Dr. Jay Nicholson: The Way to a Man's Heart is Through the Groin

Walter J. Nicholson, M.D.

The year? 1961. The place? An intimate high school math class. The instructions? “I don’t care if you ever get the answer [to a problem] right in this course, but I do care if you set it up right. If you set it up right, you are going to get an A. Because when you grow up there is going to be somebody with a computer in their hand that can put the numbers in and get the right answers,” said Mr. Modess. 

The teacher was preparing his six eager pupils in the “extremely advanced” science and math sessions at Georgetown Prep “to think,” said interventional cardiologist Dr. Walter Joseph Nicholson, one of those lucky students.

Jay, as he is known in the York community, made the decision to go into medicine when he was attending that rigorous all-male Jesuit Catholic school. He told me that he wanted to help people. No, that he had to help people. And that he didn’t want to get bored. And that he wanted to be (and that he is) a diagnostician.

The family left Jersey City for Middletown, Pennsylvania when he was in grade school and they later moved to Pittsburgh, and then Dover, Delaware. After high school, Jay went to Georgetown University for a year and then transferred to (then all-male) Franklin and Marshall College in Lancaster for tough pre-med studies. He met his wife Carol (a native of York) while at F&M. She was studying at nearby Millersville, long recognized as a fine training ground for teachers. 

Georgetown Prep in Bethesda, Maryland
(from Archdiocsis of Washington)

Jay then attended the University of Pittsburgh School of Medicine. While there, he encountered the legendary “Black Jack” Myers (1914-1998), the “pretty rough” (Dr. House-like?) chief of the department of medicine. Jay planned on being an ophthalmologist and he did an internship at George Washington in D.C. under the tutelage of prominent hematologist Dr. Wally Jensen (1921-2003) with that specific intent. 

When Jay went to Dr. Jensen one day and informed him that he had changed his mind, that he wanted to switch to cardiology and to go to Emory, the insightful Dr. Jensen “was not surprised.” The professor had good contacts, and he graciously facilitated the future cardiologist’s transition to Dr. J. Willis Hurst’s program. 

But before he went to Atlanta Jay served two years (1969-1971) in the United States Public Health Service in Tampa where he practiced general medicine as he took care of those in the Coast Guard and Merchant Marines as well as retired military. He left the Service with the rank (his wife, who was listening quietly as she was sitting across the room during our late February afternoon interview, had to remind him) of Lieutenant Commander. He and Carol still enjoy visiting the Tampa-Clearwater Beach area for a few days when it’s frigid up north.

J. Willis Hurst, M.D.

The eminent Dr. Hurst (1920-2011) had trained under “the father of American cardiology," Dr. Paul Dudley White (1886-1973). Dr. Hurst, according to his Emory obituary, "believed deeply in the power of good teaching." And he became Dr. Nicholson’s “biggest mentor.” He was “never snobby” and “always a gentleman,” and Dr. Nicholson said that he holds Dr. Hurst “in high esteem.” 

Jay did a formative year-long fellowship with master diagnostician Dr. R. Bruce Logue (1911-2007). Jay found him to be “the most intense man on the planet” and “a terror.” He was “totally intolerant of indecision.” (Those who work with our protagonist in the cath lab may, perhaps, spot faint glimmers of those endearing traits during an especially busy day, or when there is a tricky case.) 

Dr. Logue, with his steely gaze, could “seize on the one important piece of information” that would instantly clarify a clinical situation and clinch the diagnosis. Jay worked hard, side-by-side, and hour after hour, with him to acquire that valued skill.

R. Bruce Logue, M.D.

(Jay has a signed copy of the edition of the widely-read textbook The Heart, edited by Drs. Hurst and Logue, that was put together when Jay was a fellow. It was purposely left in their car when Jay and his wife came to the house to talk. My husband’s “signed” copy of that same edition, an engagement gift in 1977, was in our stuffed bookshelf to Jay’s right. It was easily spotted. It’s a really fat book, and I know my husband didn’t read the whole thing, but parts were carefully underlined.)  
  
Anyway, Jay’s second fellowship year was spent with innovator Dr. Spencer B. King III in the cardiac catheterization lab. It was there that Jay experienced the beginnings of what would become his passion in medicine. At the time (the early- to mid-1970s), a diagnostic cath was the only “procedure” available to the non-surgical heart specialist. 

Reflecting on these experiences, Jay noted that, as a doctor-in-training, the most important lesson he learned was to make himself available to the mentor. To be there. He said that he cannot stress that enough to young people. He realizes, however, that advanced training in medicine has changed, and that a close and extended mentor-mentee relationship is not common anymore.

After Atlanta, and with a single catheter in hand (“99% use three,” he said), Dr. Nicholson joined the congenial and welcoming York Hospital staff in 1976.  He teamed up with cardiologists Dr. Jack Gracey and Dr. Ed Martin. The “three musketeers” relied on the patient’s history, the physical exam, the EKG,  the chest X-ray, and the simplest of echocardiograms to make a diagnosis; “everything was clinical” then, Jay told me (with obvious nostalgia for those disappearing skills). 

Laennec's Baton ~1816 (he later coined the term "stethoscope")
(1960s poster by Robert Thom)

But things change, (“Thank God,” said Jay), and purely clinical methods gave way to advances in imaging, and precise imaging led to more procedures, the current focus within the field.

Anyway, when starting out in York, Jay’s goals (apart from expert patient care, of course) were to teach and to develop a strong and enduring cardiac program. He felt an “obligation” to share his knowledge. And he wanted to build something. So he went to work. 

At that time, the late 1970s, the cardiologist’s treatment for heart attacks in the coronary care unit (the CCU) was limited to controlling dangerous rhythm disturbances, especially chaotic ventricular fibrillation (that often resulted in sudden death), and alleviating acute congestive heart failure (due to the weakened heart muscle). 

Specific medical therapy to restore blood flow to the area of the heart that was deprived of oxygen and dying was simply not available; the heart surgeon was needed for that. After a heart attack, if you survived, you carefully rested for weeks while waiting for the damaged muscle to slowly heal.          

But the next year, 1977, things changed. 
  
The charismatic and darkly handsome Dr. Andreas Gruentzig, from Dresden through Zurich, had been inspired by the work of radiologist Charles Dotter (1920-1985). Dr. Dotter showed that clogged arteries in the leg could be gradually opened using a series of rigid catheters.

But there were complications of the procedure as the plaque was scraped off of the wall of the artery and plugged up smaller vessels downstream. Andreas had a better idea. He thought he could open an artery, even a narrowed coronary artery, more safely if with a less traumatic technique.

Dashing Andreas Gruentzig, M.D. with his balloon catheter

He toiled at his kitchen table for a year as he tried to fit the tip of a catheter with a strong smooth inflatable balloon. With this, he could carefully squish the fatty inflammatory plaque obstructing blood flow in the coronary up against the wall of the artery. This would let more blood through to nourish the starved heart muscle. 

He came up with a working prototype and then spent the next two years looking for someone to manufacture the unlikely contraption that everyone knew would never work. 

Dr. Gruentzig finally succeeded, and on 9/16/77 he cautiously (with the surgeon standing by, waiting for something to happen) used his device to open up a short segment of Adolph Bachman’s critically narrowed left anterior descending artery. This instantly relieved the awake patient’s chest pain, and the surgeon could quietly put his scalpel away. Cardiology (and medicine) was changed forever.

(As noted in an article on Gruentzig in Wikipedia: “By utilizing the arterial circulation as a 'therapeutic highway' many types of devices and drugs can now be delivered directly to the heart, kidneys, carotid arteries, brain, legs, and aorta without the need for major surgery and general anesthesia.”)

Dr. Andreas Gruentzig was given a standing ovation when he presented his revolutionary data at the big American Heart Association meeting later that year.

Dr. King (against Dr. Hurst’s advice, at first) managed to convince the sought-after Dr. Gruentzig to join his staff in Atlanta in 1980. While there, Andreas enthusiastically shared his knowledge with the world. Dr. Nicholson, ever hungry for learning, “took all of his courses.” 

“These mentors, and a bit of hard work, have made me who I am,” said Jay. (You see, his mentors had something he wanted.)

(He felt that Dr. Gruentzig, the most famous cardiologist of our time, would have received the Nobel Prize for his work had he not died in 1985 at 46 when his single-engine Beechcraft Baron crashed in a violent storm as he was piloting it back to Atlanta to take care of scheduled patients.)

It may seem to you that cardiology, the cath lab (that was named after him four years ago, to his slight embarrassment), and commitment to the York Hospital (who last year honored his 50 years of steady dedication and support) might be Jay’s whole life, but there’s much more.

Dr. Nicholson (you can spot him in the white shirt and tie) and his loyal cath lab team

After he and Carol initially got together they stayed together. And he let her know right away what he wanted to do, and that he wanted her with him. “And that’s what we did!” said Jay. So, for a short while, it was just Jay and Carol, and their shared dreams. 

“But then all these kids showed up,” marveled the proud, and (mockingly) surprised father. Tommy, now 50, arrived first; Billy and Cindy soon followed. All three played basketball in school. Jay coached both boys and rearranged his schedule so he could go to “a thousand” of their games. 

Tommy was a talented “sixth man” scorer at F&M while Billy (also a student at his father’s alma mater) settled on the more gentlemanly sport of golf.  Both boys went into medicine (a bit more on this later). Cindy (owner of, get this, eight varsity letters) was terrifyingly intense on the basketball court. She decided to take that energy to the court of law where she defends physicians against claims of malpractice.      

When the kids were involved in their high school sports Carol was the busy “taxicab driver.” A pizza for dinner from Domino's was the routine. And Jay remarked that if they missed ordering a pie two days in a row someone from the shop would call to see if there was anything wrong. (Hey, could it be that they just wanted to try Papa John’s?) 

“I tried to be the best dad in the world, and it was a thrill to have the kids,” said the sometimes-modest Dr. Nicholson. He told me, in fact, that he had the “best time” of his life with them.

Jay’s own father, one of eight children, grew up in Brooklyn during the Great Depression and didn’t finish high school. He worked for the government, and Jay said that he was “the smartest guy” he ever met. He “always wore a white shirt and tie.”  He was a “gentleman and a gentle person.” Jay’s mother graduated from college at 41 or 42. Sadly, she died in her later 40s as a result of trauma.

Men in a bread line in Brooklyn during the Depression
(from Hulton Archive)

 But let’s get back to the remarkable advances in cardiology during Jay’s five decades in medicine, changes for which he’s most grateful.

In 1980 it was definitively shown, contrary to the conventional (and wrong) thinking at the time, that heart attacks occurred as a result of an acute clot, or thrombosis, in a coronary artery, not progressive gradual narrowing to a critical point (with the clot occurring later).  

In 1986 an important study showed that adding a medicine (streptokinase) to break up the fresh thrombus resulted in a slightly lower death rate at three weeks (10.7%) compared to usual treatment alone (13%). But there were bleeding complications, sometimes severe.

Process of acute coronary thrombosis (from bioninja)

Was there something better? While the first balloon angioplasty performed during an acute MI was done in 1979 there was an annoying tendency for the vessels to close off later. So, the idea of stenting. The first metal stent, or scaffold, to hold the artery open after angioplasty was cautiously placed in 1991.  Stents have gone through several improvements since then, including a coating to prevent dangerous clotting later. The newest stent gradually disappears as it is slowly reabsorbed by the body. 

The balloons and stents have relieved countless patients of debilitating anginal chest pain and preserved the heart muscle of millions of individuals who were in the throes of an acute MI. The sooner angioplasty is done during a heart attack, the more vital tissue is preserved, so speed matters (and Jay, as I’ve heard, is fast, really fast). This technology has allowed patients to avoid the physical trauma, the slow post-op recovery, and the inherent risks of general anesthesia and coronary bypass surgery.

Most with an acute MI now have angioplasty within 90 minutes
(from PLOS ONE)

The busy physician must keep current with the advances in his (or her) field, and Dr. Nicholson made certain to do that. Not satisfied by simply passing the Internal Medicine and Cardiology boards, and not one to shy away from a difficult test, he took the eight-hour board exam in Critical Care Medicine in 1987, the first year it was offered. He passed, of course, and he was the only physician so-certified in York for several years. Jay then added certification in Interventional Cardiology in 1999 (again, the initial year it was available).  

Listening to him, I asked Dr. Nicholson (who said he’s done more than 60,000 procedures) if there were any of his former patients that he still thinks about. Yes, he said, as he looked towards his wife. He cleared his throat (he had used a lozenge-what a funny word, “lozenge”) and recalled that there were “about five patients” who stayed with him. 

Were these miraculous and dramatic “saves” in the cath lab, like on TV? Were these people brought back from the brink of death? No. They were not. 

These unforgettable patients were individuals who demonstrated remarkable bravery as, over the years, they underwent repeated major heart surgeries while their complex disease, disease that could not be fixed with a catheter tip or the latest medication, worsened. Jay felt their suffering, and he admired their courage and their faith.     

Speaking of faith, as a practicing Catholic, Dr. Nicholson said that he attends church regularly. He gives thanks for what he’s been given, and what he has been able to give to others. 

Let's get back to the heart. Unfortunately, many patients with advanced disease, it turns out, have no (or only vague non-specific) symptoms before they suffer an acute heart attack or sudden death. Stress tests and CT scans looking for calcium build-up in the coronary vessels (a good study, if negative) are useful, but they are imprecise. “If you want the 100%  test you need a heart catheterization,” said Jay emphatically. And he feels that “patients want to know,” that they want the study that will give them a clear answer.

Calcium CT scan showing calcified vessels
(from Radiology Associates of Clearwater)

And we are getting much better at knowing about the heart and treating its ailments. There has been a spectacular drop in the U.S. death rate due to heart disease from 1950 to 2017 (from 588 deaths per 100,000 to only 165). Much of this decrease was due to the understanding and control of the major risk factors such as cigarette smoking, diabetes, hypertension, and, especially, high serum cholesterol.

The effective treatment of elevated cholesterol, or hyperlipidemia, with so-called statins, discovered in 1976 by dogged Japanese chemist Akira Endo, and weakly approved by the FDA in 1987, revolutionized the medical treatment of coronary atherosclerosis. (Statins also stabilize plaques and reduce inflammation of the vessel wall.)

Thus, Jay’s typically no-nonsense straightforward advice to his patients: “Stop smoking and take a statin!”  

And about half of the decline in the death rate over the years has been due to better management in the CCU and efforts in the cath lab. In the 1960s nearly 50% of those admitted to the hospital with heart attacks died in a few days; the fatality rate now is only 4-6%. However, the decline has been leveling off over the past decade, and heart disease is still the leading cause of death in the United States.

So Dr. Nicholson, wearing a crisp white shirt and a tie, and with our dog, Toby, quietly nestled by his side, told me that to accomplish his goal of providing an enduring source for the best cardiac care possible for the people of York he managed to recruit many talented physicians who could have easily chosen to go elsewhere. He feels that the heart program here is strong. He first envisioned a free-standing cardiac center about ten years ago. It took a while, but construction for this began recently.

Artist's rendering of the new WellSpan Heart and Vascular Center
(from Wohlsen Construction)

Over the years, Jay has been given multiple teaching awards as a testament to his need to share his knowledge and experience, and his skill in doing that. He’s quite proud of this recognition.      

And what about his doctor-sons I mentioned before? The elder, Tommy, is a colorectal surgeon in a busy practice across town with two partners. His younger son, Billy, followed his father’s example more closely and went to Atlanta and became an interventional cardiologist himself. 

Father and son team

Jay and Billy have worked together for “15 thrilling years” as the protege grew and eventually handled the more complicated cases. Billy now does a full array of intricate procedures including (this sounds amazing to me) replacing a defective aortic heart valve by use of a catheter alone. 

Dr. Nicholson has often told his wife that if he “dropped dead” today, they could say of him that “that guy found what he wanted to do, and he had the best time in the world doing it.” That “he got everything he anticipated, and a lot more.”  

“It has been perfect.” Jay was pleased to tell me.

But things change. Billy is set to move on. He wanted to be more active in teaching at all levels, and he’s been asked to head up the renowned interventional program at Emory. Jay said he hates to lose him, but he understands why his son needs to take advantage of this wonderful opportunity. 

So, from Dr. Paul Dudley White to Dr. J. Willis Hurst and  Dr. R. Bruce Logue, to Dr. Spencer B. King III, to Dr. Andreas Gruentzig, to Dr. Walter J. Nicholson, to Dr. William (Billy) Nicholson, to...

When a generous teacher meets an engaged student good things happen.

(Note: Despite the fantastic advances in heart care over the past 50 years there is much more to be done. Roughly 640,000 Americans still die of heart disease each year. And heart disease has been the number one cause of death in the U.S. every year since 1910--Except for the years 1918-1920, when the most common cause of death, by far, was influenza and pneumonia during the devastating Spanish flu pandemic.)

Recommended readings:

1.  Forrester, James S., M.D. The Heart Healers: The Misfits, Mavericks, and Rebels Who Created the Greatest Medical Breakthrough of Our Lives. New York: St. Martin's Press; 2015. (Enjoyable, and very well written.)

2.  Jauhar, Sandeep. Heart: A History. New York: Farrar, Straus and Giroux; 2018.

3.  Hurst, J. Willis, Logue, R. Bruce, Schlant, Robert C., and Wenger, Nanette Kass, eds. Third edition. The Heart; Arteries and Veins. New York: McGraw-Hill, 1974. (Later editions are okay, too.)

4.  Warraich, Haider. State of the Heart: Exploring the History, Science, and Future of Cardiac Disease. New York: Martin's Press; 2019.

Orchid opening (photo by SC) 

 Anita Cherry 4/30/20

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)