Dr. Jonathan Liss: Holding a Preemie in One Hand; Her Parents in the Other

Jonathan Liss, M.D.

Neonate: An infant from birth to 28 days old, whether premature, full-term, or postmature.  The preemie baby longs to return to the womb, where she was still safe and warm. The new mother desperately wants her to return there, as well. Dr. Jonathan Liss accepted the challenge of caring for newborns in distress nearly 40 years ago. He kindly invited me to his comfortable home to share his story.

“Why medicine?” I asked. He told me that his father left the multi-generational family baking business, changed directions entirely, and went to medical school. He built a solo obstetrics practice in Phoenixville where he had “respect in the community and did good things,” Dr. Liss recalled.  But Dr. Liss, himself, wasn’t set on a career in medicine until he was in college at Muhlenberg after his father arranged for him to “hang out” with a few (carefully-chosen, I assume) physicians.

After college, he went to Temple University Medical School (as his father had done). He told me that he liked “all the rotations except psychiatry.” When he was undecided about his direction after medical school he asked his wife Andi for her advice. She quickly reminded Jon that he was happiest during his time in pediatrics, joyous no matter how the day went. He saw, of course, that she was precisely right, and he was fortunate to be able to do a residency in pediatrics at Temple and at St. Christopher’s Hospital for Children.

David Rubenstein, M.D.

Within the field of pediatrics, the diseases of the neonates “were (especially) interesting” to him, and he liked the excitement and drama of the unknown in the delivery room as the newborns were handed off to the waiting pediatric specialist by the obstetrician. This was a perfect fit, he noted, it “felt right.” So he did a highly-coveted neonatal fellowship at St. Chris, where Dr. David Rubenstein, “a brilliant clinician and a very compassionate physician,” served as an inspiring role model. (Dr. Rubenstein, by the way, is still in practice, but in New York City.)     

What would be the next step for Dr. Liss? Let’s see...His dad had a solo practice delivering babies all hours of the day and night; he was highly regarded in his small town; he seemed to have (at least some) time for Jon and his four siblings. Yes, that sounds about right. Solo practice. Build something on your own. Serve the community.

Dr. Liss moved to York, Pennsylvania in 1985 to start the York Hospital’s neonatology unit (they had been sending the sick babies to Hershey). “It was kind of crazy when I first started,” he let on, as he was the only physician with his training, but he told me that he made a commitment and would follow it through. 

For nearly two years he parked himself in the neonatal ICU (the N.I.C.U. or “Nick-U”) day and night, weekdays and weekends, holidays and non-holidays. He was there whenever a baby and mother needed him as he waited patiently for the hospital to recruit his first partner, someone with the needed skills and the same ideals of caring as Dr. Liss.

(This talk of a solo practice, envisioning Dr. Liss in scrubs all alone tending to tiny  babies while calming the frayed nerves of their deathly-frightened mothers, brought to mind images of the obsessive and fearless rock climber Alex Honnold in the 2019 Oscar-winning documentary “Free Solo” as he carefully scaled the slick vertical wall of El Capitan. He chalked his hands to dry his fingers and improve his grip as he carefully inched his way upward, but there were no ropes or other devices to protect him from a slip and a fall to almost certain death. Fortunately, I realized, Dr. Liss had plenty of well-trained support staff; he wasn’t truly alone on the climb.)

A really scary scene from "Free Solo"

Jon admitted that he was probably remiss in not fully understanding the impact of exhausting 120+-hour work-weeks on his (growing) family (they already had two children and had one on the way on arrival in York). On the other hand, he reflected, “My kids saw me working hard, and that was a good role model.” 

Continuing his thoughts on his career here, he reflected, “Neonatology has been a good niche for me. It’s been a comfort zone. It has given me more than I’ve given it.”

As we talked I sat on a deep sofa across from Dr. Liss and his wife. On the floor, at our feet, lolling on their backs with toys in their mouths, were Steve and Norm, their two very relaxed golden retrievers. Funny names for dogs, I thought. It turns out that years ago they had one called Frank, the name of Dr. Liss’s first partner (Frank Ferrentino). Steve (Shapiro), the next physician to join the group, was “envious” of that, so they dutifully named a dog after him. (“Norm,” I believe, has no such connotation.)

Norm and Steve waiting patiently to come inside

Over the three-plus decades, the hospital’s neonatology team has grown to include six physician neonatologists, multiple neonatal nurses and nurse practitioners, residents, medical students, nutritionists, respiratory therapists, occupational therapists, and social workers, etc. The neonatologist guides them to carefully coordinate the care of our tiniest and most vulnerable members of the human family.

The premature babies, those born before 37 weeks, are desperate for help, having left their mother’s protection, the temperature-controlled and nourishing womb too early, sometimes way too early (even at the very limits of viability, at 22-23 weeks).

Stages in prenatal development

Dr. Liss mastered the technical skills; using incubators keeping newborns from losing too much heat; giving artificial surfactant to open the distal airways, and using new ventilator settings and medicines to ensure adequate oxygenation for those with the common respiratory distress syndrome; applying advances in neonatal nutrition, including inserting miniature catheters for intravenous feeding when the baby’s GI tract is still too immature to absorb nutrients. Progress in quickly identifying a long list of genetic disorders has helped Dr. Liss offer a more precise diagnosis (and prognosis) of unusual conditions.

There is much more to his craft. The parents of preemies, especially the mothers, of course, are often “scared to death” as they see their helpless babies hooked up to machines and tubes and the like. The “lack of knowledge” is greatly “anxiety-producing” as they “don’t know what to expect.”  

Dr. Liss quickly discovered that he could often help by shedding light on the dark unknown, on what the future might hold. He learned that “people tell you how much they want to know, and in what depth.”  So he listened, and read their body language, and responded to their distress. It has been “very rewarding” for him to be able to help parents anticipate what’s next as their baby struggles to survive.

He remarked that these “social aspects” of his practice have been the “most pleasing” for him, as he quells fears and unease (well, I thought, so much for his “not liking psychiatry”).

Why are so many babies born before term? The “accident” of preterm birth may be associated with hypertension and the dreaded pre-eclampsia, a variety of maternal infections, many genetic abnormalities, obesity and diabetes, pregnancies with twins or triplets, and in vitro fertilization, among other and often unknown causes.

Unfortunately, while some medicines may help a bit (e.g., progesterone), there is “no great treatment for premature labor,” according to Dr. Liss, though progesterone supplementation may help. This is a very serious problem, as nearly 10% of babies born in the U.S. in recent years have been premature, and the percentage is slowly increasing.

2016 Prematurity data from the March of Dimes

Dr. Liss then mentioned the Barker hypothesis, that that factors in the intrauterine environment may have a lasting impact on later development as specific genes in the fetus are switched on or turned off. These early epigenetic effects may be permanent; they sometimes “cannot be undone.” For example, he noted that undernourishment in utero may lead to short stature and an increased risk for obesity and coronary artery disease decades later.

Changes in gene activity that occur in premature babies as a result of their particularly stressful experience in the NICU may have long-lasting consequences that are not fully understood. There are major effects on the endocrine and nervous systems and the immune response. Dr. Liss told me that Todd Barron monitors some of the NICU-graduates in his neurodevelopmental clinic.  

Andi noted that, over the years in York, as she ran into mothers and fathers of preemies and heard from them how her husband helped them, she realized that he had “excelled at getting people from point A to point B,” and that he did this with obvious compassion. Parents, it seemed, found that with Jon’s guidance “whatever happened, they could get through it,” despite facing some “terrible times.”  

Dr. Liss noted that when “you develop a rapport with patients and families they trust you” and that this trust is invaluable.  As Dr. Eric Cassell has written, “Trust in others is one of the central human solutions to the paralysis of unbearable uncertainty,” (Cassell).

As Dr. Liss looks forward to his “retirement” (he will still probably fill-in at the hospital occasionally, he said) in June of this year, I wondered what leisure activities might fill his time. What does he enjoy apart from his life’s work and his family?

He told me that he likes pedaling his bike alone for miles on quiet back roads, he fashions formless lumps of clay into beautifully finished pottery, and...wait for this...he mixes flour, water, and yeast (and sometimes eggs)  and bakes bread. Yes, He bakes bread, as his father and grandfather did many years ago in their corner Jewish bakery.

An example of Dr. Liss's handiwork

Rabbi Jonathan Sacks reminds us (I have used this thought before): “We are born as individuals, but we survive as members of a group.” Dr. Liss and his team know this to be an absolute fact.

And Dr. Liss told me that he could not have done what he did without his wife.  

Dr. Jonathan Liss, Andi, and their family

Reference:

Cassell, Eric J. The Nature of Suffering and the Goals of Medicine. 1991. New York. Oxford University Press, p.76.

Bruce Bushwick, M.D.: Doctoring the Family

Bruce Bushwick, M.D.

“We are all related. We all come from the same mother. We are all part of the same family. This has been scientifically validated. So, we need to treat each other the same,” said Dr. Bruce Bushwick, as we sat down together on a quiet Saturday afternoon to discuss his practice of family medicine.

You see, it turns out that we inherit a specific component of our DNA, our genetic code, the map of life, only from our mothers. The DNA in her mitochondria, the cell's energy source is passed on to all of her children. By analysis of these small bits of DNA (making up 37 genes) from different populations around the world, the “most recent common ancestor” from whom all living humans have descended walked the earth between 150,000 and 200,000 years ago.  (Of course, there were people before then, but their lineages came to dead ends, as did many others along the way till now.)

So everyone currently alive today, everyone, all 7.7 billion of us, carries loops of DNA passed down from that one very-tired woman. 

The loop of mtDNA

Family Medicine. The term certainly has warm connotations. Even as the nature of what a “family” is has changed radically in recent decades. Even as the nature of the practice of medicine has changed as well. Dr. Bushwick is the Chairman of the Department of Family Medicine at the York Hospital, and I wondered if he could help me understand where things have gone.   

He was raised in the Washington D.C. area and went to the University of Michigan for his undergraduate degree in general studies. In high school, he was a county champion gymnast in the “all around” category. In college, he soon dropped his athletic career and focused on “all around” academics instead. He had an “aptitude in science and math”  (where have we heard that before?) and, by his first semester, decided on a career in medicine. However, he carefully took a wide variety of non-science courses to broaden his view of life. 

University of Maryland Medical School Campus

While a medical student at the University of Maryland he did an Infectious Disease rotation at York with Drs. Manzella and McConville. He said that there was a feeling of family amongst the physicians; things were “very collegial.” Since Dr. Bushwick likes “the big picture” and a “holistic” approach (in addition to knowing “how things work”) he decided to go into the relatively new (since 1969) “specialty” of Family Medicine. The experience in York as a student drew him back for a residency, and he has stayed here since.

After a few years in private practice with two other physicians, taking care of pregnant women, delivering their babies, treating infants and children, seeing teens, adults, and the elderly and dying, and doing simple orthopedics and minor surgeries in the office, and following his patients in the hospital he left for a teaching position. 

Over the years the nature of that ideal comprehensive way of practicing medicine from birth to death in the context of the family has changed. Few doctors can take care of people throughout the entire life cycle now, and hospital care has been taken over by hospitalists.

But, while the role of the family physician has become somewhat restricted (e.g., the obstetrician handles most pregnancies and deliveries, the orthopedist sees fractures, and the geriatrician often takes care of the dying, etc.) the essential nature of what they do, and how they do it, has not.  

Dr. Bushwick said that the “pillars” of his practice remain “comprehensiveness, coordination of care, continuity, and access.” This is framed by the all-important “biopsychosocial” understanding of the patient in the context of their family and the broad community. Accountability, and having a sustained partnership with patients, are essential as chronic conditions are managed differently than acute illnesses. The focus is always on the person with the disease, not the disease. The person, not the disease. 

One Schematic of the Biopsychosocial Model

He is especially passionate about teaching. He recalled that in his residency training he was sometimes observed through a two-way mirror as he took a history and examined a patient. A social scientist watched, recorded, and analyzed the encounters. Did he listen with interest? Did he interrupt the patient? Did he gently touch the patient? Did he say affirming things? Did he position his body properly? Did he fidget, or remain too stiff? 

(My mind slowly wandered as Dr. Bushwick ticked off these studied observations. I drifted off and pictured the young Jane Goodall crouching down in her khaki shorts scribbling on a small notepad as she watched Flo taking care of poor Flint, trying her best to get him to become independent. I’d better refocus...)  

Jane Goodall in Tanzania 

Such feedback about (our primate) behavior helps immeasurably, he noted, but modeling those we want to emulate, modeling by way of the famous mirror neurons (that help us understand other people), is another way to develop the skills and traits of the accomplished family physicians. These skills include effective communication, appropriate empathy, proper engagement, and careful listening. 

Andre Lijoi, M.D.

Dr. Bushwick and his friend and colleague Dr. Andre Lijoi  (a passionate proponent of finding the patient's narrative) both mentor and mentee as they watch each other. They share what they have learned from their patients. Lifelong learning is the rule.   

But since there are few 24/7 physicians with inpatient and outpatient practices, continuity of care has suffered. Urgent care tries to fill the gap, but the absence of a familiar and trusted face when patients are frightened adds to their anxiety and their suffering. The hospitalist has likely never seen the patient before and doesn’t know the family dynamics. 

And there are time constraints in the office; for example, the 20-minute visit may not leave room for the well-known “doorknob moment.”  The critical moment when the patient suddenly “remembers” that “there is one more thing.” And it turns out, then, that this is really the most critical. 

(Dr. Lijoi suggests asking the patient up-front to try to focus on the most important issue. But patients may have trouble expressing that because, according to Michael Polanyi, “we know more than we can tell.”  Our deep-seated fears may block what we “know” from bubbling up to conscious awareness. We may need time for this to happen.)

Dr. Bushwick took courses at the Georgetown Kennedy Institute of Ethics and has chaired

Kennedy Institue of Ethics at Georgetown

the hospital’s bioethics committee for the over 25 years as they try to understand “high-stakes situations” at the beginning and end of life. While “Do no harm” is medicine’s first rule, he tries to incorporate the Aristotle’s “virtue ethics” of character and excellence into his thinking. 

He then quoted another heavyweight he admires, Emmanual Kant (1724-1804): ”Act In a way that you always treat humanity, whether in your own person or in the person of any other, never simply as a means, but always at the same time as an end.”

Two Types of Ethics

Aiming to lighten the discussion just a bit, I ask, “How are the young residents doing today?”

“They are wonderful, idealistic, engaging, and great to work with. Their hearts are in the right place. They want to improve the world and are very much into social justice. They are a generational transition that is positive. I love this generation,” he happily replied.

Dr. Bushwick takes time to be active outside of medicine. For example, he has had leadership roles at the York Jewish Community Center (where he is currently president). He is still quite athletic as he swam, in full wetsuit, the 4.4 miles across the choppy Chesapeake Bay not once, but twice (a “very tough” meditative experience), and he rode a bike from Jerusalem to the Red Sea, including a grueling, punishing, 20-km steady climb up the Dead Sea rift. And, in his spare time, he serves as the only physician on an advisory committee to the Pennsylvania Supreme Court dealing with issues involving the vulnerable elderly. (I am exhausted just thinking of doing all this while he is married and helping to raise three daughters.) 

The Twin Chesapeake Bay Bridges

As an educator, his goal is to “help people develop their natural skills to better serve humanity.” As a physician, his goal is to offer “quality, timely, thorough, and compassionate care.” As a citizen, he feels that we, as a country, need to decide whether healthcare is a basic human right (he thinks it is) or a commodity.

Reflecting on the current healthcare climate, Dr. Bushwick objects to patients being called “consumers” and doctors being called “providers.”  He objects to the reimagining of the doctor-patient relationship as nothing more than a simple commercial transaction. He knows in his heart that it is very much more than that, and hopes, by his efforts, to help protect the sanctity of this most human and intimate of relationships.

I finally asked Dr. Bushwick if he is optimistic about the future. “Yes,” he quickly said, “the evidence is that our world is getting better and better in terms of the human condition.”

I wonder whether our ancient common mother would look kindly upon her family and agree...

Watercolor by Anita Cherry ~1983

Anita Cherry

P.S. 1/4/20: Recent mitochondrial DNA data suggest that the earliest humans, and the single mother of us all,  may have populated southern rather than eastern Africa 200,000 years ago. (Read more about this here.) 

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