Gracia Etienne, MD, PhD: He Lives in Two Worlds

Gracia Etienne, M.D.

As he carefully cut the sutures the scissors snapped in half. They were designed as disposable instruments but they were sterilized and reused many times and the metal deteriorated. Seeing this, the usually sturdy surgeon “cried like a baby.” Sure, he noted, even in this third world country of his childhood, such one-time-use tools would be disposed of. But, “at one time.”   

(If you prefer, you can listen a reading of the story here.)

When he returned to York from the medical mission to a northern part of Haiti he asked the OR nurses to let him sift through the surgical “waste” before it was discarded. Items that have no value in one place may be prized elsewhere.    

Even now, more than ten years after that 2008 mission,  Dr. Gracia Etienne told me that he is moved when he thinks about the simple surgical tool that fell apart in his hands. 

Before that, he had been content to go on a volunteer medical mission every now and then. But was that enough for his terribly suffering country? To do more, he said quietly, he “needed a sign.”  

On Tuesday, January 12, 2010, at exactly 4:53 p.m. local time, a catastrophic magnitude 7.0 earthquake occurred 25 kilometers west-south-west of Port-au-Prince. Buildings crumbled and many thousands of Haitians lost their lives. “Okay,” he said, “I wanted a sign from above, but that was too big!”  

Map of the 2010 earthquake (www.britannica.com)

A week later, with plenty of medical supplies in hand, he was in Haiti trying to help. When he returned a bit later he wondered if he could do more. He decided to start a small orthopedic clinic. 

His boyhood home was damaged by the quake, with visible fissures in the walls, but it seemed safe enough for temporary use, and his father offered it to him. Dr. Etienne’s bedroom served as the OR, the living room was the recovery area, and the porch was the waiting room. “We did what we had to do,” he said. 

His father, a successful rice farmer, then saw what was happening and told his son that the people, his people, needed what he was offering. The grateful surgeon perceived this, too, and admitted that he was “hooked” as he gently ministered to the wounded. 

But before we go on with the rest of that part of the story we need to go back to the beginning. So...   

“How did you become a doctor?” I asked Dr. Gracia Etienne as he sat next to his wife Manotte in my living room.

“By default,” he simply said. In Haiti, he noted, there were three good options after finishing secondary school. You could go into medicine, you could be an engineer, or you could go into agriculture. The smartest students chose to attend medical school. 

He was bright, sure, but he was young and undecided about what to do with his life. So those who knew him best “pushed” Grassi into medicine. And once he started on that path he “fell in love with it” and “there was no going back.”  

He finished the first year and a half of medical school and was “living the Haitian dream” and had direction. But this was 1986 and the country was experiencing a period of severe economic strain. Tourism was affected by HIV, and the entire Creole pig population (the source of much of individual Haitian's income) was sacrificed (after U.S. pressure) due to feared spread of the African swine flu virus.  

Haiti's perfectly adapted Creole pig (from "The Star") 

There were violent strikes and political uprisings, and the ruthless and corrupt dictator “Baby Doc” Duvalier was forced into exile. Making things even worse, there was the beginning of a crippling embargo.  After awhile Gracia “couldn’t take it anymore.”

So in February 1988, at age 21, he put everything he had into two suitcases and moved to the States; he landed in New Jersey where he was “totally alone.” With only a visitor’s visa, he could not continue his education as planned and it took a year to get a permanent visa and a Social Security number so he could move on. During that difficult time between the two visas he “did a lot of crying”. But he was determined. He drove a taxi, first in New York, and then in New Jersey, to save up for college. 

With the needed documents finally secured, Gracia then studied biology at Seton Hall, signing up for as many credits per semester as was allowed. Halfway through his second year, he took the test for medical school admission (the dreaded MCAT)... for practice. He said he did “extremely well.” 

So, after only two years of college, he then decided to apply to medical school early... for practice. Unexpectedly, he was granted four personal interviews. 

And he was handed a letter of acceptance and a scholarship to Penn State Hershey (pause for this)...at the end of their interview. They then gave him a train ticket to get back to Jersey so he could avoid another tiring bus ride (His sinuous trip to Hershey from East Orange had been through the night to get him to the early morning interview on time.) 

“Were you surprised?” I asked.

“Yes, I was, “ he humbly replied. Dr. Etienne said he does not think he is smarter or more polite than the guy next door. Or that he behaves any better. You see, he has a very strong religious faith (grounded initially in Catholicism and now Pentecostalism) and he believes the hand of God guides him. 

So he entered medical school here without a bachelor’s degree in anything.  He had cautiously waited until then to tell his father “the truth.” That he was not actually planning to come back to Haiti, as he had led his family to believe. (His older brother was set to enter medical school in the U.S. but didn't go.)

Haiti remained under the economic embargo (that was in place for 14 years), and without the ability to trade the high-quality local rice with the rest of the world, his father’s business started to fail. Gracia needed to help. So, for nearly two years, as he studied medicine full-time during the day he worked in the Hershey sleep lab almost full-time at night to be able to send money home. 

He admitted that as he manned the sleep lab he could study, yes, but that he often fell fast asleep, a no-no. (This reminded me of the famous scene toward the end of one of my husband’s favorite movies, "Dr. Strangelove": Peter Sellers, as the president, trying to break up the confrontation between the American general and the Russian ambassador, demands firmly, “Gentlemen, you can’t fight in here! This is the war room!” As in, “You can’t sleep in here, this is the sleep lab!”)  

War room scene from Dr. Strangelove (from latimes)

Anyway, during medical school, Gracia had time to volunteer at a nursing home (maybe Haitian days are longer than 24 hours, I just don’t know). And it was here, as he saw many gratifying recoveries after hip surgery, that he “fell in love with the restoration of function.” And he decided to “go for it.” 

He first thought about being a trauma surgeon but was put off by “the lifestyle” (see Dr. Nikhilesh Agarwal's story, “Trauma Surgeon without his Mask”) and chose orthopedics instead. 

He did a five-year ortho residency at Downstate Medical Center in New York and he “clicked” with prominent spinal surgeon Dr. Paul Brisson. They got along well. They bantered in French in the OR and got away with saying not-nice things about the clueless others in the room. Even as a second-year resident, Dr. Etienne's technical skills allowed him to do major surgeries. He enjoyed the work.

Paul Brisson, M.D.

After New York, he went to Johns Hopkins for a fellowship in adult reconstruction. He then stayed on in academics for a few more years as a clinical professor.  Dr. Etienne operated on patients at Sinai Hospital In Northwest Baltimore (that was founded in 1866 as the Hebrew Hospital and Asylum), published a few scientific papers on osteonecrosis, and taught the orthopedic residents. 

But he eventually looked around, and deep inside himself, and wondered, “What am I doing here?” He told me that this activity was not fulfilling; that he felt he was “faking.” He was unhappy, and the residents he worked with sensed that. A few of them were rotating through from the Memorial Hospital in York and they told him about the OSS (Orthopedic and Spine Specialists) group. Gracia was interested. He spoke with Dr. Vince Butera and Dr. Brian Bixler about joining the practice and, after five years in Baltimore, he left and moved to York. He’s been with OSS since.

He does shoulder surgery, hip procedures, and a lot of total knees. “The hip and knee replacements are two of the most successful procedures we offer now,” said Dr. Etienne. He said that we should try to protect our knees from “micro-injury” since this is the cause of “most of the osteoarthritis we are dealing with.” Running is a major culprit, and “there’s no need for it (as we get older).”  Being overweight and having a knee deformity are also important risk factors for the development and progression of knee arthritis.

The non-surgical treatment of osteoarthritis of the knees is intended only to relieve pain; no medical treatment, no treatment at all, has been shown to alter the course of the disease. 

What can be done before the surgeon takes over? The authors of the 2013 guideline from the American Academy of Orthopaedic Surgeons favored the use of oral NSAIDS (or nonsteroidal anti-inflammatory drugs) such as ibuprofen or naproxen, topical NSAIDS, and the weak opioid and serotonin/norepinephrine-active drug tramadol, for control of pain. They did not argue either for or against acetaminophen, opiates, or steroid injections. But they recommended against the use of glucosamine or chondroitin sulfate or even hyaluronic acid (Synvisc) injections.

When these symptomatic treatments are not enough to ease the pain the orthopedic surgeon can, in Dr. Etienne’s words, “offer the solution.”   The success rate of surgery is about 90% and the materials of the prosthetics have improved so much recently, he said, that total knee replacements now last at least twenty years.
 

Total knee prosthesis (medlineplus)

As I listened to this gentleman from Haiti, the only country established by a slave revolt, I wondered what his experience has been with respect to race and racism here. So I asked him.

"I can sense (‘institutional’ racism) and I can easily brush it off,” he said. But he noted that it is much harder to do that when he, himself, is the target of overt bigotry. 

He told me that when he was in Long Island tending to a local man who had broken his tibia the patient suddenly demanded, ”Get your (insert the skin color of your choice here) hands off of me!” Reacting swiftly, and with purpose, Dr. Etienne quietly asked the nurses to leave the room. 

He then firmly addressed the belligerent patient and said, “You are here to see me. I am not here to see you. If you need my help I am going to help you. But you cannot disrespect me.” He then took hold of the man’s misshapen leg with both hands and reduced the fracture; the patient winced but did not utter a single word.  

As I heard this I felt a squeezing sensation in my chest. I was ashamed, and I apologized to Gracia. I was saddened, knowing that we have not moved beyond our dark national history of racism. That more than 55 years after Dr. King’s speech, we are not able to judge people “by the content of their character.”

March on Washington for Jobs and Freedom 1963

Anyway, where were we? Let’s continue in York. 

It turns out that Dr. Etienne’s young son went to a church-based school and when Gracia met the very busy couple who ran it, the Revs. Wendell and Juanita Burden, he “fell in love” with them. Night and day, weekdays and weekends, they have been taking care of their “relational” Pentecostal congregation located in a poor section of the city. Dr. Etienne joined them, studied, and is now an ordained pastor in their church. And (in his spare time, I assume) the Reverend Dr. Etienne hopes to unburden the Burdens.

Meanwhile, to give back to his people (who have still not recovered from the 2010 earthquake and were later hit by hurricane Matthew in 2016), Dr. Etienne, with his wife, founded the non-profit foundation MIVO in 2009 (the website can be found here). They built and then added on to the small outpatient hospital since then. Their goal is to “bring orthopedic care to the underprivileged in Haiti in the name of Jesus.” 

This is Gracia’s passionate calling as he arranges week-long missions to the hospital every three months and brings a volunteer medical team of about a dozen to join him. 

A few reliable Haitian nurses manage the hospital in his absence and stay in touch with him by phone for difficult cases. When he and the others are expected to be in attendance the people line up all the way to the road (the hospital is set back a good bit) and wait for hours. 

The MIVO orthopedic hospital in L'Estere, Haiti (MIVO) 

Dr. Etienne and his colleagues were scheduled to have a session this month but the situation in L’Estere and Port-au-Prince is currently too dangerous.  According to the New York Times, “violence and economic stagnation stemming from a clash between the president and the opposition are worse than anything (the Haitians) have ever experienced.”  Thousands of protesters are filling the streets, seeking to chase out another corrupt leader. They are blocking the main roads and creating chaos and mayhem. 

So, as this is being written (late October 2019), Dr. Gracia Etienne is stuck in the Dominican Republic, the country making up the western half of the island of Hispaniola that is shared with Haiti. He still hopes to provide his simple orthopedic clinic with much-needed surgical supplies, including plenty of “disposable” scissors, and to return there himself when it is safe. 

But the immediate future does not look promising. One may need to rely on faith. 

Please stay tuned.

Or in French: S'il vous plaît restez à l'écoute.

And in Haitian creole: Tanpri rete an kontak.


References:

1.  Isaac, Harold, and Kohut, Merideth. “All but Poverty and Despair is at a Halt in Haiti.” New York Times. October 21, 2019. Section A, page 1.

2.  King, Martin Luther 1963: archives.gov/files/press/exhibits/dream-speech.pdf  

3.  Lozada, Carlos. "Osteoarthritis." Medscape. Updated 10/21/19.


Recommended Reading:

1.  Allport, Gordon W. The Individual and His Religion. The MacMillan Company. New York, 1950.

York Water Company Reservoir Park 10/27/19 (SC)

Anita Cherry

Dr. Nikhilesh Agarwal;Trauma Surgeon Without His Mask

Nikhilesh Agarwal

“Why is the FBI looking for you? What haven’t you told me?” she demanded when her soon-to-be husband came home from on-call duties at the hospital. In “the most off-handed way,” and with absolutely no concern, he told her that they are not looking for him. 

There was no more to be said. But the next day the FBI agents returned, asking questions. Once again, he quietly told his fiancée that they were not looking for him. The third time the feds appeared at the door they admitted that they had the wrong man; they were after a different Dr. Agarwal.

Dr. Nikhilesh Agarwal surmised that the FBI did a full background check on him when he applied for U.S. citizenship. There was, thus, no more for him to say. Though he is a “private person” he is “not secretive,” and he had nothing to hide from them, or anyone else. You see, he has no interest in, or talent for, deception.      

Dr. Nikhilesh, or Nik (as he is affectionately called by his colleagues) was raised in New Delhi. His father, a strict vegetarian and observant follower of Hinduism, had moved to the teeming city from the foothills of the Himalayas for a university degree and to start a family.  He worked in the federal government in an import-export licensing division. He went to law school while he was working. 

Beautiful quiet foothills of the Himalayas

He didn’t practice law, but as he witnessed “rife” bribery and corruption in the government he could not be silent. Nik noted that this “very very strong sense of self-righteousness” often got his father into trouble. He would say something, be investigated, and then suspended without pay for months.

A busy, noisy, not-so-beautiful, but vibrant street in New Delhi

Young Nikhilesh was the fifth child in a family of eight (seven brothers and their baby sister), and yet he felt that he was the “heir apparent” to carry on his father’s religious practices. But, “intellectually, it never added up” for him, and he became an ever-questioning skeptic. Though he says a prayer in the morning (out of respect for his father) the rest of the day he is “a committed atheist.” (This reminded me of food journalist Mark Bittman’s suggestion about first trying to be a “vegetarian until six” before diving in fully.)    

Moving on. “How did you get into medicine?” I asked.  He couldn’t really say. But from the time he was about ten, when his father was not in good health, he knew that he wanted to be a doctor. Not just any doctor, but a cardiothoracic surgeon! He took a “straight and narrow” path. He did the required one year of college before the five-and-a-half years of medical school in New Delhi. 

He came to the U.S. at 23. He did an internship at the poorly funded D.C. General Hospital, the only "public" hospital serving the District (until it closed in 2001). He notes that “they had the dubious distinction of being sued for not having a CT scanner” (in the late 1970s). 

D.C. General after it was closed
and was turned into a temporary homeless shelter  
(from "The Washington Times")

Dr. Nikhilesh moved on from there and did a full general surgical residency and a cardiac fellowship at Maimonides Medical Center in Brooklyn (“the largest kosher hospital in the world then” and a major innovator of cardiac technology including the first pacer). This was followed by a heart fellowship at St. Vincent’s Charity Medical Center in Cleveland in 1977. 

But as he looked to the future he (correctly, it turns out) sensed that advances in the medical treatment of heart disease would greatly reduce the need for surgery. So he changed direction and took advanced training in trauma at the Shock Trauma Center in Baltimore, the world’s first facility dedicated solely to the treatment of trauma.

As he told me his winding story, I wondered why Dr. Nikhilesh picked such an obviously high-pressure, technically difficult, messy, and emotionally demanding surgical specialty. So I asked him.

A trauma bay at the end of a messy case  

“I just liked trauma,” he said softly. And then added, “When you have Asperger’s you don’t notice it’s hard.” 

Asperger's? Now I definitely needed to know more. 

It seems that Nik “always” felt that he was somehow different than his brothers; that he was socially awkward; that he was just not interested in what people were up to; that he could easily walk away from things that he liked; that he doesn’t “suffer” feelings of guilt; that he may ignore the people that love him; that he doesn’t return phone calls from family when he knows he should, etc. 

However, despite his constant searching for self-knowledge, he “didn’t connect the dots,” until three or four years ago. “The lightbulb went off,” he noted, when he turned on the TV one day and accidentally caught an episode of “The Big Bang Theory.” As he carefully observed the main character, Sheldon, he said to himself, “This is me!” 

He immediately went online and answered one of the many Asperger’s screening questionnaires. Well, as it turned out, he didn’t have enough of the required behaviors to make a diagnosis. But he was (and still is) convinced that he lies somewhere “on the spectrum.” 

Lorna Wing, F.R.C.P.

(Medical writer Steven Silberman noted that it was the psychiatrist [and mother of an autistic child] Dr. Lorna Wing [1928-2014] who first used the term Asperger's syndrome [in 1981] for "high-functioning" individuals with the autism traits. Traits that she concisely identified as being difficulties with social interaction, social imagination, and communication.  This was not a standard diagnosis until 1992 and it was removed from the DSM V as a separate condition in 2013.

Wing also coined the term “autism spectrum” which “provoked pleasing images of rainbows and other phenomena that attest to the infinitely various creativity of nature."  She said that “all the features that characterize Asperger’s syndrome can be found in varying degrees in the normal population” [Silberman, p. 353].)

Anyway, this sudden and unexpected insight into his brain's social and emotional wiring caused Nik to reflect on some of the decisions he made over the years: 

Maybe working every other night and being chronically sleep-deprived was not such a good thing for his family. Maybe leaving his family at a social function to “fend for themselves” while he rushed off to the hospital for a sick patient wasn’t the best idea. Maybe not taking a real vacation every now and then wasn’t helpful. Maybe advising a patient’s anxious family members to go home for a rest when their loved one was still unstable in the ICU came off as unfeeling or uncaring. 

Maybe he could have done things better if he just knew more about himself.     

But what he did know, and early on, was that he could do surgery. That he could manage the complex, stressful, and sometimes chaotic situations that trauma may present. That he loved what he did. That when he was taking care of patients he was in his element. 

R Adams Cowley, M.D.

While finishing his training in the cauldron of downtown Baltimore with Dr. R Adams Cowley (1917-1991), the well-known trauma pioneer, he received inquiring phone calls from York. Neurosurgeon Dr. Ronald Paul and general surgeon Dr. Thomas Bauer wanted to recruit him to start a trauma service for the area. 

Dr. Nikhilesh drove north on Route 83, settled in York and carefully developed and grew the complex multidisciplinary program. However, there were (territorial) politics involved in the process of accreditation, and it wasn’t until 1986 that York Hospital was designated as a regional trauma center. Nik led the team and served as director until 2000 when Dr. Keith Clancy was brought in to take over the administrative duties. Nik graciously moved aside.   

The service has been quite busy since its inception (with over 2,000 trauma visits last year). After he was no longer director Dr. Nikhilesh practiced general surgery and enjoyed teaching, and he continued to serve the community as a trauma attending until 2015. His practice has changed since then, as he now does vascular and general surgery as an independent physician. He was cut off from the surgical residents for a while but was recently asked to do some teaching again, and he agreed.  He feels most comfortable “at the bedside.” 

After the tens of thousands of patients he has treated in his career, I wondered if there were any who touched him especially deeply.

“Yes,” he said. There was one particular woman, he recalled. She was a Jehovah’s Witness in her early 60s. She had multiple traumatic injuries (“she was banged up head to toe”) and had profound blood loss. Her hemoglobin was down to a critical 4 grams (the normal is around 12). She refused blood transfusions on religious grounds, and yet she managed to survive more than five months of fluctuating critical illness in the ICU.  But the day after she was finally stable and ready for rehabilitation she suddenly arrested. 

Dr. Nikhilesh was at an early morning surgical conference when he was informed of the shocking event. He instantly “knew” that she had a massive pulmonary embolism. (He had thought about placing a vena cava filter to prevent this well-known late catastrophe after trauma, but he was worried about causing bleeding.) He immediately left the conference to rush to the patient’s room. He did an emergency bedside thoracotomy; he opened her chest to resuscitate her and remove the clot. 

But she could not be saved. He mourned her loss for nearly a week.  This was the only individual he truly grieved for other than his father (who died while Nik was in medical school).

(Pulmonary embolism may cause 10% of late deaths after trauma despite measures to prevent it.)

The most common causes of early death after trauma are devastating brain injuries (about 50%), where the neurosurgeon is urgently needed, and severe blood loss with vascular collapse, shock, and multiple organ failure (about 35%), where the general trauma surgeon must quickly survey the situation to identify sources of bleeding to control them as soon as possible. Dr. Cowley, building on his military experience, developed the concept of the first “golden hour” after trauma, during which aggressive care is most effective. Time is critical, and many lives are saved by rapid and coordinated high-level trauma care. (The survival rate at Shock Trauma, for example, is close to 97%.) 

How common is the problem? Very. Trauma is the leading cause of death in the U.S. in those under 45, and the third-leading cause of death in those 45-64. It is an extremely serious (and apparently underfunded) health problem.

CDC: Causes of death by age group (unintended trauma is in blue; suicide is in green)

The surgeon leading the team--and it takes a large and dedicated team of doctors, nurses, and support staff--needs to have a cool head and the ability to size-up and control a situation efficiently. And it helps if he (or she) has a calm and reassuring demeanor, as Dr. Nikhilesh has been said to exhibit by those who have watched him work.

(Princess Diana, I recently read, was awake and responsive after the tunnel crash. But she was treated on the scene for an hour before being taken to a hospital. She died as a result of critical blood loss due to a “small tear” of a pulmonary vein that “should not have been fatal,” according to an autopsy. On the other hand, when President Reagan was shot he was immediately rushed to a trauma center where he was stabilized within 30 minutes despite massive bleeding due to his chest wound.)

While researching the advancements in trauma surgery I watched an interesting TED talk by Australian Dr. Russel Gruen entitled “Playing God; A trauma surgeon’s view on death vs. science.” He first sought God's help when he was an intern; he returned from work one day to find policemen at his door. His brother had been in a hang-gliding accident. He died. He was 21, and now he was gone. Dr. Gruen found that God could not help. 

During his ten years as a trauma surgeon he has looked for divine intervention from time to time, but, sadly, he hasn't seen it yet. However, he sometimes experiences technology coming to the rescue. But when it does not, as is still too common, and the patient gradually succumbs to their injuries, “life, on the way to death, looks like dusk.” The busy trauma surgeon witnesses much sadness.

The progress in acute trauma care in recent years includes the quick transfer to a level 1 trauma center (as the York Hospital has been designated since October 2009), bypassing closer but less well-equipped facilities, rapid resuscitation with blood products (not just fluids, as had been the practice), better control of bleeding (including use of topical agents such as QuickClot, that promote rapid clotting at the site), timely CT scanning, early definitive surgery, and concerted efforts to prevent contamination (since sepsis is a major cause of late deaths), among others (that are way too technical to mention or for me to understand). (Yes, that was a complex sentence about complex tasks that need to be done at nearly the same time.)

Getting back to our subject, Dr. Nikhilesh confided in me that he is a “surgery addict.” What does that mean? For example, after one grueling 40-hour trip to India by himself, when he finally arrived it was two in the morning local time, but four in the afternoon body time. He told his brother (a physician) that he was “so tired that the only thing he was good for was some surgery.” (I think he was exaggerating for dramatic effect, but I’m not sure…)

[How to cope better on long cramped flights? Maybe chair yoga could help.]

Seated forward fold pose (Paschimottanasana)
 from JURU: "8 Airplane Yoga poses for a long flight."
(I still can't breathe!)

(At 115 minutes into the interview, Dr. Nikhilesh’s cell phone rang. He hesitated at first but then looked at the screen and answered. It was his brother. Nik said he would call him back “in a little bit.”) 

What is on Nik’s mind other than cutting people open and patching them up and sending them on their way? Well, he worries about us. “The human experience is cursed (in its seeming unchangeability),” he said. And “we never really know ourselves. And other people see us and (try to) interpret what is going on in our brains (but) they will never know.” 

So he is frustrated as he learns that what we know about others, even our loved ones, is often “completely wrong.” For instance, when his wife sees him and says, “Why are you angry?” and he isn’t angry at all, he wonders (how often this misinterpretation happens).  “Others don’t see us with the microscope we think they have,” he said.

Because Dr. Nikhilesh feels that he has the Asperger traits of social awkwardness and a relative lack of empathy he has worked diligently to improve his listening skills and to be more aware of, and sensitive to, the feelings of others.

He reads a lot and thinks deeply. He is concerned, for example, that our children are “taught the 3Rs” but remain unschooled in the “advances in psychology (including the psychology of well-being) over the past one hundred years.” Advances that help us understand ourselves and our role in the essential interconnectedness of the world. 

Eastern philosophy informs Dr. Nikilesh that conditions beyond him are (mostly) in control (of what happens next), that there is always cause and effect. 

According to a 2018 Medscape article: 

Individuals with Asperger syndrome have normal, or even superior, intelligence while demonstrating social insensitivity or even apparent indifference toward loved ones. Indeed, individuals with Asperger syndrome have accomplished cutting-edge research in computer science, mathematics, and physics, as well as outstanding creative work in art, film, and music. Many prominent individuals (e.g., Albert Einstein) have demonstrated traits suggesting Asperger syndrome...An unknown number of adults with Asperger syndrome may be undiagnosed for their entire lives.

As Nik strives to learn more about himself, about who he is at the deepest level, about his inner self, his patients and colleagues may be comforted in knowing that they are with the precisely right Dr. Nikhilesh Agarwal; that there is no mistaken identity.

The Bhagavad Gita, the sacred central text of Hinduism, states:

“The wise work for the welfare of the world, without thought for themselves...perform all work carefully, guided by compassion” (3:25-26).


Bibliography:
  
1.  Brasic, James Robert. "Asperger Syndrome." Medscape. February 13, 2018.

2. The Bhagavad Gita: Introduced and Translated by Eknath Easwaran, 2nd edition. Nilgiri Press. Tomales, California, 2007. 

3.  Silberman, Steve. NeuroTribes: The Legacy of Autism and the Future of Neurodiversity. Avery (an imprint of Penguin Random House), New York, 2015.

4.  Rhee, Dr. Peter. Trauma Red: The Making of a Surgeon in War and in America's Cities. Scribner. New York, 2014.

The first verse of the Gita and commentary in Sanskrit in 
"Illuminated Manuscript of the Jnaneshvari"
Artist: Unknown; Indian; 1763
(photographed by SC at the Virginia Museum of Fine Arts)

Anita Cherry

Dr. Steven Pandelidis: Endocrine Surgeon and Triathlete

Steven Pandelidis, M.D.

“I love it when I meet my dad’s former patients,” said surgeon Dr. Steven Pandelidis. “The other day I met a woman with her husband. She was in her 60s and she seemed to have it all put together. 

“She said,” he went on, “that my father saw her in his busy psychiatric practice thirty years ago, and that he took ‘great care’ of her. She said that she will ‘never forget’ what he told her:

“‘You are not crazy. You don’t need a psychiatrist. You just need to do three things: You need to get a new job, get a new car, and get a new husband.’”

The woman took this unconventional and surprisingly pragmatic advice, and, as things turned out, “He was absolutely right!” she said. 

“My dad should have been a surgeon,” said Steve, somewhat cryptically.

(Later on, trying to discern what he meant, my husband reminded me of Atul Gwande’s first book, “Complications.” Dr. Gwande expanded on what has been said, usually disapprovingly, about surgeons: that they are “sometimes wrong; never in doubt.”  Atul claimed that “this may (actually) be their strength.”  When faced with uncertainty and inexact science the physician wielding the knife must cut anyway; a decision needs to be made and action taken. Words may be thought of as scalpels too; cutting into, cutting away, and shaping the patient’s experience... But back to our story.)

Kirk Pandelidis, M.D.

Steve’s father (1927-2016) was an immigrant from Greece (after his own persecuted parents left Asia Minor, now Turkey). He settled in York to marry and practice psychiatry. Steve said that his father worked long hours, often seeing patients after dinner until ten at night, and that “he loved what he did.”  He “commanded respect” in the community and at the Greek Orthodox church, where he was affectionately referred to as “īātré.” 

(Another digression: I didn't understand the Greek word Steve used, and my mind drifted to our family trip to Greece 15 years ago.  On the worn Athens streets, I heard people softly calling out “Éla, Éla,” to one another. I wondered what it meant. Maybe it was just a strangely-popular name. On the last day of our stay I asked our taxi driver. He said, quietly, “It means to come closer.”)   

Anyway, despite his father’s hectic schedule, the family (he has an older brother and two sisters) always had supper together at six. His dad would sometimes talk about his patients (no names), and the “unbelievable chaos” in their lives.

While there was no push for Steve or his siblings to go into medicine, there was never talk of “doing anything different.” By the time he was in the “ninth or tenth grade” Steve “knew” he would go to medical school.

He graduated from high school in 1979 and during the following summer he served as a psychiatric aide (you read that right, he worked in psychiatry) at the York Hospital. He did this while majoring in French Literature (oui, Litterature franḉaise) at Haverford, and again after his first year of medical school at Penn State Hershey. (Steve dutifully followed his brother Nicholas to both schools, by the way.) 

While Steve found these summer interludes “interesting,” he was clearly not going to be a psychiatrist. He was not a fan of chaos. “How did you decide to go into general surgery?“ I asked.

During medical school, he did a fourth-year surgical rotation at York Hospital in plastic surgery. After that, he considered becoming an ENT (ear-nose-throat) specialist. Community practice had little appeal (ear tubes and tonsils and such) compared to a university setting where they did head and neck cancer surgery, but he did want not want to be an academic. At the last moment, he decided to do general surgery. But why? Because he “just liked it.” 

Where should he go next for training? 

“I thought I might come back to York (after medical school) because I am close with my family,” said Steve. So he applied to his hometown program.

Dr. Jonathan Rhoads, the director of the surgical program at the York Hospital, gladly accepted him for a residency. Steve “absolutely loved” the five years of intense work. He married his wife Julie during his third year of residency. He gradually absorbed the demanding craft of surgery and they kept things simple at home as they lived in an apartment over his father’s office just down the street from the hospital.  

(The psychiatric practice was named “Delphic” to honor his father’s Greek heritage. Delphic: pertaining to “ambiguous or enigmatic” advice or predictions.) 

Oracle at Delphi (from "The Greek Reporter")

“In two minutes I was at the hospital," said Steve. "No worries about where to park the car. No worries about traffic or safety.” Though he seeks challenges in his professional life and in athletics, he avoids unnecessary hurdles whenever possible.

And strenuous athletic activity is an important part of his routine. Dr. Pandelidis is a serious triathlete who swims, bikes, and runs on different days of the week according to his mood and the weather. He found “Bikram-style” Hot Yoga five years ago and is hooked. He wishes he had discovered it earlier.

The focus of the intense 90-minute classes in 104℉ studios is on three things: “flexibility, balance, and stamina.” They run through the same 26 gradually-more-difficult yoga poses plus two breathing exercises each session. The same sequence over and over. And wherever in the world these classes are given the routine is identical. “You can measure your own progress,” said Dr. Pandelidis. "You compete against yourself and try to improve. It’s pretty nifty.”  

"Everybody on your Toes!"
 (From a hot yoga session at Massachusetts General Hospital)

This predictable sameness, he noted, is part of the anciently ordered, comforting, ethereal, and meditative Orthodox Christian services he happily participates in nearly every Sunday morning with his wife (sometimes after a long mind-clearing run on the Rail-Trail). The Church liturgy has been essentially unchanged since the fifth century and brings people closer together as everyone chants it in unison.  

Anyway, we can leave the drippingly sweaty and scantily clad athletes in their yoga class and return to Steve's story. 

Yes, he liked general surgery well enough, but he also enjoyed the weekly “tumor board” conferences.  He listened as the “erudite” oncologists Dr. Miodrag Kukrika and Dr. Eamonn Boyle (each the subject of a previous story in this series) quoted studies about survival curves. He listened as the radiation-therapy specialist, Dr. Greg Fortier, did the same. He listened as one of the laconic cancer surgeons would grunt and confidently announce, “I can take it out!”

As he worked with Dr. Robert Davis (“an important mentor”) and with Dr. Tom Bauer, York’s first dedicated surgical oncologist, he saw an opportunity for his own career. He sought training in the new specialty and he took a two-year fellowship at the University of Illinois in Chicago. "They did a lot of melanomas, head and neck surgery, and a lot of breast cancer, but not many gastrointestinal malignancies,” he said. 

When he returned to York Steve joined six other surgeons in an independent group. As he focused on patients with specific cancers his practice evolved, and he views himself now as “an endocrine surgeon.”

I asked him what he enjoys, what he does best. His skill, he said, is doing thyroid and parathyroid surgery, and he does this more than 200 times a year. He told me that there is generally a predictable pattern to the procedures, and said that “if you do the same thing over and over you get better at it.”  (He confided later that he also relishes the test of an especially difficult surgical case every now and then.)   

When Steve started his career thyroid tumors were much less common than they are now. They were usually found during a physical exam; the gland was palpated, a nodule was felt, and an ultrasound was ordered. But most nodules he sees now happen to be discovered incidentally. They are found when looking for something else. Thyroid abnormalities may be seen, for example, on a CT scan of the chest done after a suspicious finding on a routine chest x-ray, or maybe after an ultrasound of the carotid when working up a stroke, or on an MRI of the cervical spine done for neck pain.

Thyroid nodule (arrow) found incidentally on a spine MRI

Such quiet growths, it turns out, are exceedingly common. As many as 30% of adult women have thyroid nodules, 90-95% of which are benign. To identify those that are cancerous is the issue. Small asymptomatic nodules can simply be followed by repeat imaging to see if they enlarge before a biopsy is needed. Larger nodules (more than 1 cm) and smaller, but symptomatic, nodules usually demand an ultrasound-guided fine needle biopsy for analysis. 

Dr. Pandelidis said that, as a result of the above, “there are too many ultrasounds, too many biopsies, too many surgeries, and too much (use of) radioactive iodine.”  The American College of Endocrinology and other similar bodies have developed guidelines to address this excess, but it will take time to change doctors' habits and patients' expectations.

I wondered if someone who’s been told now that they have a small thyroid nodule can cope with uncertainty so that they can leave it untouched while watching for the enlargement that suggests cancer.

The thyroid and the important surrounding structures

Steve responded, and said that there are very few women (nodules are three times as common in women as in men) who are willing to wait. Even when he explains to them that most thyroid cancers are very slow-growing and are almost always curable with surgery and radioactive iodine.
 
(Dr. Pandelidis reminded me that a similar dilemma is being seen as tiny breast cancers that might never cause harm are picked up on routine mammograms, sometimes leading to fear-driven mastectomy instead of the breast-conserving removal of just the tumor.) 

Through diligent practice, constant self-assessment, and immediate feedback, and by doing the same surgery again and again, Dr. Pandelidis has steadily refined his technique. He said that he can do a thyroidectomy as an outpatient in thirty minutes leaving only a nearly invisible scar. 

When the challenge is high and the skill level is matched, the surgeon, like the dedicated athlete or the performing musician, can be "in the flow." There is total immersion in the task that seems effortless, and there is a loss of sense of time and self. 

    Flow chart after Mihaly Csikszentmihalyi
     "Flow" is when the challenge and the skill level are matched

Reflecting on changes in the treatment of cancer since he first attended the stimulating weekly conferences decades ago, Steve said that “we are at a very interesting time.” 

Malignant melanoma is his other major surgical interest and there have been major advances recently in precision diagnosis and non-surgical treatment. This cancer has been increasing in frequency in the last 30 years and is now the fifth most common cancer. There were no new treatments for advanced or surgically inaccessible disease from 1995, when alpha-interferon 2-b was introduced, until a few years ago. 

The immune-based targeted therapies approved for melanoma like Opdivo (in 2017) and Keytruda (in 2019) “are amazing,” remarked Steve. These so-called PD-1 checkpoint inhibitors unblock the immune attack on run-away cancerous cells. They are being used to treat diseases that were “not getting a lot of attention” (compared to, for example, breast cancer). 

Patients that only a few years ago would have succumbed to their widespread cancer after a few months have now been “walking around for two or three years.”  Their “diffuse metastatic disease is all gone,” said Dr. Pandelidis with visible excitement.

His two main interests have something special in common. He said that he “chose (to treat) cancers where surgery makes all the difference in the world.” Where it was once thought that “it was the big surgery that cured breast cancer, now we know that it is the little surgery, along with the help of radiation, chemotherapy, and hormone treatment. But with melanoma, you remove the lesion and lymph nodes that it could have spread to, and most of the time you take care of it.”  Early diagnosis is still key. If in doubt about a spot on the skin that looks suspicious, "you should get that checked." 

ABCDE Mnemonic to help recognize a melanoma

Thyroid cancer treatment apart from the surgery is even simpler, and it is mostly just use of radioactive iodine (except for unusually aggressive and rare tumor types, where things get complicated and the medical oncologist steps in).

As we sat and talked together after his 40-mile morning bike ride with his wife, Dr. Pandelidis was surprisingly relaxed, and I was struck by the sense that he seemed to be an unusually happy doctor; I wanted to know more about that. 

I said that we are hearing that physicians have been stressed by changes in the way they are forced to practice in the era of cumbersome electronic health records and increasingly-intrusive insurance companies looking over their shoulders. What was his take?

He said that he “is generally a happy person” by nature (50-80% of general happiness may be genetic according to Haidt), but that he works at being happy too. For example, in his practice he delegates some of the tedious charting work. Simply ordering and arranging for a routine CT scan, a task that used to be straightforward now involves a long list of sequential steps, multiple mouse clicks, and data entry. He hands this off to his capable physician’s assistant. One more job for his support staff; one less headache for Steve. 

Documenting exercise, yes exercise, on Epic (from Kaiser Permanente)

Dr. Pandelidis told me that he serves on the WellSpan physician well-being council (yes, even doctors need doctoring in such things) where they address the increasingly-common problem of physician burnout. He listens to the stories and gladly shares his hard-won insights with his weary, less content, and struggling colleagues.

But making sure legal forms are signed, and carefully documenting procedures for the record are his responsibilities alone. This electronic “paperwork” eats into the precious time between surgical cases, the time he needs to ready himself properly for the next anxious patient.  He likes to talk to the patient’s family in the recovery room but, due to these constraints, he may (regrettably, he notes) resort to calling them on the phone instead.

But, even though his independent group decided to join the WellSpan system about four years ago and Dr. Pandelidis was reluctant to relinquish some of his highly valued autonomy. He has not let this alter his core values. 

He told me that after a surgical cure he still follows most of his patients yearly. They are comforted when he reassures them that their thyroid tumor or their melanoma has not returned. He makes sure that if they have not recently seen, or maybe don't even have a primary care physician they do not neglect other important health issues. He said that this follow-up has become a very rewarding and important part of his practice. 

And as he trains and guides surgical residents and students he transmits his way of the experienced physician-surgeon to the next generation. 

He teaches them to be flexible, to develop stamina, and to strive to be in balance (though they need not stand on their heads or their tippy-toes).


Suggested Readings:

1. Gawande, Atul. Complications: A Surgeon's Notes on an Imperfect Science. Picador. New York, 2002. 

2. Csikszentmihalyi, Mihaly. The Evolving Self: A Psychology for the Third Millennium. Harper Collins. New York, 1993.

3. Haidt, Jonathan. The Happiness Hypothesis: Finding Modern Truth in Ancient Wisdom. Basic Books. New York, 2006