Scott Cherry, M.D: "He Reads"

Scott Cherry, M.D.

Yes, I can see you as a neurologist, Scott,“ said his chief resident, stopping after softly tapping and slowly sweeping his red and white cane down the hallway. It was the late blind Dr. Francis Salerno whose words resonated with my husband and tipped the balance that I could not. 

Dr. Salerno (1946-2016)

The Reading Hospital program director, Dr. Eugene Hildreth, had watched helplessly as Dr. Salerno quickly lost his vision to diabetes. But he then made sure that Fran continued his own training, even while teaching the younger medical residents under his charge that vision could sometimes be clearer without relying on sight; careful attentive listening and a soft touch could be more telling. In fact, Fran was so adept at these skills that patients were shocked to find out later that he was completely blind! 

The general internal medicine program in Reading, PA was rigorous and strongly patient-focused. Dr. Cherry enjoyed most of the medical specialties, and, along the way, thought about doing a fellowship in several of them. But the quiet lure of neurology kept whispering to him. He was hesitant though, and not really sure what to do then.

Scott on the boardwalk (~1953)

Looking back, way back, the tiresome family story is that Scott uttered his first word standing on the wide Atlantic City boardwalk looking out in wonder over a crowded beach. That first word was...“People!” 

Well, years passed, he learned more words, and you probably know what comes next. Good in science, good in math, casual reader of the Encyclopedia Americana, etc.

He majored in psychology at F&M, and enjoyed anthropology, but he had no specific career goal during his freshman year. At the end of that year (the momentous 1969-1970, the culmination of the 60s-decade when society nearly fell apart) his father saw that Scott did okay and he offered “advice.” He calmly said, “Son, you can do whatever you want...after you go to medical school.” 

Scott trusted his wise father and listened. What did he see in him that Scott himself was blind to? Anyway, he then took the few required pre-med courses, slowly became disenchanted with psychology, applied to medical school, and went to Jefferson.    

But why was he interested in the (then somewhat) obscure field of neurology, even then? 

“As a senior in high school I took a few courses at Penn,” he said. “One evening the anthropology professor stopped, looked up to the back of the large stadium-style lecture hall, slapped his forehead, and told us, with absolute wonderment in his voice, that the human brain was the most complex bit of matter in the known universe. I can see and hear him now. That comment may have planted (or nourished) the seed, but I’m not sure.”

He went on, “At F&M I remember being in the bookstore looking for nothing in particular one day and tilting out a poetic translation of Lao Tzu by Witter Bynner. Later on, I picked up ‘I and Thou’ by Martin Buber. I then found ‘The Phenomenon of Man’ by Pierre Teilhard de Chardin.” Rereading all three recently, he noted that he still finds them challenging.

I found this in 1976

And, as his wife of more than 40 years, I know that he finds people interesting and often challenging, and worthy of whatever effort is needed to understand them and to figure out how to help them. He does this with unwavering steadiness and patience. “Where,” I ask, “did you learn to not give up on people?”’

“I would like to say that that it was a fully conscious decision, arrived at through careful thought about life, but it was not. Apart from my reading, I guess that I saw it in my father. It was never articulated overtly by him, but it was modeled, and “I” (Damasio's proto-self that lingers below awareness) knew that it was right.”

This early inclination to help, and general curiosity about who we are, was (unfortunately) not strengthened in medical school, which he found not as enlightening as he thought it should be. It was strengthened, though,  by his contact with Dr. Hildreth, a very strong and moral person (who co-wrote the American College of Physicians’ first document calling for universal access to medical care). 

Dr. Hildreth (1924-2018)

Dr. Hildreth had high expectations for his residents and helped them succeed. (The offer of the residency position at the academically-oriented community hospital in 1977 was sealed with a firm handshake, no written contract.) 

Scott said that Dr. Hildreth showed how to be with (and to sit with) a patient. He showed how to be completely on their side, that you were there only for them,  that your job was to do whatever was needed to help, and to relieve suffering, and that it was truly a sacred privilege, not to be taken lightly. And, most importantly, watching him, you realized that you did not give up until all reasonable hope was lost. 

Scott noted that after seeing a new problem the residents were encouraged to read in depth so they didn’t need to look things up a second time. Yes, I remember that his on-call room (he actually had his very own room for three years!)  was littered with copies of hundreds of articles strewn everywhere (I don't know how he found anything in that awful mess). 

(Can a quick glance at an article on Medscape or Up-to-Date substitute for deep study?)

Following up on the "reading thing" I ask, “Why are there so many crazy books piled on and under the nightstand on your side of the bed? And why do you always want to read something to me just as I’m starting to fall asleep?” 

“Following the thought process of someone who has spent time and effort to understand a difficult problem that intrigues me is quite enjoyable. I like that, and instantly have the urge to share a striking insight or the perfect phrase,” he said.

My husband and I met accidentally during his third year at Jefferson. The connection was instant when the man with the books sat down next to the (future) “If One Thing Isn’t Your

Thing Another Thing Will Be Your Thing” woman. We lived together during the last year of medical school when he took Jefferson’s first-ever neurosciences track program (run by the young Dr. Fred Lublin, now a prominent MS researcher). 

Scott had promised his parents that he would not get married until after finishing medical school, so we were patient and waited until two days after graduation. We took a four-day honeymoon in, get this, Atlantic City, and stayed at the once famed, but now faded, Marlborough-Blenheim hotel (just before it was demolished for a casino). The address of the hotel?  Monopoly’s pricey Boardwalk and Park Place. 

Marlborough-Blenheim Hotel (in its' heyday, not 1977)

Anyway, three years later, after finishing his internal medicine residency we moved to Syracuse for the first year of neurology training. After just one day in the hospital, he felt that the program was not rigorous enough for him and that we would have to move after a year. Okay, I agreed, we’ll move. 

Half-way through that snowy year, after the anesthesia wore off, I was informed that I just had a complete hysterectomy for stage 4 ovarian carcinoma. My belly was cut wide open and I was in pain and not prepared for that news, nor was my husband. 

Floating, and feeling unmoored in cold dark silence, as were the astronauts who ventured outside the mother-ship without a tether, without a lifeline, we decided at once, and simultaneously, not to look back. We would use our onboard battery reserves and thrusters to gently propel us in a different direction (yaw, roll, and pitch, and all that).  

Astronaut McCandless (1984)

Dr. Mayer (1929-2016)

We moved to Baltimore, and Scott finished his residency at the University of Maryland, followed by a one-year fellowship with Dr. Richard F. Mayer. The late Dr. Mayer was the epitome of the bow-tied clinician-scientist, and taught residents for 50 years, that’s right 50 years! Scott felt honored to be one of his fellows, and tries (though usually in vain, he notes) to “think like Dr. Mayer” when faced with a difficult diagnostic or therapeutic problem. 

Well, I completed treatment for the low-grade, but metastatic ovarian cancer, was seen at Hopkins, and, after a so-called second-look surgery, was declared to be cancer-free. We were very relieved, of course, and were ready to move on. 

We left Baltimore for a private community-based practice in York. The plan was to work with two other neurologists, Dr. Jeffrey Mosser, and Dr. Roger Weiss, but they wanted to keep the practices separate. They were “engaged” for a while, but never got “married” and the arrangement was called off a few years later. 

Solo practice with cross-coverage allowed each doctor to develop his own style. Office work, after-hours hospital consults, resident teaching, and a few brief (and unrewarding) committee stints, and keeping up with his reading kept Scott busy. He practiced general neurology.  

While he was occupied with seeing one patient at a time I taught children art, one child at a time, at the Montessori school. After a while, we relaxed and began to think seriously about adopting.  (And we were fortunate enough to do that a few years later.)

As the local health system grew over the next 15 years and employed more and more physicians two neurologists were hired to “work with” the volunteer staff. Before long other physicians were added, and the two remaining independent physicians were no longer needed to cross-cover. As the work in the hospital lessened Scott focused more on his outpatient practice. This eventually became his sole concern, and a source of great satisfaction as the interpersonal encounters, sometimes stretching over decades, enlarged his understanding of the human condition.

"The Tangled Wing"

Over the years he has become keenly aware of the always-present, but sometimes subtle and often hidden, interplay between the mind and body in neurologic disease, especially the fear and anxiety that intensify suffering. Scott notes that “Melvin Konner’s masterful analysis of how our evolutionary heritage results in ‘biologic constraints on the human spirit’ helps us begin to understand who we are, the greatest mystery.”    

Listening, I asked him: “What have been the most important advances in neurology over the past 40 years?”

Scott noted that when he was at the University of Maryland (1981-1984) Dr. Kenneth Johnson (1932-2011), the Neurology Chairman, was single-minded in his search for something to change the course of multiple sclerosis. He persisted and was instrumental in developing the protocols for the trials of Copaxone (then called copolymer-1 and developed by Israeli researchers to block experimental allergic encephalomyelitis, the animal model for MS) and Betaseron. These were the first two agents proven to be effective for MS and gave patients hope for the first time since Charcot initially described MS (as “sclerose en plaques”) in 1868. 

Betaseron was FDA-approved in 1995 and Copaxone in 1997, and since then there have been more than ten additional therapies for MS, each targeting a different part of the immune response. This has greatly improved the prognosis for patients with this unpredictable autoimmune disease. There is still no cure, but there is effective treatment.

Therapy for migraine, an often disabling and terribly misunderstood condition, has improved remarkably. Sumatriptan, approved in 1995, was the first drug shown to be specifically effective for acute migraines since ergotamine was introduced in...wait, you’ll really like this...1906. The so-called triptan was revolutionary and life-changing; other triptans followed. FDA-approved preventive therapies for migraine include propranolol and timolol (in 1977-8), the antiepileptic compounds Depakote (approved in 1996) and Topamax (in 2004), and Botox (in 2010). 

CGRP

As of this year, we have three monoclonal antibodies blocking the effect of the calcitonin gene receptor protein that is part of the migraine process. Scott has welcomed these advances for his struggling patients, having begun practice in 1984 when ergot was the only available migraine-specific medicine (it was relatively unsafe, and is no longer available).

Acute stroke treatment was revolutionized in 1996 with the approval of tPA to lyse (or “dissolve”) clots blocking blood flow to a part of the brain, but Scott said that it was slow to be accepted due to bleeding concerns and timing issues. Removing the clot mechanically was recently (2017) shown to be effective in reducing disability, even 24 hours after the acute stroke, and is available here. But better control of blood pressure and use of anticoagulants for atrial fibrillation has reduced the incidence of stroke by about 25% since 1980, and the more stringent blood-pressure guidelines should push that down further.           

There is also better treatment for Parkinson’s disease. Longer-acting forms of levodopa (replacing the deficient dopamine) and a new delivery system (infusion directly into the small intestine) allow for smoother functioning. Brain stimulation, with electrodes implanted into deep structures, can modulate the abnormal signaling responsible for the movement disorder. Special imaging can make diagnosis more accurate. There is more public awareness of this condition, and patients no longer have to hide their problem from others. Scott reminded me that patients often live full lives for many years after diagnosis. 

Dopamine transporter scans can help the diagnosis of PD

What about epilepsy? Removing a part of the brain may cure temporal lobe epilepsy (Dr. Joel Winer does this) and the newer anti-seizure medicines are easier to use and safer than the older drugs, though not that much more effective. There is still an unmet need for people with uncontrolled seizures, a not uncommon problem.  

But all is not rosy. Alzheimer’s disease, ALS, progressive muscular dystrophies, severe brain traumas, hereditary neuropathies and other hereditary or degenerative neurologic disorders are understood better but still have no effective therapies. Nevertheless, Scott notes that he has watched as patients and families often learn to adapt to these conditions remarkably well despite permanent or steadily advancing decline. Mankind is remarkably resilient, but sometimes those with such illnesses withdraw and become invisible to the outside world. 

What about cognitive neuroscience? What has happened there? Fluoxetine, the first selective serotonin reuptake inhibitor or SSRI was approved in 1987. There is debate about the long-term usefulness of SSRIs, but they revolutionized treatment of depression. So-called atypical antipsychotic drugs, often used as mood stabilizers, have also improved life for individuals with bipolar disease. Scott said that we are only beginning to understand how early life experiences affect the development of the brain's handling of stresses, and how that interaction with the environment shapes the connections of the deep, emotional, and "older" parts of the brain that can cause so much suffering.

Of course, there have been tremendous advances in understanding the mechanisms of disease, including molecular genetics, allowing for more precise diagnosis, even if not yet translating that into effective therapy.

Scott notes that there is still much that is completely unknown (and maybe ultimately unknowable) about how the human nervous system does what it does; how it can apprehend, represent, and manipulate the world; how the human brain endeavors to understand itself.

As the split-brain researcher Michael Gazzaniga has said, there are probably thousands and thousands of brain modules, built-up on top of each other and modified by evolution, working automatically, over a stupendous number of interconnections, doing their thing. And that much of what goes on in our brains is hidden from our awareness. Until things go awry. And when our left-brain interpreter that tries to make sense of it all doesn’t have the information it makes up the story. Maybe this is what keeps Dr. Cherry up at night, reading. 

Maybe we need to close our eyes a while like the Zen masters, or like Dr. Salerno, to get a fleeting glimpse of what’s really going on inside our braincase.

And Scott is always glad to recommend a book that might help.

My painting of Scott reading on our honeymoon (!).

Readings:

1. Buber, Martin. 1958. I and Thou. New York: Charles Scribner's Sons.

2. Bynner, Witter. 1944. The Way of Life According to Lao Tzu. New York: Capricorn Books.

3. de Chardin, Teilhard. 1961.The Phenomenon of Man. New York: HarperTorch books.

4. Damasio, Antonio. 1999. The Feeling of What Happens. New York: Harcourt, Inc.

5. Gazzaniga, Michael. 2008. Human: The Science Behind What Makes Us Unique. New York: HarperCollins.

6. Konner, Melvin. 2002. The Tangled Wing. Second Edition. New York: Henry Holt and Company.

7. Johnson, Kenneth. 2010. The Remarkable Story of Copaxone. Ney York. Diamedica. 
Publishing.

8. Salerno, Francis. Uncertain date. (Interview on Reach MD). Introduction to a Remarkable Career. (click link)

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.