Dr. Andre Lijoi: A Modern Knight Errant on a Mission

Andre Lijoi, M.D.

“It was a beautiful thing,” he said. The Italian immigrants in the small tightly-knit neighborhood just twenty miles outside of New York City “wanted all of their children to succeed.” It was an “unspoken communal responsibility” and “they kept an eye on you.” They made sure that no one got into trouble. Dr. Andre Lijoi, one of those children, told me that he felt cared about (and I assume that he and his three siblings didn't get into any real trouble).  

His grandfather, Bruno Lijoi (1891-1984), left the town of Sant’Andrea Apostolo dello Ionio, located “at the instep of the boot,“ for his first trip to the Americas in 1913. He went back and forth across the ocean several times as he worked as a coal miner in Virginia, a gaucho in Argentina, and a laborer in Ohio.  His wife Angela (1895-2003!) stayed in Italy, longed for his periodic returns, and bore and raised their four children. 

Though he had only a third grade education, Dr. Lijoi’s grandfather “was a wise man” who abandoned Italy for good in 1935 as he saw the rise of Mussolini's fascism and sought to avoid his son being conscripted into the army. Andre’s father was 15 when the family arrived in the States and he served briefly in Roosevelt’s military (until he hurt his hip).

Grandparents Bruno and Angela Lijoi

Dr. Lijoi’s mother’s family came here in 1928 from Alvito, a small mountain town in central Italy between Naples and Rome; she was only eight. After Ellis Island, her family first settled in the Corona neighborhood of Queens (Ironically, an area that was struck hard by the novel coronavirus earlier this year.)

Both families ended up in the village of Suffern in Rockland County and everyone needed to learn English. Monsignor Robert Ford (1918-2016), a wonderful Irish priest, helped Andre’s father with the new language and helped him get a GED. As his father, Salvatore, worked as a barber (from age 12 in Italy to 32 here), eight-year-old Andre sometimes shined shoes for a quarter. Sal attended Fordham at night and studied education. He first became a teacher, then a guidance counselor, and, finally, a principal of two schools (at the same time!). Andre’s mother studied, too, and used her own teaching degree and a Master's in library science to work as a children’s librarian.  

Andre's family in New York

With this strong belief in the value of education, this example, Andre attended Ramapo College of New Jersey, the state’s public liberal arts school located about two miles away from Suffern, just across the state line. He majored in biology, but took “some sort of” liberal arts or humanities course every semester, he said, including an influential Medicine and Literature seminar, a foretelling of the future. 

He considered doing “bench work” (that is, basic science) but was drawn to clinical medicine (both an art and a science) as he worked as a clerk in the local public library. He discovered there that he had a penchant, a knack, for listening to the patrons as he helped them find what they were looking for and voiced concerns about their health and the care they received. 

So he changed plans and went to the Georgetown School of Medicine, “heir to the Jesuit traditions of care of the sick and commitment to service and social justice” (from the Georgetown website).

He said that the first day at Georgetown the classmate in line standing right behind him as they were “picking up something” was Jamie Ferrara. Jamie had just come back from Oxford where he studied philosophy and literature. He had befriended Father Timothy S. Healy (1923-1992), who was studying Shakespeare there with one of the world’s experts. Fr. Healy, it just so happens, was president of Georgetown University. When Jamie asked Andre if he wanted to join a poetry group he was forming for medical students Andre did not hesitate; he said yes.

Father Timothy Healy chatting with MotherTheresa
(from Georgetown.edu)

So, “once a week for four years” Andre and the others, he said, met with Fr. Healy over dinner or breakfast; a much-needed break from their medical studies. The group read all of Shakespeare, and they made their way through Yeats and Eliot.  He told me that while he didn’t quite “get” the poetry at the time, he somehow “liked it.” Shakespeare? Well, it’s, you know, Shakespeare.   

After finishing medical school in 1980 Andre did a Family Practice residency at the University of Maryland where there wasn’t much time for literature. After this, in 1983, he went to the Appalachian region of Kentucky, in Hyden, to work for the Public Health Service. He soon found out that “when you ask a question, you get a story.” He was, as he said, “immersed in a narrative culture.”  

Commenting on that rich tradition, Kentucky novelist Silas House has written: “The thing, always, is the story. The beauty is in the testimony itself, even when there is ugliness mixed in, too. In these mountains, we know what it’s like for the eyesore and the magnificent to coexist. The true beauty is in that complexity.”

Transporting of coal (from Roger May)

So, the visits with his struggling, impoverished, but always proud patients were longer, but the days went by faster. After six months of listening, the young idealistic doctor understood that the story-telling was “really helpful.” Both for the doctor and the patient.

(A personal aside: I have sometimes imagined that it would be nice if we could press a specially-inked paper to our bodies like a second skin and that when it is slowly peeled off it would reveal an image, sort of like a Rorschach, of what’s going on inside. It could then be gently handed to the doctor. She would see where things are not right, where we are hurting, where we need fixing; I would not need to tell her.) 

Rorschach card #2 (from erzebet-s)

Anyway, after the enlightening period in Kentucky Dr. Lijoi moved to Hanover and enjoyed a busy private practice for seven years. His wife, Laurie, practiced with him for a while, but then left medicine to raise their two children, Katherine and Peter. 

Andre joined the WellSpan Family Medicine faculty in 1995, where he has remained. He worked closely with his colleagues and learned a good deal from Drs. Bruce Bushwick and Richard Sloan as they encouraged him in his nascent role as a teacher. 

And as Dr. Lijoi showed medical students and residents how to take care of their patients, and how to care for their patients, he found that the process of getting the story, of writing the story, and of telling and then re-telling the story, could be a powerful tool. 

This task begins with engaged listening and meticulous observation, skills worthy of Osler (as in, “Listen to the patient…”). It also requires the ability to record, to make known to others, to share, and to objectivize the findings. It requires a commitment from the doctor to get it right. And it cannot be rushed.

Surely, discovering the (sometimes) hidden narrative, how things got to be the way they are, is needed in acute conditions, where the tale is short and the effort is focused. But it is more vitally important in patients with chronic illness and loss of function, making up the bulk of medical practice now. Here, the process can span decades, and the whole being of the person and their social supports are relevant to the unfolding story.

Dr. Rita Charon

So, being accustomed to attentive listening, and thinking about such things, Dr. Lijoi’s ears were tuned to the right frequency when he heard about Dr. Rita Charon’s innovative program of “Narrative Medicine” at Columbia. 

Dr. Charon, a general internist trained in Medicine at Harvard and, later, in English (with a Ph.D. from Columbia) noted that “along with scientific ability, physicians need the ability to listen to the narratives of the patient” to grasp their meanings. (Charon 2001 p. 1897).  

Here is where we begin to get a bit technical, so bear with me. Dr. Charon emphasized the critical difference between generalizable scientific or logical knowledge and the “particularized” or singular narrative way of knowing that is set in time and space. Narrative, she notes, is concerned with the “motivations and the consequences of human actions” (Charon 1993, p. 149). She believes that skill in acquiring this type of knowledge of individuals can be fostered through critical and “close reading of literature and reflective writing.” 

And that “through narrative knowledge, humans come to recognize themselves and each other, telling stories in order to know who they are, where they are from, and where they are going,” (Charon 1993, p. 149). 

But how does listening to or reading a story actually work as we try to understand each other? How does it bind the teller and the listener together in a communal act? This is where I needed to turn to my husband, the neurologist.  

The primate brain, you see, contains a set of so-called mirror neurons, first identified by Italian neurophysiologist Giacomo Rizzolatti in 1992 in monkeys. Some fire, or are activated, during specific actions (of course) but also when we are observing another individual perform the same motor activity. Other neurons fire when slightly different actions are observed, but would nevertheless achieve the same goal. This mirroring also happens as we share memories or express emotions. 

When you tell me something that affects you deeply the areas of your brain and my brain that light up during a functional MRI scan are essentially the same. I, in a sense, experience your subjective experience. This mimicry results in learning and is critical for language and social and cooperative activities. And, listen to this... the process is completely involuntary, it’s how we are wired (together).  

Nearly the same cortical areas are activated during
  the execution of a movement and simply observing it. 
(from Semantic Scholar)

So, anyway, Dr. Lijoi decided to formally study narrative medicine in depth and he trained with Dr. Charon at Columbia. He loved the work and the warm camaraderie. He received formal certification in 2019.   

Andre has brought this back to the students, residents, current and retired medical staff, clergy, and interested nurses at the York Hospital. He runs didactic sessions with the residents and monthly hour-long get-togethers with the others. At each session, he is joined by a practice partner, a novelist, and a poet. Everyone is encouraged to share their reactions to a short work of fiction, a poem, or, perhaps, to a work of visual art. And they have to write something meaningful to themselves. He believes strongly in this and hopes that the work is valued and will be continued by someone else after he retires (he’s not ready to, quite yet).  

He used Eric Carle’s children's book about creative expression and imagination, “The Artist who Painted a Blue Horse” and Mary Oliver’s tribute to the artist, “Franz Marc’s Blue Horses,”  for his first original presentation to the residents. He wanted them to see that when you are the artist you get to pick the colors and that when you are the doctor “you must try to know best where to place your brush” on the canvas of the life of the patient. You can even paint outside the lines. He said that he always wears blue and pink when he presents (only then did I take notice of his pink polo shirt and blue patterned socks).

Franz Marc's "Die groẞen blauen Pferde" (1911)

He is partial to Mary Oliver’s poetry and the work of physician-writers such as William Carlos Williams and Anton Chekov and often uses these authors in his talks.

Dr. Lijoi is not shy when sharing his passion.  He wants his trainees to feel the same way he does about the “beautiful profession” that he so loves. Though Don Quixote’s lovingly-imagined lady Dulcinea del Toboso is in real life a poor peasant girl, as his squire and confidante Sancho Panza repeatedly reminds him, he doesn’t abandon the poetic dream of her unmatched beauty. And he doesn’t give up his knightly task of righting wrongs and doing justice. Dr. Andre Lijoi wants his students to remain similarly idealistic when it comes to their patients and their own stories.

Adam Driver and Jonathan Pryce in
"The Man Who Killed Don Quixote"
Directed by Terry Gilliam (2018)

Andre has given of his time and he has been given back. He told me that when he learned that when he had received the Pennsylvania Family Medicine Doctor of the Year award in 2008 he reflected on why he went into medicine, and on all of those who influenced him. He felt deeply touched by the patients and colleagues who wrote in support of his nomination.  

Dr. Lijoi was most grateful, he said, for his first and most important teachers, his parents. As immigrants, they wanted the American dream for their children more so than for themselves. They emphasized and demonstrated Christian virtues and the benefits of serving others. He recalled and acknowledged his many formative influences from high school, college, medical school, residency, and practice. He gave thanks to God.  

In his free time, Andre enjoys hiking with his wife (and even his grown kids), especially in National Parks, and he likes fly-fishing. He is deeply involved in his church and its several ministries and is a lector, a reader there.

Peter. Laurie, Andre, and Katherine

And he “loves” (and finally “gets”) poetry: reading between the lines, hearing what is unspoken, listening to the silence between the first and second heart sounds, between the “lub” and the “dub,” as the heart fills and then empties itself.

So as we try to share our experience of illness, of non-well-being, with our doctors, our words, conveyed through our breath, are all-important. And the accuracy and honesty of our telling, our confiding, our confessing, opens the way to healing. And the narration and reading and re-telling of the story over time is part of the process as we grow. A simple bullet list of our ICD-10 diagnoses won’t do; taking away my story, a story that has become part of me, is not acceptable. 

And as we live through Covid-19 times and adapt, and as we write our own stories, we need to look after one another. We have to ensure that everyone has the opportunity to succeed and that nobody gets into trouble.

 

Andre fishing at Maroon Bells

From “Sometimes” by Mary Oliver 

Instructions for living a life: 

Pay attention.

Be astonished.

Tell about it.

 

References:

Charon, Rita. The Narrative Road to Empathy in Empathy and the Practice of Medicine, Spiro, Howard et. al. Yale University Press. New Haven and London 1993.

Charon, Rita M.D., Ph.D. "Narrative Medicine: A Model for Empathy, Reflection, Profession, and Trust." JAMA 2001; 286, 1897-1902.

House, Silas in "A Love Letter to Appalachia" by Roger May (https://bittersoutherner.com/roger-may-love-letter-to-appalachia).

Iacoboni, Marco. "Imitation, Empathy, and Mirror Neurons" Annu. Rev. Psychol. 2009.60:653-670.  

I call these "My Buddymundas" (whatever that means)
(My morning friends, I guess...)

By Anita Cherry (11/28/20)

Dr. James Srour: Gastroenterologist with a Mission and an Irish Drum

James Srour, M.D.

When he was five, his father gave him a small black doctor’s bag. So, when anybody kindly asked him what he wanted to be when he grew up he had an easy answer: he would just say, without thinking, “I’m going to be a doctor!” And he kept saying that, giving that automatic and expected response, until he was about twenty-five. Dr. James Srour, a gastroenterologist, said that he is still trying to figure that one out. 

He took his first two years of medical school at the University of the Philippines in Manila in 1972 and 1973. And as he carried his travel bags off the plane his eyes were opened; he saw a different world.  He saw people standing behind and pressed against the fence surrounding the aging airport; he didn’t know why they were there. He saw uniformed guards with submachine guns slung across their shoulders; he guessed why they were there. 

And what he eventually saw in this typical third-world country was “chaos wherever you go.” Particularly after the brutal, corrupt, and extravagant kleptocrat Ferdinand Marcos declared martial law on September 22, 1972. (This lasted until the People Power Revolution in February 1986 that rose up against regime violence and electoral fraud).

Despite this, Jim told me that his close experience with a different culture was “a great thing” and that he “loved it.” So it was here, in The Republic of the Philippines in Southeast Asia, that Dr. Srour felt the stirrings of his interest in medical missions for the poor.

A wide view of Manila (from Pavel Sinitcyn)

He did not plan to journey thousands of miles from home for medical school. Nor was it planned that he would witness the burden of ill health and extreme poverty on people and that this would affect him so deeply. But we are jumping ahead in our story and will return to that part later.

Jim’s father, Farid (1918-2018), was born in Syria, in Tartus, a large city on the Meditteranean coast, a vacation spot, and a still-valued Russian naval base. He came to the U.S. at 26. After he arrived in New York he did odd jobs for a while. He moved to D.C. and went to Washington Missionary College, where he met and married his English language and literature professor, a London-trained Brit with roots in Northern Ireland. He wanted to be a doctor but biology got in the way as Jim was conceived and born.  And since Jim’s father now had to support a family (with three more children to come) and could not go to medical school that meant that Jim would be next to be given that task. Hence, the small black bag. 

Tartus, Syria (a postcard from ProZ.com)

Dr. Srour said that he started his college career at George Washington University, but after a few years he “needed to get away from home.”  He moved down to the University of Alabama to finish up. He eventually realized that he would not be able to “make a living” as a marine biologist, as he had naively hoped. Since his fate was predetermined he took a few additional required courses and applied to medical school, “a bit late.” 

After the two basic science years in Manila, he came home and went to the University of Maryland for the two clinical years. He did ER and Internal Medicine rotations at the York Hospital and was impressed. He decided to do his internal medicine residency there, against the unyielding advice of his best friend who thought community hospitals were not rigorous enough (he was wrong). As a resident at York from 1976 to 1979, Jim enjoyed working with GI specialists Drs. Iain MacKenzie and Bill Thorsen and decided to go into that specialty.

But he had two months between finishing the residency and starting his two-year fellowship at Johns Hopkins. What would he do?  Simple, he would go to New Zealand! 

Why New Zealand, you ask? An island country nine thousand miles away from home? This is a bit complicated.   

His future wife, Cushla, a native New Zealander, had befriended one of Jim’s cousins (his maternal uncle’s son) when she was in college. There is a tradition among Kiwis called the Overseas Experience (OE): when you are in your 20s you pack a small bag with the essentials, leave home, and go somewhere else in the world to work and to expand your view of life. You usually stay abroad for a year or more. Since Jim’s cousin had come here for his OE he thought that Cushla would also have a good experience in the U.S. So she came to the States and she stayed with Dr. Srour’s parents for a while. Are you with me?  

Sheep grazing on South Island (from crbette-Getty images)

Jim met Cushla briefly while she was here, and when he had his two months to explore he chose remarkably beautiful and isolated New Zealand as the destination. He casually wrote to her for advice about where to go, what to see. He said that she sent back a “12-page compendium.” So he went to the other side of the world. The unhurried people in the “quiet and peaceful” former British colony took good care of him. The rest (with Cushla, that is) is history. 

Dr. Marvin Schuster

Dr. Srour did his GI fellowship with, as he told me, the “phenomenal” Dr. Marvin Schuster (1929-2017) at Baltimore City Hospital (now Bayview). Dr. Schuster was “really sharp” and an “uncanny diagnostician” who recognized the importance of appreciating the psychological aspects of gastrointestinal disease and incorporating them in the treatment. He was a world-renowned pioneer in the field of GI motility, of seeing how things move (or don’t move) through the gut. 

(The long tube of the digestive tract, you see, has an extensive nervous system, the so-called enteric nervous system, to coordinate its muscular activity as nutrients are absorbed and waste is discarded. It has, one might truly say, a mind or intelligence of its own.)

After Baltimore, Jim returned to York. He worked with Dr. Thorsen for a while and then started his own practice. He was very happy when Dr. Duane Ahlbrandt joined him. The respected practice grew as other physicians came on board. The field of gastroenterology, like all of medicine, has changed dramatically since Jim’s training years. 

One of the most striking, he noted, was a better understanding of peptic ulcer disease. Stomach and duodenal ulcers, long thought to be triggered by stress and diet, are, in the end, caused by the damaging effect of acid. Until 1976 yucky-tasting liquid antacids were given around the clock to neutralize this. They were partially effective, and many patients needed major surgery to treat the complications of ulcer disease, especially life-threatening bleeding.  

When cimetidine, the first so-called H(istamine)-2 blocker, was released in 1977 acid production could be suppressed and surgery could usually be avoided. The more potent acid preventers, the proton pump inhibitors (PPIs), became available in 1988. These cut the acid by 99%, and general surgeons had to find other things to take care of. (Dr. Srour was careful to say that prolonged use of PPIs may have negative consequences for health, even though they are sold over the counter now.)

But after the bacterium Helicobacter pylori was identified In 1982 ideas about ulcers changed as it was found to be associated with nearly all ulcers. The twisty bug burrows into the lining of the stomach to hide from the immune system, and it stays there unless treated. It can cause local inflammation, gastritis. This allows the acid to injure the thin protective stomach lining, leading to an ulcer. So...ulcers are caused by infection!

H. pylori is found worldwide and is especially prevalent in poorer populations. Most carriers have no symptoms but have a 10%-20% lifetime risk of developing an ulcer. Getting rid of the infection usually gets rid of the ulcer.  H. pylori is also associated with stomach cancers. 

This specific bug is only a very small part of our gut microbiome, the enormous collection of microorganisms (trillions of them!) making themselves at home in our GI tracts. They play critical roles in digestion and directly influence the immune and endocrine systems. And they produce neurotransmitters we usually associate with the brain including (our good friends) serotonin and dopamine. 

The vagus nerve (in yellow) sends signals
from the gut to the brainstem (from Nicole Miller)

(Messages from the GI tract are relayed to the brain through the vagus nerve to affect emotions and behavior. We are beginning to understand this important two-way brain-gut interaction. The bacteria, viruses, and other microorganisms that are adapted to our GI tracts are partly responsible for that communication. And gut bacteria may influence the development and course of brain disorders such as Parkinson's by way of the immune system and inflammation. But I digress. Back to ulcers... )   

Aspirin and other nonsteroidal drugs like ibuprofen or naproxen cause most of the approximately 10% of ulcers that occur without the presence of H. pylori. Additional factors in ulcer disease include alcohol, smoking, high physical stress, a sedentary lifestyle, and lower socioeconomic status. Diet, said Dr. Srour, contrary to medical folklore, does not play a role.         

Dr. Srour told me that the identification of the hepatitis C virus in 1989 was also important in his practice. Chronic Hep-C infection, a worldwide problem, may result in cirrhosis or liver cancer. Before 2014 this was treated with injections of interferon for 6-12 months. But the cure rate was less than 50% and there were severe side effects of the treatment. Direct-acting antiviral drugs, introduced in 2014, result in a cure in more than 90% and are well tolerated (but are very costly). Anyone between 18 and 79 should be screened for the virus since asymptomatic infections are common. 

Prevalence of Hepatitis C 2015 (from CDC Yellowbook)

Another area that changed dramatically, as in most of the field of medicine since the 1970s, is that of imaging. For gastroenterology that mostly meant endoscopy.  The flexible fiberoptic scope, invented by South African Dr. Basil Hirschowitz in 1957, replaced the rigid (ouch!) scopes by the 1960s. It was said by Wilcox that this was "the singular transformative event of the last century for gastroenterology." Dr. Srour would, I think, agree.

The diagnostic capabilities were soon complemented by therapeutic applications, including removal of colon polyps with a wire loop snare. The CCD (or TV) camera endoscope was developed in 1983, and you could see and record the goings-on along the lining of the GI tract in living technicolor.  

And, Dr. Srour said, the routine search for and removal of colon polyps by colonoscopy prevents their transformation into colon cancer. Since almost all cancers arise from polyps this is the only clinical situation, he noted, where cancer is actually prevented, not simply picked up at an earlier stage. Countless lives have been saved.

Slow progression of colon cancer (from Biovendor)

There have also been tremendous advancements in treating inflammatory bowel disease, where worrying about patients sometimes kept Dr. Srour up at night. And we know more about the common problems of irritable bowel syndrome and heartburn.

The day-to-day practice itself changed, too (as we have seen in previous stories in this series). 

One notable change, he said, was the nature of communication between doctors. Early on, after Dr. Srour saw a patient he often made a phone call to the referring physician to discuss his findings. He then sent a letter. Over time, the style of communicating changed. It became cooly digitized, without the warm nuance of the human voice. Without a carefully-crafted narrative.

Dr. Srour told me that, years ago, the referring doctors, usually primary care family physicians, were “quarterbacks.” They knew their patients extremely well, he said, and “took great care of them.” And they were often able to tell him precisely why they needed his expertise. The “relationship was really powerful.”  

And the general internists in the hospital such as Dr. Leo Samuelson, Dr. Jack Kline, Dr. Ronald Reinhard, and Dr. Ben Hoover “did first-class medicine” and “didn’t miss anything. They were genuinely great doctors," said Dr. Srour. They shared information with him and with each other smoothly.  He noted, wistfully, that the hospitalists don't seem to be as tightly-knit. 

The electronic health record (EHR) was supposed to (among other things) allow the medical team to coordinate care. Jim feels that it hasn’t accomplished that fully yet. He said that it may even perpetuate errors. Mistakes for example, in a patient’s list of medicines or their diagnoses.

Communicating is even more treacherous when there is a language barrier, and this brings us back to Dr. Srour’s wide travels for medical mission work.  

When he’s in a non-English-speaking country he talks with patients through an interpreter. But the helpful amateur usually has no medical training and doesn’t fully comprehend what he’s saying. The two sides struggle to understand each other. And yet, he found that the people always appreciate receiving care, however minimal. After waiting in line for hours or even all day, they were happy, he said, “just to be seen.” 

Reflecting, Dr. Srour believes that every college student should spend a month in a developing country. It would change their lives, he said; they would not be the same when they returned home.

I asked him what kinds of things he saw on his mission trips, often arranged, he told me, through the Living Word Community Church in Red Lion.

In Mumbai, for example, he came across so-called “pavement dwellers.” These souls are the poorest of the poor. He said that “when you walk down the street you find yourself literally walking on their homes. Homes marked out by the expansion joints in the sidewalk.” He thought to himself, “I can’t do this; these are human beings.” But after a while, you do it “because everyone else does.” Yes, you do it because everyone else does.

Indian pavement dwellers (from Vishesh Gupta) 

In a Romanian Gypsy camp, he said, “the best you could do was to give them Tylenol and vitamins. You could do something for pain relief, and for that they were extremely grateful. It was very humbling.”

He was struck by the remarkable “sameness “ he experienced in each of the third-world countries he visited.  He saw utter mayhem. There were, he said, no written rules of the road. The winner was the one with the loudest horn or the heaviest foot. You had to be very aggressive just to survive.

He said that we don’t understand how fortunate we are to be born here unless you have been to an area where millions of the poor lack nourishing food, clean drinking water, safe reliable shelter, and affordable health care. But where the super-rich and the desperate-poor often live side-by-side.

But there are also uninsured individuals here too, and Dr. Srour has volunteered his services at the Katallasso free faith-based healthcare clinic in York City. He told me, with some irony, that they use the same computerized EPIC health record as the hospital, but that the well-known hassles of the cumbersome system are avoided since “they don’t bill anyone and don’t need to worry about diagnostic codes.” He said it was a “joy” working there.  

After a rewarding career, Dr. Srour retired five years ago. He is enjoying himself. For many years he, his wife, and two of their three sons, both accomplished fiddle players, have immersed themselves in traditional Irish music.

The musical Srour family

Over the past 20 years, they have performed together throughout the local area and beyond. Jonathon is a foot-and-ankle surgeon doing a fellowship in San Francisco. Josh is in the Army in El Paso doing hospital administrative work. Jim’s third son, Jeremy, has Down syndrome and is the family’s “super glue." Dr. Srour plays the bodhrán, the hand-held tambourine-like Irish drum, and the wooden flute.

His small black bag, so to speak, has been carefully placed on the shelf, waiting for the next mission.

Reference and Recommended readings:

1. Jacek Budzyński, Maria Kłopocka. "Brain-gut axis in the pathogenesis of Helicobacter pylori infection." World J Gastroenterol 2014 May 14; 20(18). 

2. Marmot, Michael. The Health Gap: The Challenge of an Unequal World. London: Bloomsbury, 2015. 

3. Narayan, Deepa et.al.Voices of the Poor: Crying Out for Change. Oxford: Oxford University Press, 2000.

4. Nhat Hahn, Thich. The Art of Communicating. New York: Harper Collins, 2013. 

5. Perlmutter, David. Brain Maker: The Power of Gut Microbes to Heal and Protect Your Brain-for Life. New York: Little Brown Spark, 2015. (Maybe a bit overstated, but interesting reading.)

6. Wilcox, C. Mel."Fiberoptic Endoscopy: The Singular Transformative Event of Our Time." Digestive Diseases and Sciences, 59, 2619-262.

Mid-October early morning on the York Heritage Rail Trail 
(looking north from the Howard tunnel)

By Anita Cherry 10/23/2020

pages2619–2622(2014)

Dr. David Neuburger: The Turning Point in My Life

David L. Neuburger, M.D.

It is the black-and-white 1950s, and the curious young boy from the Upper West Side is taken by what he sees on the small gently-curved TV screen. He is watching “Lassie.”  Watching with interest. He likes the idea that the orphan Timmy lives on a farm. But he finds himself in a tightly cramped city. He wants a dog. But his mother won’t allow it. He wishes his dad had an old pick-up truck. But it’s New York and there’s no need for one. So as he watches the Sunday evening show he feels that he’s “missing out on that sort of stuff.” He dreams. 

Dr. David L. Neuburger has a few distinct memories of the New York City neighborhood of his early childhood. He remembers the green newspaper stands with stacks of the day’s papers bundled up. He recalls the ubiquitous corner phone booths (where Clark Kent sometimes morphed into Superman). He remembers that after his school was destroyed in a deliberately-set fire he was bussed to Harlem for first grade.  He remembers carrying a dime in his pocket in case he got lost and had to rely on one of these phone booths to call home. He remembers his phone number: “Wadsworth 7, 4437.”          

The interview: It is during the early months of the Covid-19 pandemic and it is a warm June day. We are sitting in the wide backyard of Dave’s log home on ten wooded acres bordering a branch of the meandering Codorus Creek in Southern York County. We are, of course, carefully sitting at least fifteen feet apart. We had talked about doing this by Zoom or such, but Dave thought this setting would be safe enough, and much nicer. The freshly-mowed grass, the tall mature trees, and the lovely songbirds were a welcome delight. 

So a relaxed Dr. Neuburger sat on a bench, stretched his legs out, and told his story. 

He was born in 1953 in Manhattan and spent his early years in the immigrant-rich culturally-diverse but sometimes scary Upper West Side (recall the ground-breaking 1957 show “West Side Story”). His parents were refugees who fled the anti-Semitism and violence of Nazi Germany as children. They didn’t talk about this when Dave was young, and he didn’t experience anti-Semitism himself as a child. Their harrowing stories, including the untimely death of his paternal grandfather, a well-respected member of the small Battenberg community, after he was taken into “protective custody” by the local police would not be allowed to intrude into Dave’s childhood, and he only learned the details much later.

West Side Story: The rival Sharks and the Jets from the 1961 movie (IMBD) 

 Dave was born in 1953 and when he was almost seven, with the help of GI benefits from his father’s military service during the war, the family moved out of tightly-packed NYC to the village of Nyack in more-spacious Rockland County, about 20 miles north of the city. Dave and his two close friends in high school would often “go canoeing in the “swamp” (that was later made into a reservoir) near his house, where they “caught snakes and that sort of stuff,” he said. He kept his two younger brothers “in line” as they all followed the “rules and regulations” of their “kind but strict” Germanic parents.

As we talked, I found out that Dr. Neuburger’s path to becoming a physician was not exactly a straight line. 

I will try to trace it. He was a Boy Scout, but dropped out “when that got old.” Well, his two buddies planned to go into medicine and that influenced him. So in his senior year of high school, he joined a medical Explorer Post based at a local hospital. While, yes, medicine might be “a better fit“ as a career he, instead, had envisioned life as a field research biologist, “leaning towards large animal biology.” 

But federal funding for such research was being cut off. So he talked with someone from International Paper about “managing a forest for wildlife.”  They were only interested in “cutting down trees.” 

Anyway, even though field job prospects were slim Dave still wanted to attend Cornell to study forestry.  He applied there, and to MIT, on a whim, as his so-called “reach” school. When the principal called him down to his office one day (“What did I do wrong?” Dave instantly thought) and informed Dave that he was accepted at MIT there was no real question; he would go to Boston, “a cool city.”

The MIT Dome at dusk (from Frontiers)

But this was not such a good choice for a biology major who was interested in large animals and field research; in Cambridge, they were more focused on microbiology and genetics. So he improvised and did an “alternate biology” program where he could study civil engineering and field research and even some literature. Dr. Neuburger said that the intense school by the Charles River “was like drinking out of a fire hydrant.” 

During the summer of his sophomore year, as he thought about what to do, he volunteered at Peter Bent Brigham as a transporter. He then took a gross anatomy course (with cadaver) in conjunction with Harvard. He was “fascinated by the whole thing” and he was “struck by the engineering aspects about how the human body works.” 

So medicine, it turns out, had a certain allure. Dr. Neuburger describes himself as “a people person” and he likes an intellectual challenge. And he had specific ideas about how he wanted to live (“in the country,” he said). A life in medicine could satisfy those needs. And he thought it would be “fun getting to know families.” 

While living in Boston he dated a girl from Harrisburg and she told him about Hershey Medical School. Family Medicine became a boarded specialty in 1969, and in the mid-1970s Hershey was positioning itself as a training center for primary care/family physicians for all of Pennsylvania. Dave was interested.

He worked hard and graduated from MIT a semester early. He had six months before starting the grind of medical school and he wanted to spend it traveling. So he bought an old Dodge van and converted it into a camper, and he and his boyhood buddy Mark (who lived two houses away and who now studies sediment cores from freshwater lakes) decided to explore Central America.

Map of Central America (from Lighthouse Magazine)

The road trip through Mexico, Belize, British Honduras, Guatemala, and El Salvadore was “transformative.”  He saw that “there was a world outside of the U.S.” He saw people “living in very poor conditions” and that they were “happy, kind, and honest.” He saw that “you didn’t need material things to get by in life.” And he saw that “people who have the most don’t tend to be happier.” But he also saw dead bodies cast by the side of the road due to the civil war in Guatemala, and he looked down into the crater of Pacaya, an active steaming volcano. The six-month trip was “eye-opening.” 

Steam billowing from the Pacaya volcano

(The two intrepid travelers sometimes went to a local police station to ask where they might safely camp for the night. The police offered them “protective custody” as they were told it would be best for them to park the van there.)

While he was traveling Dave tried to stay in touch with his girlfriend from Pennsylvania (she wanted to join him on the trip but the timing wasn’t right), but mobile phones were not yet available. And while he was gone (to find himself) “she met someone else.”

Anyway, Dave entered medical school in 1975. He had been promised that he would be assigned to a family and that he would follow it closely for the four years he was at Hershey. But that program was dropped because it “interfered with the academics.” He was disappointed.  He settled into his studies. He was let down again when things changed and he could no longer follow his Family Practice patients after they were admitted to the hospital. 

He met his future wife, Marilyn, in 1976. She was the childhood friend of his roommate from college, Bill. Dave was the Best Man at Bill’s wedding on Long Island. Marilyn was there, and they hit it off. She was a speech therapist and when she took a summer job in the Poconos, Dave valiantly offered to drive her the four hours from Long Island to the camp so she didn’t have to take the bus. They kept in touch as she did her Masters in speech pathology in Illinois. Things worked out and they began living together in 1977. 

After medical school, Dr. Neuburger decided to do his family practice residency in Harrisburg and he and Marilyn lived on one farm, and then another. They decided to marry in 1980. He generally enjoyed his post-graduate training.

During his residency, he did a few rotations at the York Hospital and he liked what he saw. He liked the feeling of the well-trained specialty staff and he liked that as a primary care physician you could admit your own patients, even to the ICU and CCU, and take care of them through their acute illnesses. And he liked that the relationship with the internists and specialists was seen as a partnership, contrary to what he sensed while with Hershey. And he liked the setting; that you could live “in the country.”

Dale Kresge, M.D.

So he joined the practice of Drs. Dale Kresge and Mike Dobish, Dallastown Medical Associates. He enjoyed his practice, and as he saw many of his patients every three months they often became “like extended-family.” The gratification was in getting to know his patients as individuals, “not numbers.” These relationships over the years were very important to him.

 Dr. Neuburger felt that he could handle 95% of the problems that came through the office.  And he became good at “recognizing that something that looked like it was one thing was really something else” so he would not hesitate to refer the patient to a consultant who knew a bit more.  

In the era of specialization, what is the role of the family doctor? According to the AAFP:

“Family physicians are personal care doctors for all people of all ages and health conditions. They are reliable first contact for health concerns and directly address most health care needs. Through enduring partnerships, family physicians help patients prevent, understand, and manage illness, navigate the health system, and set health goals.“ 

The focus in clinical primary care medicine in the 21st century is, we have been repeatedly told, on the patient. It is said to be patient-centered rather than disease-oriented. And the patient is a person, someone with a history. As Dr. Eric Cassell wrote:

“Knowledge of persons is particularly important today because what most clearly distinguishes chronic disease [the bulk of primary practice] from acute disease is that it takes place over a long enough period of time so that the nature of the person has an undeniable influence on the unfolding narrative of the disease, and the disease influences the further development of the person.” 

And Dave is, as he already told me, and as I can clearly see, is definitely “a people person” and someone who tries to see the long view.

Anyway, when my husband and I bumped into Dave and his wife one day while he was hiking with close friends around Lake Williams I asked him if he would let me interview him; he quickly said yes. Marilyn walked behind, with my husband, and she wondered if I had written any stories about the pain of legal actions against doctors. She felt that it was important to talk about such things. So I cautiously asked Dr. Neuburger if he would mind telling me his painful story; he said he didn’t.

Late in his career, he was accused of failing to diagnose a patient’s cancer in a timely manner. The legal suit was brought a year later and went to court two years after that. It was “one of the worst experiences” of Dave’s life. The jury found him “not liable” as he had followed the relevant guidelines and shared his thinking and decision-making with the patient. Relieved, he broke down and "sobbed." 

But the terrible emotional trauma was not over. There were several groundless appeals that dragged on over the next two years. These were denied. And it was over. But the finality was, in a sense, anticlimactic. Dave said that there must be a better way of handling such things. 

I wondered if this experience changed the way he practiced? Did he become more defensive? No. Did he order more diagnostic tests? No.     

But as the practice of medicine itself changed over the decades it became more and more difficult for Dr. Neuburger to find the joy. When he started out, he said, wryly, “You could write for any branded medicine and order any test you wanted! Anything you wanted to do, you could just do it! We were kind of like doctors then.”  But now, we have “other people second-guessing everything,” mostly to save money for the insurer. New bureaucratic changes introduced every few years made doctoring increasingly cumbersome as they pulled him away from what he thought was best for his patient.  

“Why and how did that happen?” I asked.

Big-business saw how much money there was to be made in the world of medicine. The insurance industry, the large pharmaceutical companies, the medical device firms, and the number-crunchers in the big hospital systems saw the piles of money for the taking. Dave told me that the number of bureaucrats went up dramatically as the number of physicians inched up only slightly (as their influence went down).

Striking growth in the number of administrators over 40 years (Bureau of Labor Statistics)

So Dr. Neuburger retired in 2015 after 32 years in practice. Though he was “the tech guy” in the office, and was even asked by his partners to pick out which electronic health record to use, computerized notes were not his thing. He saw that this would change the personality of the intimate medical encounter between patient and physician. He didn’t like what he saw coming, and since he “didn’t want to be a complainer” he left medicine early. 

How does he spend his time now? He has more time for family, he enjoys his lovely backyard, he cuts down trees and clears brush, he fashions beautiful wood furniture, he raises honey bees, he is a bow-hunter, he rides his bike (sometimes “pretty fast”) on the nearby rail-trail and elsewhere, and he loves hiking and backpacking through wilderness areas with his wife and their friends. How serious is the back-packing thing? How about hiking the entire state of Oregon on the Pacific Crest Trail, all 455 miles, for starters? (I’m exhausted and feeling blisters on my feet just listening to that.)

Back-packer Dave posing for a photo on the Pacific Crest Trail 

He is proud of the service he has given to the York County Farm & Natural Lands Trust,  including several years as president. This non-profit organization is, according to their mission, “dedicated to preservation of the finest agricultural and environmental landscapes for future generations to enjoy.”

Did I say that he studied literature at MIT? Dave said that he greatly appreciates Mark Twain and has a few first editions of his works.       

What about Dr. Neuburger’s biological family? 

His son and daughter are married. After fleeing the early phase of the pandemic in New York City, son Mark and his wife Heather, a psychologist, now live in White Plains, New York. Taking after his dad, Mark completed a through-hike of the 2,190-mile (!) Appalachian Trail eight years ago with his buddy, Dane Jensen, and is a self-employed software developer. Daughter Becky and her husband, Darren, an accountant,  live nearby in York Township. Becky is a behavioral specialist consultant. Their eight-month-old son, Jon, is the light of "Grandpa" Dave's life.

Dave's parents are “comfortable” and in their 90s. His father was trained as a mechanical engineer. He worked for Raymond Lester & Associates, the famous model-building firm that created the precise 1:1200 scale model of New York City for the 1964 World’s Fair (Dave said he could even pick out the apartment where they lived when he was a kid). His mother was a teacher. His brother Jon is a film editor for PBS who has done shows for American Experience, Nova, and Frontline. And his brother Dan works for Lockheed-Martin, but he is forbidden to tell Dave what he actually does.

1964 World's Fair New York City Panorama (from the Queens Museum; still on exhibit)

 At the end of the pleasant nearly two-hour interview, Dr. Neuburger guided me and my husband around his property. He pointed out the large wooded area that he had cleared by hand. He showed us his three beehives with buzzing worker bees doing their thing. He pointed to dried dung on the ground that he quickly identified as from a fox. 

And as we walked under the green leafy canopy I was reminded of “forest bathing,” the Japanese practice termed Shinrin-Yoku; the meditative process of “taking in the forest atmosphere through all of our senses.” This simple “exposure to nature and green environments” has been shown to lower heart rate and blood pressure, to reduce stress hormone production, to boost the immune system, and to improve overall feelings of well-being. 

So, as Dr. Neuburger knows, there are recognized benefits of playing in, living in, and simply being in nature, or “in the country.”  

Reference:

Cassell, Eric J. Doctoring: The Nature of Primary Care Medicine. New York: Oxford University Press, 1997.

Reading: 

Twain, Mark, (Samuel L. Clemens) ."The turning point in my life" in What is Man? New York and London: Harper and Brothers, MCMXXIV.  ( https://www.google.com/books/edition/What_is_Man/qv0QAAAAMAAJ?hl=en&gbpv=1)  

Dave's leafy backyard the day of the interview 

by Anita Cherry 8/1/20