Dr. Leslie Robinson:Fille rencontre garçon; La femme rencontre l'homme

Leslie Robinson, M.D.
(from a 1983 clipping
as she joined the staff)

She was eleven when she initially met her new minister’s son at the Valley Forge Presbyterian Church. He was four years older, and she didn’t really “know” or “like” him then, she said. Years passed, and during the summer before her junior year in high school, they met again. He had just finished his sophomore year at Harvard and was hired to paint her parents' house. 

Leslie knew him as “one of the three Jensen boys,” and Lynn knew her as “one of the three Robinson girls.” As he carefully painted, she carefully watched. He was cute, she thought to herself. She offered him a cool glass of lemonade. And while she was “reading” she quietly moved around to where she could see him. 

Of course, she knew that he was “totally unattainable” and that what she was feeling was just an “infatuation.” Nothing happened, and he returned to Cambridge. 

But the next Christmas, she dragged her younger brother to “the manse” (the term for a Presbyterian minister’s house). She was a little more confident now; maybe the scholar-painter would join them in caroling. He did.

So, as the story unfolds, and with a twist on the tired formula: Girl meets boy. Girl meets boy again. Girl meets boy once more. (And, as we will see, they stay together.)

The girl? Obstetrician/Gynecologist, Dr. Leslie Robinson. The boy? Emergency Physician, Dr. Lynn Jensen. They practiced medicine in York, Pennsylvania, and are both retired. Leslie, now 66, left medicine five years ago. 

She trudged 35 minutes through new wet slushy snow one Saturday afternoon to sit in my living room and tell me her tale. The fireplace was going, I brewed her a small pot of my favorite English tea, and our dog Toby (a Blenheim-colored “Cav”) sat on her lap, pleading for attention. 

After breezing through high school she thought she wanted to go to Radcliffe. She didn’t get in, but she had several other good choices; Penn State was too close to home, and Wellesley was “all women,” so she decided to go to the University of Michigan, where she was accepted into the Honors College. She thought of going into teaching, like her parents.

It just so happened (surprise!) that Lynn was in his first year at the University of Michigan medical school. They got together (that wasn't the plan when she decided to go to Michigan), and one day he took her to the lab showed Leslie the cadaver he and his partners were slowly taking apart for their anatomy studies. 

The University of Michigan, Ann Arbor

When she looked down at the opened-up lifeless grey body she saw how “cool it was that everything fit together.“ With that, she recognized that she had the ability to think three-dimensionally. And that’s when, she told me, she was “bitten by the bug.” 

So she put “physician” on the short list of what she might want to become, adding this to, maybe, being a teacher, or a psychologist (or perhaps she could squeeze in all three). 

Leslie majored in Botany (there was no Biology major), took the required premed courses, and applied to medical school.  She and Lynn were already married by that time, and they had to coordinate her school choice with his residency. She said that things were “pretty competitive back then” but she applied to the one school they were both most comfortable with. She became one of only ten women in the entering class of 100 at Penn State Hershey that year. 

Matthaei Botanical Gardens at UM

It was 1975, more than a decade into the “second wave” of the feminist movement (concerned with equality between the sexes, not just voting rights). She felt “honored and privileged” to be accepted into a discipline that was dominated by men. 

But Dr. Robinson told me that while she certainly was, and still is, a feminist, she is “not a radical feminist.” She said that even now she “can't remember feeling overt prejudice” (that she was a woman in a man’s field).

I asked her how she came to her chosen focus within medicine. She said that she was first exposed to women’s healthcare issues when she was a student in Ann Arbor. She volunteered at a rape crisis center where she was trained to help women who had been assaulted. It was here that she became acutely mindful of the emerging and controversial birth control and abortion issues.

She said that she had not been raped, but that she was motivated by a frightening experience she had as a college freshman. One warm evening she was walking from her dorm to meet Lynn (who lived off campus) when a car slowly passed by her and then circled back several times. The men whistled at her and she was “scared shitless.” 

She reacted quickly. She ran as fast as she could and stumbled down an embankment to an empty parking lot to escape. She could breathe normally again only after she spotted Lynn heading towards her. 

While in medical school, Leslie was “on the fence” between going into pediatrics or obstetrics and gynecology, the only rotations where she “didn’t mind being up at three o’clock in the morning” taking care of patients. 

But as she did her brief OB stint at the York Hospital (where Lynn did his internal medicine training and was already working as an Emergency physician) she “loved it.” She did 18 deliveries as a student (an unusually big number, she said) and she enjoyed being in the operating room. However, she wasn’t confident that she could be a part of that world. While she cherished the OR experience, she also loved all of the other aspects of caring for women. 

Nicolas Simon, M.D.

The York OB/GYN residency director, Dr. Nicolas Simon (1935-2016), took a liking to her as a student, and he later facilitated her acceptance into the program. And only two weeks into her rotating internship she “knew” that she made the right decision as she soon “could (confidently) do a C-section.” Though 95% of gynecologists at that time were men, this was clearly destined to be the specialty for Leslie.

She “loved” delivering babies, but obstetrics was just the icing; the broader issue of women’s health overall was the cake. To her, answering women’s questions was “just as important” as performing surgery. Questions, for example, about birth control, or unwanted pregnancy, or breast cancer, or issues of infertility, or sexually-transmitted diseases, or sexuality, or whatever was on their minds as women. 

She believed that she could act as the “liaison” between women and what is known or understood about women’s health; she could explain things, she could educate.

Hearing this, I reflected on my own experience in gynecologist’s offices in the early 1970s. I wondered if they were typical; they were certainly not very pleasant. I had sweaty palms and shivered in the flimsy cotton gown as I nervously looked around the chilly exam room waiting for the doctor. There was a wall poster showing the female reproductive organs, another explaining endometriosis, and yet another revealing the feared effects of gonorrhea and syphilis. 

And then there was that take-apart model of a woman with a big-headed upside-down baby inside her waiting to be born into the world. 

There was no discussion of any of these interesting things by the doctor, and I was too anxious to ask him the right questions. That, my friends, was the extent of my “formal” women’s health education; a few colorful and mysterious wall posters and a plastic replica of a woman ready to deliver. 

An early edition

(Note: The revolutionary book Our Bodies, Ourselves, tackling taboo subjects important to women’s health wasn’t published until 1973 and I don’t recall seeing a copy of that controversial book at home, but we knew about it.)

Leslie, almost exactly my age, agreed with my recollection of how it was then, that ”many doctors would not take the time to listen” to women’s concerns.  She wanted it to be different, and she knew it could be. In fact, she told me that one of her important mentors during residency, Dr. Detlef Gerlach, was an exception, as he did listen.  

After decades in medicine, she was often dismayed when she heard a patient say, after the first visit with her, that they had not previously had the experience of a physician listening to them the way she did.

She completed her residency in 1983 and joined Dr. Marsha Bornt in her practice. Dr. Bornt would limit herself to gynecology and Leslie would do the obstetrics. But this arrangement soon turned out to be too demanding as she had to be available every day and every weekend without any help. She didn’t know what to do.

During this stressful time, she and Lynn hoped to start a family, but there were fertility issues and she was given only a 15% chance of getting pregnant. 

After Leslie decided that she needed to part with Dr. Bornt she was delighted when there was the prospect of joining Dr. Gerlach and his partners, Drs. James Smith and Jay Jackson, in their busy practice.

She still hoped to get pregnant and when one of the three men asked about her plan should she conceive (a question that should not have been asked then, and cannot be posed now) she innocently replied that she would want to work part-time for a while. But they didn’t want a part-time partner. She respected them and felt that their practice was a wonderful opportunity, so she joined the group and agreed that she would not seek special treatment because of her gender. (She told me that this was the only place where, as she eventually realized later, sexism, “institutionalized sexism,” truly affected her life.)

Three months passed and, defeating the long odds, Leslie became pregnant with her daughter Annie.  

No excuses, she worked full-time during the pregnancy. She had morning sickness with vomiting until late in the pregnancy, and it was tough. The “three guys and a girl” delivered up to 90 (yes, 90!) babies a month, and there were grueling three-day weekends without defined back-up, even if there was sometimes too much going on for one person to handle. 

This went on for a while, but when Annie was a year old Leslie went to her colleagues and said that she really needed to work fewer hours so that she could fulfill her roles as mother and wife, as well as that of physician/surgeon. They agreed to let her work a bit less (but on salary, off the partnership track) for a couple of years. 

She eventually returned to being full-time and became a partner in the practice. She enjoyed the work immensely, but she still felt that she needed more time for her husband and her two young children, now seven and nine. She needed more balance in her life.

But this time she and her partners couldn’t work things out, and as she felt that she no longer had a “voice in the practice” she left them in 1993. (More than 25 years later, the pain of that separation is less, but the wound has still not fully healed.)  

Leaving the group and her close relationships, however, lead to an unanticipated turning point in Dr. Robinson’s career. Dr. Simon offered her the position of Associate Residency Director for the York OB/GYN program. She took the job and “ended up being a teacher, and having a much more reasonable schedule.”  

Dr. Simon saw that there was a growing need to have someone who had expertise in the common, but complicated, issues of bladder, uterine, and rectal prolapse, and incontinence.  So Dr. Robinson took additional training in this area with Dr. Hilary J. Cholhan in Rochester, New York.  

He helped her as she sought to understand the complexities of surgery of the pelvic floor and the new specialty of urogynecology. Dr. Cholhan helped her so that she could, in turn, pass along important information and skills to the York residents.  After a while, she developed her own private Uro-Gyn practice and did surgeries one full day a week.  

[The anatomy: The floor of the pelvis is the boundary on which the pelvic and abdominal contents rest. It is composed of several muscle groups and ligaments connected at the perimeter of the bony pelvis. Defects may occur as a result of childbirth, with stretching and tearing of tissues. Pregnancy itself, without vaginal birth, is a risk factor as well. Other conditions that may result in prolapse are obesity, chronic pulmonary disease, smoking, and constipation. Urinary frequency, urgency, or incontinence are common symptoms. Pelvic muscle exercises and vaginal support devices (pessaries) are the main nonsurgical treatments for women with pelvic organ prolapse. Randomized trials provide no evidence that improvement of pelvic floor muscle tone leads to regression of pelvic organ prolapse. Thus, the need for surgery. Adapted from Medscape] 

Female pelvic floor anatomy (from "Nursing Times")

And with her varied and interesting work schedule, “things worked out well” and Leslie told me that she had a “very rewarding and satisfying professional career.”

Now retired, she has a few interests. Her younger sister Jane,  a hospice nurse, developed acute myelogenous leukemia 16 years ago. Leslie and her sister Tracey were with her when she died in a hospice setting at age 50. 

The two became involved in hospice work to ease the pain of losing their sister and to carry on her work.  Leslie met Beth Gill-MacDonald of the Healthy York Coalition, who was convinced there could be a local “social or community model hospice” not owned by a hospital or a for-profit agency. 

It took ten years for the “compassionate end-of-life” hospice facility, Pappus House, to be developed from an idea. Leslie helps support the mission and volunteers there twice a week. 

She also belongs to two quilters' guilds (in York and Camp Hill) and, through this, she became involved in an international effort called “Days for Girls.” This program, started in 2008 in Bellingham, Washington, aims to “empower women and girls worldwide through providing sustainable menstrual care and health education.” The colorful hand-sewn “DfG” kits are donated to girls and women across the globe. (Leslie, it seems, is drawn to needle and thread.)

Girls celebrating their DfG kits in Nepal (photo by Sarah Webb)

Is she athletic? Yes. Leslie has a goal of walking or hiking 14,000 steps a day (thus, the trek to my house, and the insistence on walking back at least half-way despite the nasty weather and slippery terrain through the woods). She also does yoga (mostly, she said, to improve balance), and she sometimes takes a heart-pounding spinning class or a leisurely mile swim at the York JCC.

Throughout her career, her husband Lynn has been unfailingly supportive. He never questioned her right to do what she was doing, even when life was "really hard." He shared fully in caring for their children, and he took care of her and was always proud of her accomplishments. 

Her son Dane, now married and the father of a young son, went to Vassar and has a Ph.D. in Clinical Psychology from Temple, and practices part-time. Her daughter, Annie, a mother of two, did a pediatric ophthalmology fellowship at Penn and was recently offered the first (yes, the first-ever) part-time contract with Children’s Hospital of Philadelphia. They can both raise their own families with treasured balance.  

As Simone de Beauvoir said in 1949: “It is through work that woman has been able, to a large extent, to close the gap separating her from the male; work alone can guarantee her concrete freedom...There is no longer need for a masculine mediator between her and the universe” (The Second Sex, p. 813).

And as Leslie noted, Marie Shear (1940-2017) said that “Feminism is the radical idea that women are people.”

Leslie and Lynn

And as she reminded me: “Men and women are equal, but not the same.”  She was “excited” when she realized that “true liberation is getting to do what you want,” that she and Lynn did not have to share each and every task equally, that they could follow their natural inclinations and complement each other, pursuing equity.

And now, more than fifty years after Lynn and Leslie first encountered each other, boys and girls, men and women meet together, and work together, on a more level playing field.

(And for a bit of forgotten history: The Equal Rights Amendment to the Constitution was first proposed in 1923. It didn’t catch on. Interest in it was revived in the 1960s, and by 1977 it was ratified by 35 states, with only three more needed for passage. Conservative women mobilized against it, and five states rescinded their ratifications. The deadline for passing this was extended to 1982. The amendment has been raised again in every session of congress since but has not come to a floor vote.)

Untitled (by Anita Cherry 1983)

Reference:

Beauvior, Simone de. The Second Sex (translated by Constance Borde and Sheila Malovany).New York: Vintage Books; 2011.

Anita Cherry (03/27/20)

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