do these questions push me to tell doctors’ stories? Maybe.)

Anyway, so how did bariatric surgery become Dr. Monk’s special interest, his life’s work?

One year early in his practice, he went to one of the huge American College of Surgeons meetings (with nearly 18,000 attendees!) and as he was milling around he peeked into one of the darkened side rooms where they happened to be discussing gastric bypass for obesity. He walked in.  He had thought that weight loss operations were risky, and the results poor, but the talk changed his view. He came away from the lecture thinking that the surgery was not only safe, but that there could be amazing results.

So the request by the lady he met in the clinic in 1993 and whom he later operated on fell upon the ears of a man already primed for the challenge.

Dr. Monk followed her surgery with a few more similar cases over the next couple of years. But four hours was a long time to spend in the OR. Could he do better? He (as an assistant director) went to a meeting for directors of surgery departments. “One of the most famous weight-loss guys in the world” was at the meeting and Dr. Monk took another chance and summoned up the courage to ask if he could visit him at his hospital to see how he did things.

(Bold, but as someone once said to me in a similar vein, “What is the worst that could happen? He could say No.”)

Walter Pories, M.D.

Anyway, Dr. Walter Pories not only said that Dr. Monk could come to the hospital, but that he would arrange for him to get privileges so he could actually help in the surgery. The esteemed Dr. Pories would be happy to share his knowledge, not only of the surgical technique but of the importance of patient selection and critical follow-up treatment. This remarkable physician remains one of the “most favorite people” Chip has met, and Dr. Monk is still amazed by him and his generosity.

(I like a guy with chutzpah and gratitude at the same time.)

The excited protege returned to York, applied what he learned, and practiced. Some time passed. He remembered that Dr. Pories had told him about “a guy in Pittsburgh” doing surgery “through little holes” and suggested a visit, but he wasn’t ready then. Well, what do you know, one day, along comes an instrument salesman offering him the opportunity. Should Chip take him up on it?

A cartoon (one of many) by Dr. Pories

Next thing, he and his colleague, Dr. Paul Sipe, fly west for a lecture. After the short talk, the presenter abruptly leaves the hall and walks across the street to the OR. Transfixed, they watch the laparoscopic surgery “live” on the big TV screen. It takes only 90 minutes. "It was beautiful...it was beautiful,” gushed Dr. Monk. He signed up for the course and quickly grasped the details of the new technique.

Back in York, he shared the idea of the new less-invasive procedure with some of his patients. He told them carefully that he had not yet performed the surgery and, sure enough, one trusting soul jumped in and said, “Oh, you can do it. I’ll be your first!"

After three of four cases he was able to complete the surgery without resorting to opening the belly, and laparoscopic surgery has been the standard since then. The 30-day mortality rate for weight-loss surgery at the York Hospital is 0.1% (much safer than, for example, gallbladder surgery).

Surgery for weight loss can either restrict the size of the stomach (how much one can eat) or work by causing malabsorption (how much one absorbs through the small intestine), or do both. The most commonly performed procedure now is the gastric sleeve, essentially taking out 80% of the stomach, but not affecting nutrient absorption.

Various weight-loss procedures

However, the most effective treatment for weight loss is the so-called “modified duodenal switch.” A large part of the stomach is removed and the first part of the duodenum at the end of the stomach is then attached lower down into (nearly) the end of the small intestine so that food “bypasses” much of the surface where it can be absorbed by the body.    

“Banding” of the stomach was popular for a while but is rarely done now.

What are the results of bariatric surgery? Nearly 80% of patients will keep off 50% of their excess (that is, over the ideal) weight at five years. Dr. Monk said that “nothing else works like that. Not medication. Not diet. Not exercise.” After surgery type 2 diabetes (exceeding common in such patients) is almost always easier to control, usually without medication, and more than 50% have a completely normal A1C (the test for long-term blood sugar control) without any medicines.

And (this is very interesting) the improvement in diabetes occurs before the weight loss. Dr. Monk said this has something to do with food “not touching the duodenum.” There is a complex effect, “markedly elevating (the hormone) GLP-1, analogs of which improve diabetes and may help people lose weight.”  There are also changes in leptin (produced by fat cells to inhibit hunger and regulate long-term weight control) and ghrelin (which increases hunger). 

These two particular hormones act on the brain (at the hypothalamus, the base of the brain) to tightly regulate energy balance. In obesity there is resistance to the effect of leptin, blunting the feeling of satiety, of having eaten enough. “The adipose cells (then) trap excessive calories as fat and do not allow it to be used as energy for the rest of the body,” (Taubes p. 115).    

Hormonal regulation of hunger and satiety

“Obesity is a chronic disease that affects (nearly) every organ…(and) there are great benefits to weighing less,” said Dr. Monk. “Why do people see surgery for morbid obesity as an extreme option, when it’s the only option?”

Cutting back to his own story, his path in medicine, I wondered aloud about all of the people who looked after Chip, who helped him along the way.

"That's what I'm thinking,” he calmly said. “Some people would call it coincidence, but I have this spiritual thing. I'm probably doing what I am supposed to do in life." Somehow, he noted, he just “happened onto” what turned out to be a “nice and gratifying career.”

The future for Dr. Monk? For one thing, he has gone on church mission trips to Africa with Dr. Robert Davis. One time he visited his daughter who was in the Peace Corps and stationed there. He wanted to see one of the hospitals. While looking around with curiosity they asked him to do an emergency appendectomy. Needless to say, he obliged. He needs to do more of this giving-back, he feels. 

But he also wants to be “more than a doctor.” So, he is a member of the Chestnut Society, bringing back the American Chestnut tree.  He keeps bees and collects their honey. He goes camping with the Scouts. It’s “fun to learn,” he noted.

The American Chestnut

I can see Dr.Monk years from now. He will again be wandering around at some meeting, peering into a side room somewhere. But no doctors around, this time. He will cautiously step inside a room and look up at a 3-D display. Someone will notice him and call out, "Can I watch with you?" They will observe together, and Chip will say to his new buddy, "That's really beautiful. I want to learn to do that. And his friend will put his arm around him and say, "Sure."

Yes, I like a man with chutzpah and gratitude at the same time. (I'll have some honey with that.)

Chip's honey

Wait...

Chip and his real honey

Reference:

1. Taubes, G. 2016. The Case Against Sugar.  New York: Alfred A. Knopf.

By Anita Cherry 10/27/18

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.)