Matt Howie, M.D.: From Family Medicine to Public Health

Matt Howie, M.D.

The nearest traffic light? An hour away. The closest large town? Two hours. It was here, in northern Arizona, that the warm terracotta-colored earth against the deep-azure sky welcomed the doctor, his wife, and their young children. They were thousands of miles away from the world they knew. The idealistic physician, Dr. Matt Howie, had finished his Family Medicine training at the York Hospital, and he wanted to make a difference. 

It was after gentle encouragement from his teaching attendings and a brief clinical experience on a Zuni Reservation during his third year of residency training, that he decided to commit to doctoring at an isolated Indian post. His wife, the daughter of a Methodist minister, was game.

The staff at the new Hopi Health Care Center took care of the people of the Native American Hopi and Navajo tribes. (The two groups have different lifestyles and different ways of providing for their families and they have had an ongoing testy land dispute since 1882 when arbitrary lines were drawn by the federal government.) 

“It was a fantastic time for me,” said Matt, as the ten or so recently-trained family doctors like him were forced by their remote location to become “mini-specialists.” 

They did mostly outpatient work, but also manned the emergency room, managed five inpatient beds, and staffed the few labor rooms (where the native women gave birth quickly). The doctors soon learned their limitations, and complex difficult cases were rushed by air to Flagstaff.

Hopi Health Care Center in Polacca, Arizona 
(photo: Indian Health Service)

As I listened to Dr. Howie tell his story I was struck by his enthusiasm. This experience, I sensed, was clearly a different way to do medicine than he was used to here in York, Pennsylvania. 

“It was a fantastic way to practice,” he gushed.

But medicine wasn’t his first career choice as he finished high school in rural southern Maryland. While he thought “it might be cool” to be a doctor, maybe this was his father’s idea, not his own. So he went to Emory for a business degree. The school work there was easy, but not fulfilling, and his soul wasn’t in it. His grades were mediocre; he wasn’t thriving.

Life changed when he took part in a program with the Methodist Wesley Fellowship Group in Atlanta. As he spent time in soup kitchens and homeless shelters he found that he enjoyed these activities much more than his college studies. And during one spring break, he helped build a house in Appalachia. He told me that he was nourished by “the experience of serving others.”

Appalachian (Kentucky) family: William and Vivian Comett 
and their 12 children (photo: William Gedney)

Since a career in business was out, and since he was “always a science and math geek” anyway, the decision to switch to medicine in his third year at Emory came easily. His parents (both educators) were supportive. 

So he returned to Maryland and transferred to UMBC for his premed studies. He was “very focused” on getting into medical school, but it wasn’t all book work; he made time for other things.

He volunteered in the OR at the University of Maryland Hospital. He also worked at a church camp in the summer (where he told me he met his future wife). 

Matt was accepted to the University of Maryland School of Medicine in 1993. The study of medicine was demanding, of course, but even so, the idea of service to others remained in his sights and was repeatedly reinforced by his experiences. 

After medical school, he took Route 83 North and did a Family Medicine residency at the York Hospital. He was strongly influenced by several members of the teaching staff including Dr. Andre Lijoi, Dr. Andy Delp and, especially, the calm, self-effacing, and always incisive, Dr. Richard Sloan (whom Matt recalled with great respect).   

While in Baltimore (where 24% live in poverty), and again in York City (where the poverty rate is nearly 36%), Dr. Howie frequently witnessed inequities in healthcare, inequities that were grounded in economics and longstanding fragile social circumstances. He was optimistic (during the Clinton presidency) when there was the hope of “a unified system” so that “you didn’t have to worry about who is insured,” he said. He was disappointed when the idea of access to healthcare as a basic human right was put aside (again).

Dilapidated row homes in Baltimore (photo: Scott Beyer)

So it was, that after three years in York, he and his family packed their things and headed to the Southwest, to a place where he felt his services were most needed, where he could make a difference.

The next three years on the secluded Indian lands were formative. Practicing medicine in such a desperately underserved area gave Dr. Howie a sense of inner calm that he feels he might not have otherwise enjoyed. With that peacefulness, he could “sleep better at night.”

Though Matt and his wife were content in Arizona they decided to leave in 2003 when it was time for their children to start school; they knew that education is critical and home-schooling was ruled out. They looked around as a team and chose to return to York. 

Back in Pennsylvania, Matt worked closely with (and “followed”) Dr. Christopher Echterling at the Community Health Center.  He enjoyed being part of the busy inner-city “safety-net” practice for twelve years. When Chris left for another position in 2012 Matt took over as medical director.  

Dr. David Hawk

Things were going along just fine for Dr. Howie until one day when he received a letter from Dr. David Hawk of the York City Bureau of Health. Matt said he was asked to join a group hoping to “partner” public health and clinical medicine in several “joint initiatives.” An attempt, he said, to avoid the dilemma of the two disciplines operating in their own “silos.” (A nice rural Pennsylvania metaphor.)

Dr. Howie was delighted by the prospect of building a better health system at the local level.  He had toyed with the possibility of going into the public health arena for a while, and this opportunity resonated with that unformed idea. 

Time passed, and as Dr. Hawk was planning to retire from his position (he left in 2015) he approached Dr. Howie to see if he was interested in taking his own job with the Bureau of Health. Matt considered it, discussed it with his wife, and said yes. But by then, funding for the half-time position was no longer in the tight city budget.  Dr. Howie waited patiently, and he was grateful when WellSpan Health offered to help financially.

In this capacity with the city (one of the few municipal programs in the state), he has helped formulate a number of public health endeavors. Among these is the multidisciplinary “Healthy Moms-Healthy Babies” program where nurses visit mother and baby regularly for two years. This program remains important for impoverished city residents and for the health and well-being of the next generation.

Matt also helped develop an expanded downtown clinic that provides screening and exams for sexually-transmitted diseases. He said that syphilis, including congenital syphilis, is being diagnosed with increased frequency (along with newer STDs like HIV and hepatitis C). I was shocked; I thought that the “older” diseases were no longer problems.  

He told me that the reappearance of syphilis points to a “dysfunctional system.” He said that we still have a significant population (in the city) “that is disenfranchised.” And he noted, sadly, that “bad things” are more common in this group of people who do not receive routine medical care and have other stubborn life obstacles.

The rising rate of syphilis in Oregon 2013-2018 (Oregon.gov)

One of the “bad things” is a high rate of substance abuse. This may involve nicotine, alcohol, cocaine, methamphetamine, benzodiazepines, marijuana, heroin, or prescription opiates.  

Addiction to potentially harmful substances is, of course, a long-standing and serious worldwide public health problem.  For example, in the U.S. in 2017 there were over 488,000 deaths due to smoking, about 88,000 deaths as a result of alcohol use (and 21 million DUIs), and approximately 47,600 fatal opioid overdoses (15,000 with heroin).

Opiate use and misuse are now in sharp focus, but not everyone who takes an opioid is equally liable to develop an addiction. For example, it has been estimated that about 25% of those who use prescription opiates like oxycodone or hydrocodone for pain misuse them and that 10% of that group becomes addicted. 

Risk factors for addiction include genetic, epigenetic, and even transgenerational epigenetic factors (accounting for 40-50% of the risk), younger age at first use, the type of substance used, peer pressure, mental illness, homelessness, incarceration, lack of attachment, and poverty. 

Specific adverse childhood experiences (ACE), including emotional, physical, or sexual abuse, and living with household members who are substance abusers, mentally ill or suicidal, or ever imprisoned, are especially potent predictors of later substance abuse.   

ACE score and injection drug use (from Kaiser)

The use, misuse, and addiction to opiates have increased dramatically since the mid-1990s (for complicated reasons too controversial to go into) and I asked Matt if he could tell me about the local public health response to this.

But before discussing his ideas, it is helpful to go over a few things about addiction, and why it is so difficult to treat. (My husband helped me here and I read through Judith Grisel’s recent and enlightening book, Never Enough.)

Addiction, as a disease of the brain, involves three interconnected neural systems. 

So, here goes (bear with me). 

First, certain areas of the basal ganglia (deep-seated in the brain) are responsible for producing the pleasurable or rewarding aspects of a substance (e.g., food or water) or activity (e.g., sex or social interaction) that is important for individual and species survival. 

Next, is the extended amygdala, including the nucleus accumbens, and connected to the hypothalamus. This limbic, primitive, “fight or flight” (fear/anxiety) emotion system generates quick, unthinking responses to potential danger signals (e.g., a predator) by matching these signals against memories of past experiences. 

And there is the prefrontal cortex. This newest component of the evolved human brain is intimately connected to the older deep nuclei. It is the executive, or conscious decision-making structure, and needs a bit of time to evaluate what is happening, and to determine its significance. It can be engaged to exert control or override the emotional brain. It can help us decide whether to stop or to go, whether to avoid or to approach. To decide: is it a snake or just a rope? But the prefrontal cortex is not fully wired up and connected until we are in our 20s (later for men than for women).  

The basal ganglia, the extended amygdala, and the prefrontal cortex.

The three connected systems of addiction (NCBI: NIH)

What is it about the pain/pleasure/assessment and survival system that results in addiction? What is it that leads us (according to the American Society of Addiction Medicine) to use substances or to engage in behaviors that become compulsive, and continue despite harmful consequences? 


The reward system relies on dopamine and opiate signaling. The natural opiates, endorphins, mediate the pleasurable (the “positive” or survival-related) effects of a substance or activity. Dopamine reinforces the behavior. All addicting substances result in an increase in dopamine activity in the nucleus accumbens.  

Now the tricky part. Because the nervous system (like all life) needs stability (equilibrium, not too much and not too little) it adapts to change to re-establish balance. 

In her just-published book, neuroscience researcher (and recovering addict) Dr. Judith Grisel used the “opponent-process theory” to explain what happens in the addicted brain. 

To restore harmony, the rewarding, or the “a” effect, of an addictive substance, also leads to an opposite, or so-called “b” effect. 

With repeated use of a drug, the brain learns what to do to return to balance, to compensate, and the “b” effect becomes stronger and longer-lasting. This results in tolerance, (i.e, the need to take larger amounts of the drug for the desired effect), as well as the "negative" unpleasant withdrawal symptoms. 

Schematic of the initial, later "a" and "b" and 
summated (black line) effects of a drug (after Grisel) 

Eventually (and this I find most discouraging), the opposing process, without the presence of the drug, is triggered by cues associated with prior drug use, leading to craving. A vicious cycle develops.    

And yet there’s an even sadder part. The changes that occur in the brain wiring, including learning how to respond to the initially-rewarding but now no longer pleasure-producing substances, can be long-lasting. This type of enduring damage is most likely in the still-developing adolescent brain and may, tragically, lead to dangerous relapses after years or even decades of sobriety. 

Okay, now that we understand the problem a little better, let's get back to Dr. Howie.

While addiction is now seen more clearly as a chronic relapsing brain disease, we still don’t know the ideal way to manage it. There is no simple answer in a disease as complex as this, and Dr. Howie stressed the importance of an individualized approach (as in most chronic ailments). 

He feels that medicine-assisted programs such as those using methadone or Suboxone are a start, but that comprehensive treatment is essential, especially since many individuals have serious mental health problems and social stresses.  

And as he lamented that it is very difficult to get people into treatment he said that this is a start where his public health skills can be used. 

Dr. Howie told me that 28% of people who died of a drug overdose in York in 2018 were in “some sort of parole or probation program.” As were nearly half of the individuals who overdosed and didn’t die. This is an easily-identified vulnerable population that receives inadequate care.

So Matt is working with a group whose “intent is to marry up the correctional system, and the judicial system at large, with the treatment for mental health and substance abuse.” These entities now do their thing in nearly-complete isolation, with almost no sharing of information, and certainly not in real-time, when it can be of most benefit.

Dr. Howie said that when an individual commits a low-level crime related to their substance abuse or to their mental illness, putting them in jail “does not help either one of those conditions at all.” Instead, for the right person, diverting them (even before booking) from the criminal/judicial system directly into mental health and substance abuse treatment is a much better and more humane option. 

With that goal, the group is planning to organize a physical “wellness and diversion center” (perhaps in a space at the prison). If the individuals cooperate, their charges disappear. He said that a program of this type in Seattle showed that fewer people return to prison, and that lives are saved. He is looking forward to getting this program off the ground.

“Public health has drawn me into areas I never thought I would have gone, but that’s where the pain is,” said Dr. Matt Howie, as we neared the end of the early afternoon interview. 

At this time he works 60% for the city, 30% for the county, and 10% for WellSpan. He sees himself as a generalist, dealing with a range of issues including birth outcomes, STDs, prostitution for drugs, the opiate crisis, food insecurity in the city, human trafficking, unwanted pregnancy, gun violence, and others.  

While the opioid situation currently commands his attention he noted that there is a common thread, as these public health issues all center around poverty.  “This is where our society is being strained,” he said. 

Overdose death rates in 2014 (note the high rate in Appalachia) (from NYT 2016)

And where there is emotional pain and where there is stress there will be attempts to soothe this, to escape from pain. Attempts that lead to unwanted and harmful reliance on addictive substances. Substances that no longer satisfy. 

As Judith Grisel remarked toward the end of her frank personal account of addiction and addiction research from the point of view of a concerned neuroscientist:

Among the most astounding findings in recent neuroscience is the context-dependent nature of all neural activity. Even as our thoughts, feelings, and behaviors are products of neurochemical brain activity, what gives rise to this activity is mostly not in our brains. Rather, our brains express the evolutionary, social, and cultural context we occupy. It follows that the answer to the addiction crisis is not solely in the brain, but must include the context. 

Drug addiction, thus viewed, is an enduring societal issue intimately connected with who we are, with what happens to us, and how our brains adapt. A comprehensive public health approach is needed to treat, and, more importantly, to prevent, this affliction.

Dr. Matt Howie is prepared to help.


"Let us put our minds together and see what kind of life we can make for our children."
                                                                                                                     Chief Sitting Bull

P.S. Then Covid-19 came along, and the critical public health response...

Reference/Suggested Reading:

Grisel, Judith. Never Enough: The Neuroscience and Experience of Addiction. New York: Doubleday, 2019, (p.214). 

York Reservoir Park 2/22/20 (photo: SC)

Anita Cherry (2/26/20)

P.S. "The number of yearly overdose fatalities surpassed 100,000 for the first time ever in 2021. Halfway through 2022, the ate appears to be rising even further." (NYT July 5, 2022)

Dr. Thimmapuram: He wants you to lengthen your telomeres

Jayaram Thimmapuram, M.D.

Let me tell you a story. We are somewhere in the south of India. The man sits perfectly still and erect with his eyes softly closed. He seems to be doing nothing. His son Jayaram thinks he looks silly. But as he watches his father do the same thing day after day Jay becomes intrigued. He needs to know more, so he asks. 

His father, a zoologist, quietly replies: “If you are interested to find out what this business of doing nothing is all about, try it out for a few weeks. See if this is something that would help you. If it helps you, carry on with it. If it doesn’t help you, it’s okay, you have still learned from it. And you can make your future choices based on that.”

Jay dutifully listened to his father. He sat down, closed his eyes, and did “nothing.” But his thoughts kept coming. It was not easy to face his “inner chaos,” said Dr. Thimmapuram, an academic internist at the York Hospital. After a few weeks of trying this, he wanted to stop and just walk away. But he continued, and he worked with a trainer to help him with the meditation practice. One day he had a totally unexpected “wonderful experience.”

Jayaram told me that it felt as if his “mind was removed, put in pure water, and put back in again.” He had never before experienced “such clarity.” And this was not just a subjective feeling, it affected his behavior as he found that interactions with family and friends were simpler. At 18, he was beginning to feel more comfortable, or at ease with himself.

Don’t turn your head
Keep looking at the bandaged place
That’s where the Light enters you
And don’t believe for a moment that you are healing yourself

(Rumi)

The meditating affected everything he did. He was on track. But he was young and lacked commitment, and Jay didn’t stay with the practice consistently. He told me, for example, that when he was in medical school and meditated regularly his grades were much better than when he slacked off and didn’t. This pattern of on-and-off practice continued for a while.

Chaotic bicycle "contraption" parked by the York hospital (Photo by SC)

But “something happened” after his residency here in York, as he felt “a calling to get back to that inner discipline state” that helped him before.  And when he once again meditated faithfully, set aside time for it, it felt as if his “inner alignment was coming back.” An alignment that sharpened his focus on his career path in medicine. 

But let us step back first and trace the beginnings of Jayaram’s medical journey.

His father, as mentioned, is a zoologist, a scientist who studies the behavior, classification, and “vital phenomena” of animals (according to Merriam-Webster). His mother (she passed away in 2017) held a doctorate in linguistics, the study of the “structure and nature of human speech”  (again, from Merriam-Webster), the study of how we communicate and connect with one another. 

So Jay was raised in a home atmosphere infused with the biosciences and its probing and questioning. His brother and sister are both physicians, so it was “normal” for him to “be inclined” toward the field of medicine, he told me. 

After secondary school, he went to Gunter Medical College in Andhra Pradesh on the southeast Indian coast nestled by the beautiful Bay of Bengal. When he finished medical school he wanted (maybe he needed?)  to explore the outside world, and to find himself.

Jubilant Gunter graduates. What's next?

How do you know that I do not know 
that the fishes are enjoying themselves? 

(Kazuko Okakua in Langer)

Well, one of his brother’s friends had gone to the U.K., and at 24 now, and not too picky, this seemed like a good enough destination. You see, the young Dr. Thimmapuram was a practical man, and as he found out that the requirements for a position in the U.K. could be satisfied easier and more quickly than for a spot in the U.S. He decided to take the shorter route to the West.

He first landed a job as a house officer at Norfolk and Norwich Community Hospital. He then worked as a Registrar (equivalent to a Fellow) in internal medicine at Borders General Hospital in Scotland. Following that stint, Jay studied and did gastroenterology for a few years.

As we sat in my living room Jay quietly told me that the pace of medicine in Great Britain was relaxed, as morning hospital rounds, for example, could start at a leisurely nine-ish instead of a crazy five-thirty here (yikes!). He greatly enjoyed the hands-on clinical style of the Brits and even had time to hone his cricket skills. 

His role on the pitch (as they call the field) was as a “one-down” (whatever that is) with the Melrose club in Scotland, where he merited a few fondly-recalled mentions in the local sports pages. 

Cricket pitch by the Borders General Hospital (Can you squint and maybe spot Jay?)

(An aside: Our cab driver in Bermuda tried to explain the rules of cricket to me and my husband. I was completely lost after the first few seconds. It seemed like he was speaking gibberish, and I zoned out. You see, watching baseball bores me to tears.  My mind becomes blank and still. Blank and still ...maybe even Zen-like...I think I’m falling asleep...asleep...asleep.)
   
Anyway, after seven years of tea and crumpets, Jay felt the need to move further west, to the States, and he gamely took the (unexpectedly) long and arduous USMLE exam. His first interview for a position was here in York. He was impressed by the staff, and it seemed like a nice fit. So he added to his training and did a three-year general internal medicine residency. He said that he learned something from each of his attendings. When he found things that “resonated” with his “heart” he accepted them.

Dr. Wolfe Blotzer (we have met him before in these stories) was one of his important role models. Jayaram said that “he is an encyclopedia, (and yet) his primary concern was always to the patient.” Wolfe’s physical examination skills were “great” and since this part of the craft of medicine is slowly fading away, watching Dr. Blotzer was as if he was “seeing someone from another planet.” 

From IMDb

Jay has also learned a great deal from Dr. Sharon Scott, a fearless member of the academic inpatient team (whose own story can be read on this site here). 

Jayaram certainly enjoyed clinical work with patients but felt especially drawn to teaching, so he joined the faculty.

Leonard Bernstein noted that the words for teacher and learner are nearly the same in German and Yiddish-Lehrer/Lerner. 
(From Langer)

As he practiced hospital-based medicine and mindfully taught the students and residents he continued to meditate routinely. And “as a scientist” Dr. Thimmapuram remained intrigued by this practice and wanted to know more about what happens to us by “the simple act of closing our eyes.” 

So he was primed when his program director had a request. Dr. Robert Pargament had just read an interesting article and came to Jayaram and said: “I know you meditate. Can you do something with our residents?” The paper was about “burnout” in medicine, an important and timely topic. Jay recognized this and quickly agreed to help, and he suggested doing a formal study.

Dr. Thimmapuram told me that there are a “lot of stresses and a lot of strains” for those working in the caring and healing professions and that “we take those (stresses) home to our families and loved ones, who may become the victims.”  The stress level is particularly high during the training years, and as this affects the physician it affects their patients.

Another linguistics point: The word “Patient.” From the Latin “patiens,” the present participle of the verb “patior,” meaning “I am suffering.” 
(Wikipedia)

Burnout, according to the upcoming ICD-11, is defined as an employment condition, not a disease (the code-everything has to be coded, you know-will be QD85). It is defined by the three dimensions of emotional exhaustion or depletion, depersonalization with cynicism towards work, and lack of personal accomplishment (“professional efficacy”).  

Dr. Thimmapuram said that at any given point “at least half of physicians suffer from burnout.” Half! 

This can lead to anxiety, depression, addiction, and, especially sadly, suicide. Physicians commit suicide at twice the rate of the general population, and we lose nearly 400 U.S doctors yearly as a result. How much of this is triggered by burnout is not known. 

Physician suicides by specialty (from Dr. Pamela Wible)

So Jay designed a twelve-week study of residents, nurses, and faculty members. One group did “heartfulness” meditation an easily-learned practice that Jayaram, himself, has used for years that focuses on one’s “inner alignment.” The other group “carried on as usual.”

At the end of the study, the group that meditated showed improvement in all three burnout dimensions compared to the group that did not. Jay noted  that measures of “anger, anxiety, stress, fear, irritability, jealousy, addiction, apathy, cynicism, and impulsiveness, all decreased.” 

And the “positive” attributes of concentration, calmness, clarity of goal, harmony, sleep, joy, positive thinking, self-confidence, and honesty to oneself increased. 

Dr. Thimmapuram wanted objective data in addition to the subjective reports. He wanted to see if there were quantifiable physical effects of short-term meditation. (He knew that such effects have been found in expert meditators after decades-long practice.)

Once again, everything is the same until it is not.

 (Langer) 

He chose to measure the lengths of the telomeres. These are the caps that are at the tips of the chromosomes. They prevent the degradation of DNA and end-to-end fusion of chromosomes. Their lengths reflect the state of our well-being and lifestyle and may predict longevity. Jay said that chronic stress shortens telomeres. 

He found that the subjects who meditated (especially the younger ones) had an increase in telomere length from the beginning to the end of the three-month study.

(An increase in telomerase, the enzyme that adds to the ends of  telomeres, is also seen with regular physical exercise, a body mass index less than 25, not smoking, and a healthy diet.)

Stresses shorten telomeres 

The study showed that even short periods of regular meditating can alleviate some of the manifestations of occupational burnout and can provide broad health benefits.  (Of course, addressing the many causes of burnout is the other half of the equation that needs attention.)

Each time that we awaken to no longer being present to ourselves or to another is, paradoxically, a moment of presence.
 (Santorelli)

Hearing the result of his study, and knowing that a form of meditation is found in many diverse cultures and religious traditions, I wondered if Dr. Thimmapuram meditates within a specific spiritual background.

While he said that he was born into a Hindu family and that he respects those who adhere to that tradition, he doesn’t like such labels. He would rather be considered simply “as a human being more than anything else.”   

He feels that “identification (with a group) is okay, but when it crosses its (useful) limits it causes problems.” When we feel that we are better than others we erect barriers and promote separation. If we feel great, or superior, maybe we should consider the other greater. This will “balance things out.” 

But we should not go too far in the other direction, he said, and believe that we are substantially less than others. Neither superior nor inferior “we are what we are.”

As we live in the world with others we create stories. We are, in fact, the story-telling animal, and as the split-brain researcher Michael Gazzaniga showed, “left brain interpreter” tries to make cohesive sense of our experience. Jayaram noted that the most important such story is the one we tell ourselves about ourselves. The story about who we are in our hearts. And the story of how we fit in the interconnected world. 

I wondered how he came upon this insight so early in his professional life. He said that he found it through the “heartfulness” meditation practice of understanding of himself and the universal human dilemmas. One of these, he noted is that we carry unprocessed “emotional baggage all of our lives.” 

He said that with the eyes closed in steady repeated contemplation “the body does the chores it has been longing to do.” (The body, our evolved physical body, and our heart-mind, “know” more than we can be aware of.)  

The human heart is a listening device far more perceptive than the ear. 
(Santorelli)

Because others selflessly helped him on his own journey, Jay feels the urgency to share what he has received by “paying it forward.” If someone, for example, “wants to explore” any of the various meditative, or even the specific heartfulness practice with him, and wants to be “the best that he or she can be,” Jayaram is happy to assist. And he gently encourages practice; nothing is forced.

When it comes to teaching students and residents at the hospital, sure, he helps with the “medicine” and the “studies,” but he is also softly supportive as he tries to find out where they are in their career development, and then meeting them and working with them from there. He told me that his pupils respond best when they feel respected. 

And when they need more concrete general guidance he tells them about two important words; Excellence and Acceptance. 

Dr. Thimmapuram said that “when we try to excel and do not accept the results, it leads to frustration. But if we keep accepting things as they are and do not try to excel, this is laziness.”

This balance of striving for excellence and accepting the outcome, whatever happens, leads to a state of inner rest and equanimity. But if we fail to do our best, and if we fail to accept the consequences of what we do, there is unrest and tension. Jay believes that this friction of unrest, this dis-ease, bothers us almost more than anything else.

Whether offering or seeking help, we are all wounded and we are all whole.
(Santorelli)

“I tell the residents,” he said, “that when we simply sit down and close our eyes it almost feels as if we are doing nothing. It might look silly, but perhaps we are putting up with our own selves. And then we realize it’s not so easy. And if it is difficult to put up with ourselves, how do we expect others to put up with us!”

With the practice of heartfelt meditation what we do is very gently restore attention on the source of light within our own heart. We strive to “refine ourselves” in an effort to be better as human beings, as members of the genus homo sapiens ("wise man"). 

“I cannot say that one form of meditation is better than another, as what works for one person may not work for someone else. You have to find what resonates with you,” he told me. “When the heart is at peace, the mind is at peace.” And you have to put the knowledge you have gained into practice, into encountering the world, encountering others.

Speaking of others, I wondered about Jay’s family. His wife (she was two years behind him at medical school) is an internist with the WellSpan Hospitalists. Their daughter plays basketball and is learning the piano, and she and her brother play tennis. (Neither child has shown any interest in dressing up in whites and trying to figure out the best way to handle a sticky wicket.) The rest of his family has remained in India, and Jay visits them at least once a year.

As I listened to Dr. Thimmapuram tell me about his wandering journey to this point I was reminded of Thich Nhat Hahn’s walking meditation; mindful walking “to establish calm in ourselves and to be nourished by the wonders of life in the present moment.” 

The Vietnamese Zen monk taught young French children to use two special words: Oui and Merci. When walking and breathing in, they say “Yes” to life and to the Earth. When stepping gently and mindfully, and breathing out, they say “Thank you” to the Earth and to life.  Their feet caress the Earth with love. And their hearts are opened to their own special odyssey. 

Do you have the patience to wait
till the mud settles and the water is clear?
Can you remain unmoving
till the right action arises by itself? 
 (Lao-Tzu Trans. by Stephen Mitchell)

Untitled (Charcoal on paper by Anita Cherry 1982)

Selected Readings/References:

1. Langer, Ellen. The Power of Mindful Learning. Cambridge: Da Capo Press, 1997.

2. Mitchell, Stephen. Tao Te Ching: a New English Version. New York: Harper Perennial, 1988.


3. Santorelli, Saki. Heal Thy Self: Lessons on Mindfulness in Medicine. New York: Bell Tower, 1999.

4. Thimmapuram, J., Pargament, R. et.al. "Effect of heartfulness meditation on burnout, emotional wellness, and telomere length in healthcare professionals." Journal of  Community Hospital Internal Medicine Perspectives, 2017 Jan 7(1) 21-27.

Anita Cherry 1/3/20

Dr. Alina Popa: A Role Model

Alina Popa, M.D.

The people were meant to be cut off from the outside world, but her parents had a “smuggled-in” short-wave radio and they sometimes found the “Voice of America” broadcasts. If you were caught listening to such "propaganda" you were a dissident and were forced into hard labor or even killed. 

A year before the violent 1989 Romanian revolution a sympathetic member of the KGB went a step further and “sneaked” the small family a color TV from West Germany. Thirteen-year-old Alina saw Jim Henson’s Muppets for the first time; her “mouth dropped” as she was “mesmerized.”  

She was able to go beyond the Russian literature that had been available and read American works including, she told me with excitement, "Gone With the Wind,” the saga of one woman’s struggle for survival. She learned about John F. Kennedy and his soaring dreams; how he promised to send men to the moon "before the end of the decade" (with the help, we now know, of Katherine Johnson’s mathematical skills), and it happened. Alina just idolized him.

And she came to “love” American culture. She saw that there was something better outside of stifling Communist Romania. Not perfect, but better. And she saw that there could be freedom to be who you really are, freedom to be who you want to become. 

Buzz Aldrin and the Lunar Module on the moon;
 July 20, 1969 (NASA)

“As a child, you don’t know what you don’t know,” said Dr. Popa, infectious disease specialist, and full-time teaching attending at York Hospital, as we sat and talked. But the innocence of childhood passes. Even as a young teenager, she was aware that things around her were not as they should be. 

“It was a tough life," she said. "We learned how to shut our mouths and never say a word (against the government). Not even to your neighbors, friends, or relatives. You didn’t know who might betray you. We almost never talked about it at home, and when you spoke in the house you whispered because you didn’t know what the walls contained. Outside of the house, (the Romanian President) Ceauşescu is your father. You love him and adore him.” 

Listening intently, it was I who was mesmerized (and shocked). “Were you afraid?“ I wondered.

“No. I was angry and outraged. Knowing that this is not how human beings are treated,” she said. Yet, somehow, she could deal with it, she told me. What she could not deal with was the lack of electricity, the lack of water, the lack of heat, and, especially, the lack of food. The utter starvation.

There was rationing of sugar, flour, eggs, bread, milk, and whatever. You had to stand in line and wait for hours for your turn. But the shelves in the stores in Bucharest were often completely empty. “After a while,” she said, ”you don’t feel hunger anymore. When you are always starving your stomach shrinks.”

Waiting patiently for food in Bucharest in the 1980s 
(by Andrei Pandele)

The long winters were particularly “brutal.” It was terribly cold, the water pipes froze, and fresh food was scarce. It was the same diet week after week, month after dark month. “The only fruit was apples, and the only vegetables were potatoes... and pickles,” said Dr. Popa. 

There might be some pig fat (with no meat on it) and “stinky feta cheese” (kept on the outside balcony). Sneaking a bit of cooked meat, even in the countryside away from the city, could mean death if the (nosey) neighbors got a whiff of it and called the Securitate, the ruthless Romanian secret police.

Summer on her grandmother’s farm was a little better, Alina informed me, with more fresh fruit and vegetables, but she was still usually hungry. 

“It toughens you up. You don’t realize that your childhood is gone,” she remarked. While being forced by the harsh circumstances to grow strong emotionally and mentally she also shot up in height, and her pants and skirts were “always too short.”  

Her parents were underpaid engineers in the large state petroleum industry. They were overwhelmed by too much work and by having too little money. You see, as educated people in a communist society, they were the feared “intellectuals.” People who think for themselves. They could not be brainwashed “to act like sheep.” So the system oppressed them to suppress them...and to try to break them. 

Alina sensed early that education was a way out. She was determined to find something better for herself and she worked hard; she knew what she had to do. At 14 she passed the difficult exam to get into “the best high school in the country.” She did her homework by candlelight and her vision was permanently affected as a result. She was drawn to the sciences and had a special feel for mathematics. In fact, she was headed for a career in math. That is, until something happened.

At 15 she got “super, super sick.” It was summertime, and she went to the mountains with her father. She loved hiking with him and she was delighted to be in nature and free. But the weather suddenly changed (as I know it can in the mountains) and following the chilly hike she became ill with fever and congestion, maybe “strep pneumonia” (as she reflects on it now). 

Hiking in the Carpathian mountains in Romania 
(Mihai Constantener)

There was no money for her to see a doctor, and her condition steadily worsened. Her right eye became red and swollen. She became increasingly lethargic. Then unarousable. Her eye was (literally) “popping out.” 

Her frightened parents rushed her to the hospital where she had “signs of meningitis” as she had orbital cellulitis (an infection behind the eye, probably spreading from sinusitis). 

Alina was admitted to the pediatric ward but she was already a lanky 5’9” and there was no kiddie bed big enough to cradle her. One of the doctors gave up his own sack so her feet didn’t hang unceremoniously over the end of the mattress.

She rested and was on antibiotics for three weeks, and they saved her vision.  But while she was in the hospital something else occurred; she “fell in love” with medicine. She liked the smell of the hospital, she liked the cleanliness, she liked the food. She said she “just loved it.” She talked with the nurses and the doctors and asked them lots of questions “all the time.” She made up her mind on the spot and boldly told her cautious parents that she wanted to become a doctor. 

So, in the tenth grade, Alina changed her course of study from math and “heavy-duty” physics to biology and chemistry. The chemistry came naturally; it was all logical (”you count”). But “memorizing” (non-logical and messy) biology was a “struggle.” Dr. Popa is proud of her accomplishment, however, as she finished near the top of her large class.

She then began six years of medical studies (three years of theory followed by three clinical years) at the prestigious (and international) Carol Davila University of Medicine and Pharmacy in Bucharest.

Students hard at work in the ornate Carol Davila library
 in Bucharest (from Euroeducation.net)

But by the time she was 20 she became disillusioned with what she was seeing in the Romanian hospitals. Communism was gone, yes, but there was still incompetence, greediness, overt corruption, and misogyny. This was clearly not what she was dreaming about, not as the daughter of “fair and honest people who were not willing to be greedy and sell out.”

The border was open now. If you could speak English and pass the standard “Step 1” and “Step 2” exams you could practice medicine in the U.S.  So Alina decided to learn the “difficult” language (with unusual spelling and “a lot of “nuance”) and take the required tests.

But there was no money. Not for the exam fees. Not for an English tutor. And not for the (anticipated) airplane fare to the land of liberty, to America. What to do?

Her father knew his daughter’s goals, and he reassured her. He calmly told her that his grandmother had left him a valuable piece of land in the foothills of the mountains; the mountains where Alina became ill and found her calling. He would happily sell the property and give her the proceeds, more money than he could ever make himself. There was never a doubt about what to do; her parents, she noted, were completely selfless.

So Alina bought second-hand books and studied intensely (she “ate them alive”) for the exams. And she learned English. Not with an expensive tutor, but by herself.  With the fall of communism, she could listen freely to American music on MTV (when that was hip) and VH1 (for the slightly less cool). She learned how to pronounce the words by listening to music on the bus.  (Probably not the best way to pick up on “nuance.”)

Dr. Popa paused and told me that her father passed away three years ago (her mother still lives in Bucharest).  She cried as she recalled his memory, and his love for her, even as he reluctantly but generously let her go. As he let her go to find herself.

Anyway, she had to leave Romania briefly to go to Budapest for the Step tests. It was her first real travel experience. The city was “so beautiful” she told me. Bucharest had similar beauty once, “like little Paris,” she said. But much of the historic district filled with many homes, churches, and synagogues, was destroyed by the monstrous Ceauşescu “out of hate for religion” to build his €3-billion Palace of the People. 

The grandiose administrative "Palace of the People" 
in Bucharest (from Rick Steves)

Alina was anxious to finish medical school and leave the place that caused her so much pain. She was one of many who simply had to escape. Four million hurt people left, most of them for other parts of Europe, many for the New World.

I wanted to know how Dr. Popa and her well-mannered six-year-old son Gabriel came to be sitting together with me in my living room in York, Pennsylvania, rather than somewhere else in the country.

Alina left Bucharest behind and came to the U.S. in 2000. She had arranged for several interviews for a residency in internal medicine. The first was in Chicago at St. Joseph’s Hospital (with Northwestern), on Lake Shore Drive. It went well, and they offered her a three-year position before the “match.” She quickly accepted. 

Dr. Roberta Luskin-Hawk

It was at the Catholic hospital overlooking Lake Michigan, while interacting with students, that she discovered that she “loved teaching.” She knew “from that moment on” that she wanted to teach (a second unexpected calling). One of the attendings she most admired and “loved” was Dr. Roberta Luskin-Hawk, a prominent infectious disease specialist who, she said, “believed” in her. 

(Alina had been attracted to microbiology in medical school because “the Latin names [of the bugs] came naturally” to a native speaker of Romanian, “a Romance language.”)

Through watching and emulating Dr. Luskin-Hawk, Alina learned how to treat patients with one of the most feared infectious diseases of our time, HIV. She took care of Chicago’s stricken gay community and the area's mostly-poor injection-drug users. (In Communist Romania there were no gay individuals at all, she noted, without a hint of irony.)

After bitterly-cold Chicago, she applied “all over” for a  fellowship in infectious disease. She landed in warm sunny Miami at Jackson Memorial Hospital for two years of study (on a J-1 “exchange visitor” visa). It was there that she met the “beautiful” and “damn smart” Jamaican-born physician, (and second special role model) Dr. Lorraine Dowdy. 

Since Jackson was a regional referral center Dr. Popa saw complex cases involving immune-suppressed transplant recipients from across the South and HIV patients from the Caribbean, mostly migrants from Haiti and the Dominican Republic. 

On her “awful” visa she needed to take a so-called “waiver” job after her fellowship. That usually meant working in primary care for an underserved population or in an underserved area (“where nobody wants to go”) for three years before being allowed to apply for permanent resident status.

She was quite happy in 2005 when they informed her that she could satisfy the requirement by practicing in her specialty of infectious diseases in the under-resourced and impoverished downtown area of York.  She was made the medical director of the York County Health Center. This is supported by federal funds from the Ryan White (CARE) Act of 1990 (co-sponsored by Senators Edward Kennedy and Orrin Hatch--when working together across the aisle was doable and appreciated) that provides community-based grants for direct HIV services. 

While at the Center she took care of many patients with HIV (thankfully, a generally manageable disease now) and many individuals with hepatitis C (95% curable).  Dr. Popa also worked at Family First Health in the city and she taught residents from the York Hospital programs and medical students from Penn State and Drexel. She showed, yes, showed, them how to understand and navigate the specific and difficult challenges of caring for the underprivileged. 

Poverty and HIV (CDC Data from 2007)

(The risk of HIV infection through sexual contact can be reduced by more than 90% by use of the pre-exposure prophylaxis-or PrEP-antiviral drug Truvada. The monthly cost for this in the U.S. is $2,000 but only $8 in Australia. But as of June 2019, commercially insured individuals can receive it at no cost under the Affordable Care Act. It is currently underused.)

Shortly after receiving her cherished Green Card in 2011 Alina received a call from Dr. Kevin Muzzio at York. He was aware of her efforts in town and he told her that there was an unexpected opening for a full-time teaching position at the hospital. She eagerly accepted the offer, and she has been at WellSpan since 2012.  

The root of the word "doctor" is the Latin "docēre" or "to teach." And the essence of teaching is communication. Dr. Popa strives to connect with her students and residents and inspire them to develop the skills of critical thinking, careful analysis, and proper weighing of clinical data. And how to apply this to compassionate and individualized patient care. She hopes to serve as a role model for the next generation of physicians.

As Schwenck and Whitman (1987) have said: 

Patients feel that the most important characteristics of a physician that lead to high patient satisfaction are knowledge, understanding, interest, sympathy, and encouragement. These equally worthy qualities of an excellent teacher lead to high learner satisfaction.     

With this academic position (no long nights at the hospital), she has enough time to be an attentive mother too. 

(You see, I first met Alina at our JCC pool when I looked up from an especially slow lap and saw her gently and calmly interacting with Gabriel. I sensed that she was a physician and I took a chance, got out of the water, and introduced myself. I guess I recognized a doctor’s manner. I don’t understand how I knew this, but I just did.)  

Gabe’s half-brother, Edward, by Dr. Popa’s brief first marriage, is 15. Dr. Popa was busy and had been single for a while when she met her current husband, a Romanian physician, here in York through a mutual colleague. They are very happy, and she believes that “after 20 years” she belongs here.

(The interview was over and Alina was preparing to leave with her son [I think he was tired of patiently waiting] when she stopped and softly confided in me that she was “a little bit Jewish, too.” Her maternal great grandmother had escaped the Nazis in Transylvania.  She married a German and converted to Christianity, but she still baked “Jewish delicacies; breads and pastries.” I sometimes braid a challah for Shabbat, and hearing this nearly made me cry.)

Anyway, her harried residents have been known to exclaim: “Nothing fazes Dr. Popa.” 

She admitted, yes, that she can “put up with a lot of stress” and "still have a smile" on her face. 

Knowing her story, we can see why.


Reference:

Schwenck, Thomas L., M.D and Whitman, Neal A, Ed. D The Physician as Teacher. Williams & Wilkins, Baltimore, 1987, p.12.



Watching intently and learning:

"The Intubation" 
by (physician) Georges Chicotot (1868-1921)

And...

Dr. Alina Popa and family in front of the  
Liberty Bell at the National Constitution Center

By Anita Cherry 
November 22, 2019 (exactly 56 years after a very sad day for our country)