Can You Keep Up With Dr. Kukrika?

PROLOGUE: Unique; the only one.

Miodrag Kukrika, M.D.

On the website howmanyofme.com their “best estimate” is that there may be “1 or fewer” people in the U.S. named “Miodrag Kukrika.”  In fact, there is just one. He is a retired hematologist/oncologist in York; I asked him for his story.

Because of his accent, he said, people sometimes wonder where he's from. His mysterious reply? “I am from a country that no longer exists." 

ACT ONE: It is 1936 in the central Balkans. Adolph Hitler is spreading hateful xenophobic nationalism. Jesse Owens embarrasses him by taking four gold medals at the 1936 Olympic Games. The rest of the world watches.

“Mića” was born in 1936, in Belgrade, in the Kingdom of Yugoslavia. He was an innocent toddler when the war began in September 1939. The German invasion of April 6, 1941, ended 11 days later with surrender. The Axis occupation followed, and the country was partitioned along ancient ethnic and religious lines. The Croats, in a German puppet state, using the fascist Ustashe militia, brutally tortured and murdered between 300,000 and 500,000 Serbs who lived among them; 20,000 died in a concentration camp. (Thousands of Jews and Romanians were also targeted.)

The partitioning of Yugoslavia in 1941 (from US Holocaust Museum)

The fractured country was finally liberated from the Germans in October 1944 by the Soviet Red Army. Bringing Russian Communism with them, they “immediately” jailed Michim’s industrialist-father.  And "because there was something to be taken" his successful factory was confiscated.

Dr. Kukrika's dad was slated to be sent to "hard labor" for a year, but he was more useful as a machinist and was spared that. After a while, when things settled down, his father was freed, and he resumed his metal work and supported his family nicely. "He worked from five in the morning until ten at night until a week before he died," lamented Dr. Kukrika.

Though Michim and his younger sister could not clearly recall the swift German takeover he was old enough to remember bits of the Nazi occupation and then, several years later, how the Russians treated his father, and, especially, how he was filled with fear as the family was under threat.

[An aside: His hard-working father was born in Bosnia in 1905 and died at 79 in Serbia. Dr. Kukrika flew home to be with him in the ICU in Belgrade, where the nurses were "drinking coffee and smoking incessantly." The attending surgeon was puzzled by his father’s illness and did an exploratory laparotomy. He found "nothing."  His father "never came out of the anesthesia."] 

Dr. Kukrika said, with boyish enthusiasm, that he absolutely “loves” history and geography. So, for those who have forgotten (or never knew), here goes...

Yugoslavia, under various names and forms, existed from 1919 (as the Kingdom) until 1993 (as the Federal Republic of Yugoslavia) and cannot be found on a current map of the Balkans or anyplace on earth. Belgrade is now the capital of Serbia. The Serbian Kingdom, itself, was first recognized in 1217, went through several changes, and became part of Yugoslavia until after WWI. It is now The Republic of Serbia and is surrounded by, starting from the north and working clockwise, Hungary, Romania, Bulgaria, North Macedonia, Montenegro, Croatia, Bosnia, Herzegovina, and (the disputed) Kosovo. And where are the Balkans? To the right of Italy, across the Adriatic Sea. (See, that wasn’t so hard, was it?)

Dr. Kukrika said that “Bosnia is an unfortunate part of the former Yugoslavia because it has populations that hate each other.”  Hate, a strong word. The Serbs (on one side of the Dinaric Alps) are Eastern Orthodox while the Croats (to the other side) are Roman Catholic.  In the middle are descendants of a group that converted to Islam during the Ottoman Empire or Turkish conquests.  Dr. Kukrika is very disturbed by these long-standing ethnic hatreds, seemingly triggered in part by subtle religious differences, that have led to so much conflict and misery. Organized religion, he quickly determined, was not for him.

[An aside: My husband has told me more than once about Freud’s “narcissism of minor differences” where the most heated interpersonal conflicts are often between those who are pretty much alike and who come in close contact with one another.]

ACT TWO: The 1950s. Yugoslavia after Tito’s surprise break with Stalin. Our young man begins to find his way. He thinks about leaving home. Thinks about who he is.

Josip Broz Tito and Joseph Stalin

“How did you get into medicine? Were you, like others I have interviewed recently, ‘good in science and good in math?’” I asked. No answer. It seemed that this was the first time he had thought about this question.  But maybe I just spoke too softly, and I repeated it.

Pausing briefly, he proudly admitted that he was “good in everything, but, in nothing very good.” This was an interesting answer and, later on, I had to listen to my recording carefully to get it right.

As mentioned, as a student he loved history and geography, yet he could not see himself working as a research historian, with history “written by the victors.” A history that told, he knew, only one side of the story. He then thought about law, maybe criminal law. But his protective mother worried that someone would kill him, and she forbade it. His doting father wanted him to become an engineer. He was stuck. He couldn’t decide.

But two of his best friends announced that they were going into medicine, and he naively thought, “Why not? I will go too!” Since he had excellent marks at the ‘gymnasium’ (the 5th through 12th grades) he did not need to take the qualifying exam, and he went directly to the University of Belgrade Medical School. While there, he studied as an exchange student in Poland for six weeks, quickly learned the language well enough to pass for a native-speaker (he had already practiced English and Russian and liked the sound of Italian, from across the sea) and met and fell in love with his wife-to-be, Ewa, a pharmacist.

University of Belgrade 

After that, he did an (unpaid) internship for a year and then practiced as a GP for four years in two small picturesque country villages just north of Belgrade.

He wanted to practice internal medicine, and at one point he seemingly had the option, but there was a catch; he had to agree to be a member of the reigning Communist Party. Without hesitating to consider the consequences, he flatly refused; he would not compromise himself in that way. Becoming an internist in Yugoslavia was now “just a pipe dream.” From the age of 14, he had been geared to leave Yugoslavia, and it was time. Where to go?

He had several nice offers from Germany and Sweden. Possible, he thought, but not far enough away from a very unpleasant family situation. Dr. Kukrika confided in me that for some unfathomable reason his mother “absolutely despised” his wife (though his father adored her). But, even so, “God-forbid” he and Ewa didn’t visit his mother on his rare weekends off! “The farther we go, the better,” he said to himself sadly.  So, a different continent altogether, “the United States is just far enough.” 

(By the way, he said that  his wife was a person that could forgive almost anybody, anything, and she tried “everything” to bring his mother around, but never could.)

ACT THREE: The year was 1967. The "Early Years" of the Vietnam War. The Six Day War between Israel and its neighbors was fought. Rioting and looting in Detroit and other U.S. cities. The British brought us Twiggy and “Sgt. Pepper’s Lonely Hearts Club Band.” The Corporation for Public Broadcasting was formed. The world was again in turmoil as Dr. Kukrika arrived in a new land.

Vietnam war protest at Harvard in the late 1960s

“So how did you decide to go into hematology and oncology?” I asked.

“I came to this country (a beacon of freedom) in 1967 and did an internship at Frankford Hospital in Northeast Philadelphia,” he replied. During that year he became more fluent in American English and he became interested in cardiology. In fact, he read all of the EKGs at the hospital and was excited about the field. But when he looked around carefully he saw that he “might not be accepted as a foreigner” in that prized specialty. He needed another plan.

While in Yugoslavia he had spent time working with a hematologist and developed an interest in coagulation. A relatively obscure field (there was no specialty board then) might be a better choice, he reasoned. His stay at Frankford was followed by two years of an internal medicine residency at the Abington Hospital in the Philadelphia suburbs. He then took a two-year fellowship at the University of Michigan in Ann Arbor, and a further year in Rochester, New York.

[Aside: He had turned down--yes, turned down--a fellowship opportunity at the MD Anderson Hospital. “They didn’t read their own bone marrows” and left that critical task up to the pathologists; he thought that was wrong. A hematologist should read his own slides. To see for himself.)

Miodrag might have stayed in academics at the University of Rochester, but there was no position available at the time. So he decided on private practice. He did a year in Kalamazoo, but the partners were at war with each other and he was in the middle; he had to leave. He then interviewed at the well-regarded Marshfield Clinic in Wisconsin where they (are you ready for this?) liked and looked forward to the bitterly cold weather; he and his wife did not.

He came to south-central Pennsylvania in the spring of 1974 for a practice in Reading, and as he drove from Philadelphia he passed the gently rolling hills coming alive in the spring and he signed on for one year at St. Joseph’s Hospital where “the GPs ran the hospital.”

The inviting Pennsylvania landscape

While there, Dr. Ross Moquin reached out to Mike (his Americanized name) from the York Hospital and asked him to consider joining his own practice. The audition? Presenting Thursday’s Medical Grand Rounds on the rare (and then) almost always fatal blood disorder TTP, or thrombotic thrombocytopenic purpura. (This is now successfully treated with plasma exchange and specific monoclonal antibodies). The staff was impressed by his talk and he joined Dr. Moquin.

ACT FOUR: It is 1975.  Starting a practice of oncology and hematology in York. The Vietnam War is over (lost) as the Communists take over South Vietnam. The UK happily joins the EU. “Jaws” is the highest grossing movie of all time.

After working with Dr. Moquin for a year Dr. Kukrika decided to open his own independent practice. Dr. Eamonn Boyle joined him a few years later, and Cancer Care Associates grew and added more (international)  physicians and (dedicated) nurses. Chemotherapy for most cancers was dangerous and unpleasant, and generally not very effective early on. People often got sick, sometimes very sick, before they slowly recovered. The word ‘cancer’ itself provoked intense anxiety and fear, and truly effective therapies were few. Dr. Kukrika waited patiently for something better.

Things slowly improved and more successes eventually made his practice less grim. He was greatly heartened by the advances in his field by the time he retired in 2000, but he is absolutely awed by the “unbelievable and fantastic” understanding of the genetic aspects of cancer and the new targeted cancer treatments that have evolved over the past two decades. Though gene technology has spectacularly improved diagnosis and management of cancers and blood disorders old-fashioned skills should not be discarded:

It is 1984 and our doctor gets a frantic phone call in the early morning hours about a blood smear from a patient in the ER. It looks bad they say. Dr. Kukrika is worried. He tries to sneak out of bed and not bother his wife, but she is up already. He goes straight to the hospital lab, puts the prepared slide on the microscope and instantly sees the problem.

The patient’s blood is jam-packed with promyelocytes, immature blood cells. This is acute leukemia, and a rare version that may be rapidly fatal as a result of the accompanying bleeding disorder called DIC (disseminated intravascular coagulation). Dr. Chip Monk, a surgical resident, is the patient, and he is quickly flown to the University of Maryland. Serious bleeding is prevented, and his life is saved. A delay of even a few hours, waiting for someone else to read the pathology, could have resulted in a disastrous outcome.

[An aside: Where was I in early 1984 I thought?  My husband and I were in Baltimore finishing his fellowship. One of his colleagues, a neurology resident from Bogota, Colombia, Ernesto, and his wife, asked us to be stand-in godparents at the baptism of their son. We are Jewish, but they said it was okay. We watched intently as the priest performed the joyous ceremony and gently placed drops of holy water on the baby’s forehead.

Baptism ceremony

He then asked us, one at a time, if we believed in Christ. The quiet Catholic parents said nothing. Scott stayed quiet too. When it was my turn I confidently (as the good stand-in godmother) said, “Yes.” They all looked at me with raised (or was it furrowed) eyebrows. Anyway, after that, we went to a fancy Chinese restaurant down the street. While in the church I felt like I was an extra in a movie, one of my few long-time fantasies. Wait! I just realized I was (am) an extra...in this story.]

Speaking of Chinese, Dr. Kukrika said that in 1988 researchers in China found that treatment with vitamin A could cure promyelocytic leukemia, but this “natural” treatment wasn’t accepted here until after the French tried it a few years later. Dr. “K” (as he was sometimes affectionately called) is not very happy with the idea of “American exceptionalism.” 

Anyway, as I thought about Dr. Kukrika’s decades of intense and emotionally tiring work I wondered if he needed special social and personal skills to take care of people with cancer? Almost always helping anxious, frightened patients facing their mortality. Patients who turn to him for answers. Answers that he was often not able to provide.

His reply: ”Special skills? Not really.” Dr. Kukrika feels strongly that all doctors, by the very nature of their work, should be the ones able to hold the patient’s hand through difficult life-threatening illness, to guide, to be present. He feels that this most human of tasks cannot, and should not, be delegated to someone else. “You have to have a (strong) feeling for the person (to provide proper care),” he said, and continued, “If you don’t, I’m sorry.”

ACT FIVE: It is the 1990s. Bosnia secedes from Yugoslavia and Bosnian Serbs kill 100,000-200,000 Croats and Muslim Bosnians and displace 2,000,000 in “ethnic cleansing” of their region. Again, the world watches a genocide.

Dr. Kukrika continues to take care of patients as cancer doctors lead the way in bringing advances in genetics and "precision medicine" to the bedside.

ACT SIX: The year is 2000. Y2K fears of computer disasters did not materialize; nothing happened when the clock struck midnight. Yugoslavian president, and accused war criminal, Milosovic is overthrown in an uprising. The US Supreme Court stops the recount of the presidential vote in Florida; George Bush wins. It is time to move on.

Dr. Kukrika continued to practice his unique brand of cancer medicine until he retired in 2000. So, what has he been doing since then?  For one, he has been very involved in local and national politics, strongly supporting several Democratic candidates (and hearing from the public their desire for universal health insurance). He still keeps informed about his specialty and skims some of the medical journals, but the new information is mind-numbingly complex and doesn’t stick in his brain when it is not used daily in caring for patients. He visits his daughter Anna in North Carolina and his son Nicholas in London.

Finally, he and his wife had enjoyed going to New York for theater, and since losing her to pancreatic cancer in 2004 at age 65 he has continued to seek the stubbornly-hidden answers to life’s difficult questions from thoughtful playwrights and meticulous museum curators. And he has traveled to far away places with strange-sounding names, searching for home.

You see, the country of his birth no longer exists. 

CODA: From Beckett (a favorite author):

VLADIMIR  [to Estragon]: Let us not waste our time in idle discourse! (Pause. Vehemently.) Let us do something while we have a chance! It is not every day that we are needed. Not that we personally are needed...But at this place, at this moment of time, all mankind is us, whether we like it or not. Let us make the most of it before it is too late!...What do you say? (Estragon says nothing).

Samuel Beckett

(Beckett, Samuel.Waiting for Godot. Grove Press, 1954, p. 51.)

;

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)