Dr. George Robinson: To Sleep, Perchance to...Stop Breathing?

Dr. Robinson

The idea of a life in medicine was always sitting quietly in the back of his mind. But as a self-described “nerd” who nevertheless went to West Virginia University on a sports scholarship as an already-injured right-handed first-baseman, George studied accounting (with a minor in chemistry). After graduation, he joined the international accounting firm of Peat, Marwick, and Mitchell where he did auditing and tax work.

Sure, he had plenty of fun outside of the office and made lots of friends. But he said the work itself was just “shifting numbers and balancing books." This was not “terribly exciting” and wasn’t “fulfilling.” Though he admitted that it  “sounds too altruistic,” he really wanted “to make the world better.” 

So he changed direction. After six years of debit and credit, George Robinson, the future pulmonologist, critical care physician, and sleep doctor, went to medical school. He viewed the practice of medicine as his chance to have a positive impact. 

But why, perhaps, did he start with accounting? His father was a manager in a large food business and “ran plants that made stuff,” said George. Because of that, he moved the family around. His parents were living in Ohio when George came along. From Bay Village outside of Cleveland, they moved to Akron, then to Port Huron, Michigan, then to New Jersey, and, eventually to Maryland. 

George’s father, an Ohio State graduate,  wanted his two sons to go to college to be able to work for themselves, not for “the man.” You could do that as a CPA (though George didn’t) and (at least back then) you could do it as a physician. 

George’s mother, a registered dietician, also an Ohio Stater, agreed about college but gave her elder son a slightly different message. A message she carefully pinned to the back of his coat. It read: “Please Don’t Feed My Child!”  

These days, Dr. Robinson shares attending duty in the Covid-ICUs, defined areas within the York Hospital filled with patients struggling to breathe, struggling to survive. 

Sitting in my living room with his wife Diane, and more than six feet from each other, our facial coverings betray the seriousness of the moment. And as we talk, the subtle puffing out and then retracting of George’s mask with each breath suddenly reminds me of those old-fashioned ventilators with accordion bellows I’ve seen on TV. Filling up, and then deflating. Filling up, and then deflating...over and over.

(Some people, it seems, still don’t see that this viral pandemic is a nightmare. Even with December’s jump in the number of new infections daily and the deaths, so far, in early January 2021, more than 360,00 Americans. Deaths often occurring in the strained and lonely Covid wards. Deaths as weary and disheartened doctors and dedicated and overworked nurses practice the best cutting edge medicine available for this new and unpredictable disease. I don’t know what it’s going to take...) 

I asked Dr. Robinson how he was managing “on the front lines.” He quickly replied that “this is what we signed up for.” He likened it to the mid-1980s, early in the frightening AIDS pandemic, when everyone was to practice “universal precautions” to avoid any possible contact with the virus. The fine details of the transmission of the HIV virus were not fully known in the beginning and since there was no treatment there was mortal fear of contagion. 

Diane, a medical librarian, reminded us that patience is needed since understanding a new disease like HIV or Covid-19 takes time and there may be early missteps. (A much younger Dr. Anthony Fauci was already carefully leading the way at the NIH in the ‘80s.) 

To continue the military theme: George enjoys reading American history and he tells his residents on the Covid Service a story about General Eisenhower and the D-Day invasion. About the decision to order young and naive 18- and 19-year-old soldiers to land at the dangerous Utah and Omaha Beaches, a risky task that older soldiers, the “seasoned professionals,” would know to avoid. 

Soldier receiving medical treatment following the 
June 6, 1944, D-Day Invasion (from History.com)

So Dr. Robinson lets his young charges venture in to see the patients first and to report back to him, the wise seasoned professional. The residents (of which, quipped George, there is a “large supply, but only eleven of us” ) usually laugh. They usually laugh. 

But, in fact, he is careful, and said that he “feels safer in the Covid unit than most any other place in the hospital.”  (And by the way, Dr. Robinson made sure to tell me later that he really loves the residents and that teaching them is a joy.)

At this point, I gaze at his tan starched-looking fabric mask again, looking for the creases, the laugh lines, at the corners of his eyes that tell of a smile.  But with our faces half-covered, it’s much harder to read people now, increasing our “distance” from one another beyond the recommended six feet.

As I started writing this story more than a month after our interview, trying to get to know who Dr. Robinson was, I wanted to tell him that things were underway. So I casually sent him a text. He quickly texted back to tell me that his story had changed; he had contracted Covid-19! My heart sank. I anxiously called him. As he answered I could hear his breathing. He said calmly, with that matter-of-fact doctor voice I’ve come to know from my husband, that he had a cough and was fatigued. 

But he was upbeat (that’s George, I guess), and said that he was taking care of patients remotely. No need for time off for the general, for the seasoned warrior. Diane, I learned, was sick, too, with the same symptoms. (Ironically, the first vaccines for Covid-19 would become available in just a few weeks.)    

The Covid-19 ICU is a new twist in critical or intensive care medicine. It is claimed that the world’s first intensive care unit was set up in Copenhagen in 1953, one year after the polio pandemic that hit that city especially hard. There was one, just one, iron lung in the entire city, and adults and children were dying daily of respiratory failure. Dr. Bjørn Ibsen decided to use positive pressure ventilation, instead of the negative pressure of the bulky iron tank, for a young girl seemingly about to die. In six-hour shifts, medical students took turns squeezing the rubber bag attached to her tracheostomy. Twelve-year-old Viv Ebert survived. A new idea was born. 

Tending to Dr. Ibsen's patients (from nature.com)

What about intensive care in the US? A sort-of ICU was created in 1954 at Chestnut Hill Hospital outside of Philadelphia to allow short-staffed nurses to closely watch over a group of their sicker patients. But Dr. Peter Safar in Pittsburgh is given credit for developing the first real ICU in the States in 1958. The first critical care residency was established in 1963, also in Pittsburgh; the first board exam in the new specialty was offered in 1987.

These days, Dr. Robinson, in his role as an experienced pulmonary/critical care practitioner, needs to figure out what to do for his patients with Covid-19 who have trouble breathing. Some need only supportive care without supplemental oxygen, some need low-flow nasal oxygen, some need high-flow nasal oxygen with assisted ventilation, and some need a mechanical ventilator. Some patients, we learned, are periodically flipped from being on their backs to their belly, from supine to prone, to aerate different parts of their lungs (an old technique that is easier on the nurses now, said George since all of the rooms are fitted with cranes).

(An interesting historical tidbit, recounted in a story recently by newspaperman Gordon Freireich: The first-ever report of the use of supplemental oxygen for a patient with pneumonia to be published in a professional journal appeared in 1885. An astute 23-year-old doctor, only a few years out of medical school, wanted to make other “country practitioners” aware of the treatment. The patient, 16-year-old Frederick Gable, survived. The physician, Dr. George Holtzapple, of Loganville, was a staff member at the York Hospital.)   

Painting of Dr. Holtzapple delivering oxygen to Frederick
on March 6, 1885, and a plaque marking the event
(from the "York Daily Record")

In addition to the life-threatening respiratory problems, Covid patients may develop acute cardiac complications, kidney failure, liver damage, blood clotting abnormalities, and neurologic impairment with agitation, delirium, or strokes. Teamwork is required to support the patient until the body heals itself, and Dr. Robinson guides his squad steadily (and, when needed, especially now, with a dose of wry humor).  

(Another image popped into my head. As we were first learning about the spread of the novel coronavirus we were shown how showers of tiny droplets were sprayed into the air as we coughed or talked without a face covering. This reminded me of the Jewish folktale about the danger of malicious gossip: It is as impossible to repair the damage done by harsh words or outright lies as it is to put the feathers back in a pillow once they have been released and scattered to the wind. So the virus, once dispersed, cannot be recalled, cannot be gathered up and stuffed back into the "pillow.") 

Spread of aerosols and droplets on coughing or exhaling
(from ScienceDirect)

But let’s take a break from Covid and go back to tracing George’s career path. After his bleary accounting days, admitted fiscal conservative that he is, he looked around for an affordable (very affordable) medical school and decided to apply to the West Virginia program. It was a good choice. 

  Dr. Ferimer

You see, it was there that he met Diane. She was on the faculty as one of the librarians. Though it wasn’t kosher for faculty members to date students, George's cadaver-mate, Howard Ferimer (now a pediatric critical care physician in Pittsburgh), chose to play matchmaker anyway. It took some, but not much, maneuvering and they were “sort of together” said Diane, through medical school.

As George did rotations he carefully considered the different specialties. He thought about orthopedics, but he discovered one day in the OR that he was allergic to the cement used to anchor the prosthetic parts. He thought about cardiology, but he didn’t want to “stand around all day doing caths.” He thought about ophthalmology (like his uncle) but the “Number one or number two?” stuff turned him off. He even thought about neurology. 

His decision was finally influenced by infectious disease specialist Dr. Robert D'Alessandri at WVU who, besides being an expert clinician, showed the student that “attendings actually had a sense of humor.” So George realized that he enjoyed internal medicine, and since he wanted “to do things,” he was drawn to the brand new field of critical care. 

The University of West Virginia Medical School (from UWV)

When Dr. Robinson graduated from medical school in 1987 at the age of 32 to start an internal medicine residency he wanted to move closer to his parents in Severna Park. He looked at programs at Hopkins and the University of Maryland but wasn’t happy with either one. One night in the WVU ER someone told George of a doctor who “had a great time” at the York Hospital (it was Dr. Chris Due). He decided to take a look, and Dr. Robinson told me that “the rest is history.”

Dr. Zwillich

So, George moved to Pennsylvania and brought Diane along later; while she worked in the hospital library, he did his residency and a year as Chief Resident.  After the enjoyable four years at York, he did a three-year pulmonary and critical care fellowship at Penn State Hershey. Dr. Clifford Zwillich ran the program where they saw many patients with sleep-disordered breathing problems. Dr. Robinson said that it was while he was there he “found out” he “liked sleep medicine more than anything else.” 

In fact, his personal goal, his vision, over the past 25 years in York has been to build a strong sleep program for Central Pennsylvania. He’s been inching towards that, despite a few temporary administrative setbacks.  Even as he (as someone who knows about accounting) carefully explained to those who made such business decisions how just a few more sleep-lab beds would provide them with a nice “return on investment.”

So, as we sat together we spent a lot of time talking about George’s real passion, sleep. And why we often don’t get enough. And what happens next. 

All life, it turns out, has a built-in roughly 24-hour metabolic cycle, a circadian (“about a day”) rhythm. This clock keeps us synchronized, in tune, with nature and with each other. Failing to abide by the schedule causes problems. Dr. Robinson said, for example, that disrupting this rhythm in the spring for only one hour as we switch to Daylight Saving Time and get an hour less sleep results in more car accidents, more heart attacks, more strokes, and more medical errors over the next week as we adjust. We should probably stick to Standard time, he noted. 

NEJM: Canadian study of auto accidents 
after time changes (from Vox.com)

The shifting of the cycle, whether we wake up ready to go, like young grade-schoolers, or tend to stay up late and sleep late, like most teens, for example, should be considered as school start-times are set. 

Light, sunlight, especially blue light, is the strongest natural modifier of the cycle that slowly adjusts as the length of the daylight varies through the year. Exposure to light early in the day encourages wakefulness and energy. And the gradual dimming of light toward evening is the signal for us to stop and rest, and to sleep (and to dream). 

Speaking of dreaming, narrative dreams, where there is a story, occur in the REM, or rapid eye movement, stage of sleep. This is the time when the brain waves recorded on the EEG look like waking but most of the body is essentially paralyzed, preventing us from moving. 

This stage of sleep was first identified by Eugene Aserinsky (1921-1998) in 1953 while working with the founder of sleep medicine, Dr.  Nathaniel Kleitman (1895-1999), his thesis advisor. Gene performed the first all-night recording of ocular movements and EEG activity (now standard in sleep labs). This showed that sleep was an active state, not passive, as had been assumed. (The subject of the historic recording was Aserinsky’s eight-year-old son and the paper tracing was nearly a mile long!)

EEG patterns of waking and stages of sleep: 
compare waking with REM sleep.
(from Semantic Scholar)

But how does sleep itself come about? Melatonin, the sleep hormone, produced in the pineal gland deep in the brain, is geared to be released toward evening, preparing us for restful and peaceful slumber. Seems fine. But bright light late in the day, thanks to Thomas Edison and his bulb, messes things up. 

So we stay up late doing things, watching TV, or simply gazing mindlessly at our phones. And when we need to wake up early for work or for school we haven’t gotten the required seven to eight hours of sleep (needed for adults). We are tired. We yawn. We lose focus. We are irritable. We make mistakes. We should have turned down the lights earlier, but we just have too much to do. 

Sometimes, even though we go to bed early enough, fall asleep quickly, and spend eight hours apparently asleep (and our phones assure us that we slept) we are still sleep-deprived. We have a sleep debt and we are tired during the day, not fully awake. The most common cause of this, said Dr. Robinson, is the serious and increasingly recognized problem of obstructive sleep apnea (or OSA). This makes up the bulk of his sleep practice. 

What causes OSA, I asked? Here goes. Muscle tone decreases as one falls into light sleep. If the upper airway is already narrowed by enlarged tonsils, fat deposits, a large tongue, or other anatomical features, including the general (sadly) sagging of tissues with age, the partial collapse of the sidewalls of the throat that occurs during light sleep can block the flow of air. 

Partial blockage produces snoring. When complete blockage occurs breathing stops, snoring stops, and the blood oxygen level gradually falls. As a result, the brain, though busy with its sleep stuff, arouses itself to correct the problem. And the sudden reopening of the airway by expelled air is often accompanied by a loud snorting noise (often awakening the sleep partner). This cycle repeats through the night, maybe hundreds of times. Deep restorative sleep doesn’t happen. Chronic daytime tiredness results as sleep debt increases and sudden brief sleeps without warning may occur.

Where obstruction typically occurs

Yet simple tiredness, said George, is not all that happens. Not by far. Individuals with OSA have an increased risk of developing high blood pressure, diabetes, obesity, heart disease with dangerous rhythm disturbances, heart attacks or heart failure, cognitive impairment, and strokes.

It is estimated that more than 70% of individuals with OSA are obese. So, as obesity (especially central obesity) is the major cause of the pandemic of diabetes it also fuels the pandemic of sleep apnea. A vicious cycle.  

Obstructive sleep apnea said George, also greatly increases the chance of complications of surgery and anesthesia and he and his colleagues have started a program to screen patients for OSA before surgery. And since it may negatively affect the unborn fetus as oxygen levels fall in the second trimester of pregnancy he wants to identify women at risk before that happens. 

In addition, Dr. Robinson hopes to work closely with the trucking industry since falling asleep at the wheel is costly (trucks are expensive, he noted) and nearly 30% of truckers may have sleep apnea.

How is OSA treated? When it was first identified in 1965 (in Germany) it was treated with a tracheostomy to bypass the obstruction. The continuous positive airway pressure or nasal CPAP device to hold, or to stent, the upper airway, to keep it open, was devised in 1981 by Australian Colin Sullivan, said Dr. Robinson. CPAP is still the most effective treatment...but only if people use it regularly. Fitting the right mask for a patient is an imperfect art, and George believes it will be easier with new custom-made designs. Weight loss is also important if the patient is overweight and it may become easier to lose pounds as sleep improves; a virtuous cycle.

Dr. Robinson also sees individuals with other sleep issues, too. For example, he sees those with REM-sleep behavioral disorder. In this, the normal inhibition of voluntary muscle activity during REM doesn’t occur; people act out their dreams and may become violent. Fortunately, it responds well to medication. Curiously, it is sometimes a very early symptom of Parkinson’s disease. He sees other so-called parasomnias such as sleep-walking or night terrors, and there are circadian rhythm disorders. 

Narcolepsy was the first recognized sleep disorder. It is uncommon, but dramatic, with abrupt sleep attacks, sudden collapses or near-collapses due to loss of muscle tone, vivid waking dreams, and frightening episodes of momentary immobility upon awakening. The orderly sleep system, so-called sleep architecture, is disrupted as REM-sleep and waking occur at the same time. (II guess that is sort of like when I feel half-asleep.) 

Narcolepsy is probably an autoimmune disease due to damage to a small group of cells at the base of the brain that releases the wakefulness hormone hypocretin/orexin. Stimulants help the sleepiness and antidepressants can alleviate the embarrassing collapses, the cataplexy. 

Hypocretin modulates alertness through
dopamine, serotonin, histamine, etc. 
(from ResearchGate.net) 

Restless legs syndrome (RLS), a surprisingly common condition, was first described in 1685 but was“overlooked” until 1945 when Swedish neurologist Karl Ekbom wrote about it. RLS interferes with falling asleep (the legs are oddly uncomfortable and there is the urge to move them) and staying asleep (due to involuntary kicking of legs). It has genetic features and evidence of brain pathology regarding dopamine and can be mostly alleviated with medicines. Some sufferers have an iron deficiency.

I asked him about insomnia. He implied that he leaves that thorny problem and the emotional aspects of perceived sleeplessness and true insomnia mostly to the mental health team. He said, however, that cognitive-behavioral therapy (CBTi) is often useful. He was doubtful about CBD: “Show me the data,” he said. 

So, Dr. Robinson, as a pulmonary physician, noted that chronic lung disease or COPD is difficult to treat since it doesn’t improve over time. Sleep disorders, on the other hand, generally respond well to therapy. He said that he likes to help people get better and that his sleep work is very rewarding.

And as we were wrapping things up and George was talking about his outside interests, including travel with friends, Diane mentioned their special trip to Cuba.  She recalled the exquisite taste of the fish, freshly caught from the sea and then simply grilled and immediately brought to their table. For a moment they both seemed to be somewhere else; they were suddenly more relaxed, more at ease. George stretched out his long legs and Diane’s arms waved about as she spoke. I could see the smile creases at the corners of their eyes. It was an unexpected blissful remembrance of a before-Covid experience. 

George cruising in Havana, Cuba

I watched and listened. And waited for them to return to our new reality, yet looking forward to life after-Covid, when the Covid ICUs will be dark and empty and a dedicated sleep center will be up and running. When we will be able to sleep soundly again and drift into REM sleep and have pleasant dreams.

(George and Diane, you’ll be glad to know, while still easily-fatigued a few weeks after their Covid infection, are improving daily. George is back in the hospital where there are now four ICUs for Covid patients.)

References and recommended readings:

1. Aserinsky, Eugene and Kleitman, Nathaniel. "Regularly occurring periods of eye motility, and concomitant phenomena, during sleep." Science, 1953, 118, 3062, p.273-274. (A turning point in the history of sleep medicine.)

2. Dement, William C., M.D., Ph.D., and Vaughn, Christopher. The Promise of Sleep; A Pioneer in Sleep Medicine Explores the Vital Connection Between Health, Happiness, and a Good Night's Sleep. Delacorte Press, Random House. New York, 1999. (Somewhat dated, but worth reading.)

3. Freireich, Gordon. "York and the history of oxygen in medicine." York Daily Record, February 2, 2020. (Clarifying the story.)

4. Hamblin, James. The Mysterious Link Between Covid-19 and sleep. The Atlantic. December 21, 2020. (He says that "The coronavirus can cause insomnia and long-term changes in our nervous systems," and speculates that "sleep could also be a key to ending the pandemic.")

5. Jung R, Kuhlo W. Neurophysiological Studies of Abnormal Night Sleep and the Pickwickian Syndrome. Prog Brain Res. 1965;18:140–59. (First description of obstructive sleep apnea.)

6. Leschziner, Guy. The Nocturnal Brain: Nightmares, Neuroscience, and the Secret World of Sleep. St. Martin's Press. New York, 2019. (An enjoyable up-to-date read.)

Canada geese flying across the
York Heritage Rail-Trail (SC)

By Anita Cherry 1/3/21

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)