Dr. Fred Kephart, internist: The Importance of Time

A young Dr. Kephart

Soon after general internist Dr. Fred Kephart announced that he was retiring early he received a few touching note cards from his patients. They said they had appreciated him, that they appreciated his steady caring for them over the years.  He told me that, reading these handwritten notes, it felt as if he was attending his own funeral. His patients liked him and were going to miss him. “Well,” Fred thought, maybe he “wasn’t such a bad guy after all.”  Perhaps he should practice medicine a while longer. He smiled as he recalled this ambivalence for me.

Dr. Kephart left the practice of medicine in 2012 at age 62. His mother had died a year after she retired at 65, and he told me he did not want to go with his “boots on.” But no longer being needed by his patients, he said, required an adjustment that he hadn’t fully anticipated.

As the oldest of four, with two sisters and a brother, Fred had a lot of responsibilities as a child. He told me that “there was no room to make a mistake,” and that “you had to behave.”

He was born and raised in rural Huntingdon County, Pennsylvania, roughly in the middle-lower part of the state, as were his parents. His mother’s family had migrated to the area before the Revolutionary War and his great grandfather’s family came up from Maryland’s Eastern Shore as farmers. 

Fred’s father William (1926-2018) enlisted in the Army in January 1945 and served as an M.P. in Korea until his discharge in December 1946. When he returned home he worked in a hardware and appliance store, sold furniture for 30 years, was a candy distributor, and, finally, was the County Sealer of Weights and Measures. After the kids were raised, his mother, Emilie (1928-1994), trained as a stenographer, became the high school receptionist.   

With that non-medical background, I wondered how Fred ended up choosing medicine for himself.

Well, he was (of course) a “good student” in high school. One day his kindly chemistry teacher said (with nobody else around), “Freddie boy, you should be a doctor or a dentist.” So, as he heard this advice, this prodding, more than once, it sort of became his duty. But there was a serious obstacle; he recalled that he was standing in the kitchen with his mother when she said, “We want you to go to college, but we can’t afford to send you.”

And yet with mowing lawns (starting at the age of ten for 85 cents an hour), and caddying at the local golf club across the street from his home (for two dollars for a round), and with grants and loans, Freddie boy was able to pay for college himself and, later, with somewhat more lucrative weekend work (as we will see), even medical school. 

Education

He doesn’t remember that anyone offered advice about where to head for college; there was not even a word from the school guidance counselor.  So he applied to a single school, Juniata, a good private liberal arts college in, of all places, Huntingdon.  

View of the Juniata campus in bucolic Huntingdon County

As a freshman in (turbulent) 1968, Fred didn’t do so well. He had breezed through high school, but he was not prepared for college work. He realized that he had to make a change and that he had to leave the comfort of his hometown.  And he saw that his chance of getting into medical school was poor with his mediocre grades. 

(Image from hmbd.org)

So in his sophomore year at Juniata, he applied to pharmacy school.  He was accepted and transferred to the Philadelphia College of Pharmacy, the nation’s first pharmacy school and still top-ranked (now part of the University of Sciences). Fred studied there from 1970 to 1973 and he enjoyed the work. He figured out how to study, and graduated near the head of his class. With renewed confidence, he sent in medical school applications. 

He got into Hahnemann (now  Drexel University College of Medicine) where he helped pay his way working as a registered pharmacist on Sunday afternoons at Pat Tancredi’s pharmacy in South Philly for $6.36 an hour.

Looking back, Dr. Kephart thought that it might not have been the best decision to go to college immediately after high school; that he might have done better at Juniata with some time off first (it was the late 60s, after all).

A sort-of epiphany

Anyway, one day as Fred took the rotations through the specialties that help a young student decide on a career path he had an epiphany; an attending nephrologist showed him how to proceed methodically, step-by-step, to make an accurate diagnosis (and to avoid a serious mistake). 

The students were taught that practicing internal medicine demanded one to think logically. You listened as patients told their stories and gently guided them with a few probing questions. You examined them meticulously to help narrow your hypotheses. You then reviewed lab work and x-rays or other images. Finally, you put all of this together and came up with a list of the likely possibilities, a “differential diagnosis.”  Additional studies might be needed to pin down a diagnosis, and the treatment options would follow. That was how it worked.

From a video by Dr. Edward Strong at Stanford

When it was time to choose a residency Fred said he “never considered” something that he would simply like to do, such as orthopedics. In the 1970s it was understood that “you’re not going to be a real doctor unless you go into internal medicine.” And Fred was going to be a real doctor.

Where should he go for the needed training? After taking electives at several Center City university hospitals in Philadelphia and at a few in community settings he sensed  that the patient care was better and that the general tone was more relaxed (and more his style) away from “the ivory tower.”   

Residency and program director

So he looked at several small internal medicine programs in rural (and familiar) Pennsylvania settings including those at Reading, Geisinger, and Robert Packer. It was during his OB/GYN rotation at Pennsylvania Hospital (home of the nation’s first medical library) that Fred first heard of the York Hospital; a resident whose brother practiced in York had good things to say about it. 

Dr. Samuelson
(1927-2022)

Fred visited and liked the program, and came to York in 1977 for a three-year residency in internal medicine.  He went through the different medical specialties and as he worked closely with Dr. Miodrag Kukrika he noticed that the “cancer patients were the most motivated” he had seen. Fred thought briefly about doing an oncology fellowship but there were several very strong generalist role models at York (including Drs. Leo Samuelson, Ben Hoover, Jack Kline, and Ronald Reinhard) and he felt that he would be satisfied enough to follow in their mold. He sensed that it would be a good fit, that he could practice in York, and that he would have a fulfilling career.

But, there was another important reason for him not to leave York for further training. You see, Dr. Kephart’s first encounter with his future wife, Dr. Cynthia Patterson, occurred during his second year at York. She was a first-year Family Medicine resident and she called him from the ER to ask about the dose of a medication for a patient suffering acute alcohol withdrawal. The Internet wasn’t available until 1983 and there were no smartphones so you had to rely on smart people when you needed to know something important right away (if you couldn’t find your tattered spiral-bound Washington Manual). When later, by sheer chance, Fred and Cindy took an elective together they hit it off (but wisely kept their relationship quiet).

So after he finished his internal medicine residency in 1980  Fred stayed in York and took over the position of program director. There were very few applicants for the training positions that year and they “matched” only one or two of the five available slots. As a result, Dr. Kephart had to run the so-called Residents’ Service himself. 

A break before private practice

Ron

After he decided to step down and go into private practice with his close friend, Dr. Ron Benenson, he wanted a break. Cindy had finished her residency and the two chose to take a year off to travel. They first spent the first months (July to September 1982) on the road with Ron and his wife Tracy as they logged about 10,000 miles visiting friends across the country and touring several National parks. (The two couples currently live next door to each other and there is no fence between the homes). 

A month after they returned home, Fred and Cindy left for a six-month medical mission in South Africa. Cindy had done an elective there during her training.  Her stint was facilitated by Dr. Victor Gordeuk, a hematologist specializing in sickle cell disease who did his residency at York.  They worked in the bush with the Tsonga people in Gazankulu, one of the Black self-ruled homelands cunningly devised during apartheid by the ruling white minority to deprive the black majority of full South African citizenship and voting rights.  

Presbyterian Swiss missionaries brought the Gospel to the Tsonga and they had set up several hospitals and community health centers.  So when Fred (a life-long Presbyterian) and Cindy were in South Africa they stayed in a cottage on a medical compound. Dr. Kephart recalled that deadly snakes, including puff adders and black mambas, slithered through the grass and would sometimes sneak right up to the cottages. The serpents had to be carefully avoided as antivenom was in short supply and their bites could be fatal. (Yes. it’s often a rope, but sometimes it really is a snake.)  

Feared Black Mamba (from wallpaperaccess.com)

Fred manned the rural medical clinic three days a week where he (with an interpreter) took care of ten patients an hour (there was no paperwork). While there, he saw nearly 200 cases of typhoid fever, encountered exotic parasitic diseases such as schistosomiasis that he had read about and thought he would never see, managed patients with tuberculosis (still, in 2022, the leading case of death in South Africa), and (after hurried on-the-job training from a real surgeon) did 24 C-sections (with Cindy deftly handling the anesthesia).

The intrepid couple also saw patients who were wasting away and dying without a  diagnosis and Fred believes that these unfortunate souls had AIDS. (Even now, nearly forty years after the HIV virus was identified, 20% of the South African population is HIV-positive, the largest ongoing epidemic in the world.) 

Fred’s experience in South Africa from October 1982 to June 1983 as he lived amongst people “with very little” helped him further appreciate what he had. It was, he said, “quite an experience.” And, since then, medical mission work with the church has been a vitally important activity for him and his family.

Colorful Tsonga dancers (from facebook.com@TsongaDance)

(Nelson Mandela had been in prison for 20 years and had seven more years to remain incarcerated when Fred and Cindy witnessed the pain and fear of apartheid. Among his often-quoted sayings is this: “What counts in life is not the mere fact that we have lived; it is what difference we have made to the lives of others.”)

Return to York and how doctors think

When Fred returned to York, he and Dr. Benenson started to build their practice of general internal medicine. They took care of “everything” as they could continue to manage their patients after they were admitted to the hospital, even when they were in the ICU or the acute cardiac unit. The practice soon became busy and Fred and Ron added more like-minded generalists who were capable of taking care of the entire patient; generalists who were, we might say, (with no disrespect towards other physicians) “real doctors” (of their time).

A digression regarding doctoring and diagnosing: 

Accurate diagnosis, of course, precedes treatment and Fred was, as we have seen, introduced to the concept of an orderly logical diagnostic process as a third-year student.

After the interview, as I pondered Fred’s story I wondered if this is really the way doctors work? Is this the way internists think when they see a patient? My husband (always ready with a book about this or that) slipped me Jerome Groopman’s insightful and well-written How Doctors Think to help an outsider understand what happens in a doctor’s mind. 

Many times, a diagnosis arises effortlessly without deliberate reasoning, almost automatically. It appears with surprisingly little information for the physician to go on. It is believed that this happens by pre-conscious pattern recognition, by intuition, by a rule-of-thumb, by what is called a “heuristic” or a shortcut. This “fast thinking” relies on the doctor’s experience. The almost-automatic diagnosis is often correct, but sometimes quite wrong. 

And the diligent physician recognizes when things don’t fit. He knows when to ignore the evolutionarily adaptive and reflexive response of ancient deep brain structures and to turn, instead, to slow analytical cortical frontal lobe thinking (loyal followers of these stories knew, by now, that some neurology stuff would be sneaked in). This is the rational problem-solving deductive method Dr. Kephart was shown as a student, the approach of the well-trained general internist when dealing with uncertainty. The two modes make up the dual-process theory.

Homer Simpson vs. Mr. Spock (from BehaviorDesign)

And, says Groopman, as the physician searches for a diagnosis he recognizes when he has reached the limits of his knowledge and when he needs help. He is keenly aware that uncertainty is built into the system; that we don’t know, we can't know, everything.

The effective clinician learns that a key to not missing a diagnosis is getting the story right. So he listens attentively to the suffering patient before him. And Dr. Kephart confided in me that he believed that over the years he became a good listener. (As we sat together and talked I saw that he, in fact, was.)

Practice

Getting back to his story…

Despite his experience, his skill, and his thoroughness, the practice of medicine was “always kind of stressful” for Dr. Kephart. You will recall that young Fred wasn’t allowed to make a mistake and as he used the two modes of thinking mentioned above, dual-process thinking, there were still “tough patients.”  He was aware that he didn’t always know enough and there was “a nagging sense of inadequacy.” Looking back on his career, he hoped that he “was honest” about where he was “deficient” and that he mostly “did the right thing.”  But even as he felt burdened, he appreciated the close relationships he had with patients.

(As Dr. Groopman notes:  “Uncertainty sometimes is essential for success” as “paradoxically, taking uncertainty into account can enhance a physician’s therapeutic effectiveness because it demonstrates his honesty, his willingness to be more engaged with his patients, his commitment to the reality of the situation rather than resorting to evasion, half-truths, or even lies,” p. 155.)

The first issue

Anyway, as American medicine continued to change to become a lucrative big business enterprise and more and more competitive his practice was bought by WellSpan Health.  The insistent corporate push to be more “productive” followed, and Fred and his partners did their best to resist this pressure. He felt that the physicians at ( what was initially) Gotham Internal Medicine  (the name, said Dr. Kephart, reflected a local street, not  the Batman comic) were able to maintain their “culture.” 

During the early years in practice, reflecting his residency training and the respected general internists he had modeled, Dr. Kephart took care of “everything.” But as full-time hospital-based internists were hired Fred and his partners were no longer permitted to manage their patients in the hospital. And as they had less and less time to spend with patients in the office, Fred was distressed. The importance of having enough time to be with patients was ironically made more obvious when they began using the electronic health record (EHR) in 2008. 

Busy screen shot of the "Single Sheet Medical Exam"

Adapting to the electronic record

Because the EHR was new and it was felt that the program might be cumbersome for the doctors at first the practice manager reduced the number of patients to be seen in a day for a while. Fred told me that by booking only two patients an hour he had enough time to explore side matters that needed attention without worrying about (or being distracted by) getting the next patient in.  

Fred was happier for a while, and he said that by being employed by a large system with resources there were benefits in terms of, for example, physical office space and financial rewards (including a stable income and a reliable retirement package). But It wasn’t long before the manager increased the workload. As expected, physician satisfaction dropped. 

As EHR documentation became more complex and intrusive, requiring real-time data entry and way too many mouse clicks, wrestling with the process became arduous and burdensome. As the nature of practice was altered and he saw that “every little thing has its specialist,“ Fred still thought that he became “pretty good” at taking care of his patients with hypertension, heart disease, and diabetes. These three conditions make up the bulk of the outpatient practice for the internist and the treatment options (the pharmaceuticals) have become exceedingly complex since Fred’s early years.   

Regarding the EHR, Dr. Groopman warned: “Electronic technology…risks more cognitive errors, because the doctor’s mind is set on filling in the blanks on the template. He is less likely to engage in open-ended questioning, and may be deterred from focusing on data that do not fit on the template”( p. 99).

Thoughts about the future

As Fred witnessed the evolution of the role as a general internist since the late 1970s and has had time to reflect on that change I wondered what he thought about "the future."

Fred said that he was pessimistic. But he wasn't talking not about the future of medicine. He was pessimistic about “the future of our country.” He lamented that “there is no truth anymore” as each person has their own version of things. And, chillingly, he feared that misinformation is taken as fact when it is repeated over and over. He reads history, and he said that this reminds him of reports of Germany in the 1930s.

Innocent German boys reading "Der Stürmer" propaganda posters 
(from the US Holocaust Museum c/o Julien Bryman Archive)

The generic term “provider” is now in widespread use when referring to physicians. According to last month’s issue of The American Journal of Medicine, handed to me by my husband, this word was first employed by the Nazi regime in the 1930s to debase German-Jewish pediatricians. By 1938 as their medical licenses were revoked instead of being called “Arzt” (i.e., “doctors”) they were “Krankenbehandler,” mere “practitioners” or “health care providers.” The term was later applied to all German physicians of Jewish descent. Mass deportations followed. Words, the authors of the editorial noted, have societal implications.

When we contemplate the future we think, of course, about our children. Fred and Cindy have three adult children, a married daughter (the oldest and now running the math department at the Salk School for Science in Manhattan) and two unmarried sons (both living in Austin; one trained in web design and the other, as a musician). There are no grandchildren yet. 

I asked Dr. Kephart if there was anything particularly special he learned as a parent of three. He calmly told me that “it doesn’t matter what you do” since kids have “personalities and minds of their own.” And he added, later, that “one hopes you have given them a good foundation.” (We send them on their way; they eventually find their own paths.)

Leaving medicine 

Dr. Kephart, of course, has a mind of his own, and I suspect he feared that this independence was threatened by the demands of practicing internal medicine inside an expanding health system whose goals and means didn’t always mesh with his. And yet, after he left his practice at 62 he felt, as noted above, that he lost his role, his identity; that there was “a void.”

“So what do you do now?” I asked. He reads (mostly biographies and histories). He goes to the gym routinely, still wearing a mask during the current surge in COVID-19 cases (though almost nobody else there does) despite being fully vaccinated and boosted.  He drives the two hours or so back to Huntingdon weekly for a friendly round of golf with his childhood buddies. And he remains intimately involved with his church and mission work with Cindy, where he feels needed. 

And, quoting Jefferson in Jon Meacham’s biography of our third president, Fred, since he retired, loves"the ineffable luxury of being master (of his own time),” (page 453).

Dr. Philip A. Tumulty the master physician who ran the storied internal medicine program at Hopkins offered third-year medical students in 1970 this wisdom:

The "ability to listen and to talk, so that valid clinical evidence is gathered, anxieties are dissipated, and understanding and motivation are instilled, are the clinicians' greatest assets."  Deep meaningful communication of this sort takes time. 

Time is, indeed, of the essence.

References and Suggested Reading:

1. Groopman, Jerome, M.D. How Doctors Think. Houghton Mifflin. New York, 2008. (Engaging.)

2. Meacham, Jon. Thomas Jefferson: The Art of Power." Random House, New York, 2012 (p. 453) (Dr. Kephart's suggestion.)

3. Tumulty, Philip A., M.D. "What is a Clinician and What Does He Do?"  New England Journal of Medicine 1973: 280, p. 20-24. (Sounding an alarm and setting the bar nearly 50 years ago.)

By Anita Cherry 2/13/22

 

Dr. Ronald Benenson: The ER of the Past, the Present, ...and the Future?

Ronald Benenson, M.D.

We didn’t notice right away that a car had pulled into our driveway. But as soon as my husband spotted it he went out through the garage to greet Dr. Ron Benenson who was waiting patiently at the front door. He ushered our guest in and as we settled into our seats in the living room for the long-awaited interview, we became aware of a barely audible buzzing sound coming from the foyer. 

A few seconds later, Scott, my husband, realized that this was the sound of our doorbell. Dr. Benenson had pushed the switch, the soft ringing started, no one heard it, and the switch got stuck. The weak sound, the sound to alert us that someone was calling, continued unheeded.

“We have a doorbell that doesn’t make a lot of noise. We like it,” I said.

“Oh, okay,” said Ron, with a smile.

“It usually takes a while to know there’s someone at the door,” I said. 

“You have a good doorbell when you hear it and wonder, What’s that sound? That’s as loud as it gets,” said Scott. 

“Wow,” deadpanned Ron.

We laughed. 

(We were without protective masks after being vaccinated against COVID-19 before the more contagious delta variant had us concealing parts of our faces again.)

After a bit more light chatter, I asked Dr. Benenson to tell us his story.

Dr. Ronald Benenson retired from medicine a few months ago, in mid-2021. He said, with a sense of some pride and loyalty, that he and his wife Tracy, a registered respiratory therapist, worked a combined 87 years (87 years!) for the York Hospital, and then WellSpan Health. They had met at a New Year’s Eve party in 1977, during Ron’s internship. At that time, his path in medicine, where he would find his place, was still hidden. In fact, Ron’s entry into medicine altogether was partly the result of unforeseen events. 

The beginning

We will start at the beginning. He was born at the former National Homeopathic Hospital (it became Hahnemann in 1956) in D.C. between 11th and 12th on F off New York Avenue. In the mid-1950s, when he was a youngster, the family moved out of the crowded urban area to more-open Wheaton, near Silver Spring, just off of Connecticut Avenue, he said. 

The 75-bed National Homeopathic Hospital in D.C. circa 1920

His older sister had succumbed to polio at five or six, during one of the recurring epidemics, and his saddened parents, he told me, “wanted a change.” Ron was “shielded” from this by his mother and father, and he has no memory of these frightful times before the Salk vaccine became widely available in 1957.  Since then, worldwide vaccination programs have nearly eliminated the ancient virus from the Earth (a handful of wild-type cases occur yearly in  Afghanistan and Pakistan). 

Ron’s father, an economist who worked for the Department of Labor as an unemployment insurance expert, had emigrated from Belarus. He landed in New York in 1926 where he later met his future wife; both were hearing-impaired (he had scarlet fever, a common cause of deafness then). 

(At a high school event including parents, one of Ron’s good friends whispered, “Let’s go talk to your dad. His accent is great!” Ron was confused: “My dad has an accent?”)

College and medical school

Anyway, young Ron liked science in school and he went to Johns Hopkins University for his undergraduate degree. While there, he worked in a microbiology lab. But he soon realized that he was not cut out for a life of sterile laboratory work. He thought of getting outside and doing environmental biology (at the University of Michigan, maybe), or, “like everybody else at Hopkins,” going into medicine.  So he decided to take the GRE for graduate school as well as the MCAT for medicine.

The night before the GRE, Ron and his friends went to D.C. to catch a few repertory movies at the famous Art Deco Circle Theatre (where double features cost a dollar). Fortuitously (it turns out), on their way back to North Baltimore his 1964 Bel Air broke down with a cracked engine block. He missed the chance to take the test. But he had already sat through the seven-hour MCAT and he interviewed at the University of Maryland Medical School two weeks later. A letter of acceptance followed a week after that and he said to himself, "I guess I'll go to medical school." 

Circle Theatre in D.C. showing 1973's weird "Fantastic Planet" 
(The full movie can be watched here.)

Dr. Benenson didn’t tell me too much about his medical school experience but he did recall that his mentor for physical diagnosis was the master clinician-scientist infectious disease specialist Dr. Richard Hornick (1929-2011). Ron was amazed by Dr. Hornick’s uncanny ability to get the patient’s history and to arrive at the right diagnosis by “asking only four or five questions” before turning to the exam. 

Anyway, Ron likes being with people and talking with people, and he was drawn to the relatively new patient-centered specialty of Family Medicine. When he asked if he could do a rotation at the University, they said they didn’t “have time for medical students.” 

He was advised to look into the program at the York Hospital, an hour north, under Dr. Philip Roseberry, the second director, after Dr. Thomas Hart, of one of the earliest Family Medicine residencies. Dr. Roseberry was welcoming, so Ron did his rotation in York.

When, like many eager students, he wanted to do an emergency room stint in Baltimore he lost out again. The ER rotations at Maryland (the nation's first public medical school) were so popular that they were awarded by lottery. He didn’t “win.” So in 1976, he came back to York for his ER experience as a student.

Davidge Hall at the University of Maryland, the oldest building 
in the Western hemisphere used continuously
 for medical education (from wikiwand)

When it was time to look for a residency Ron picked internal medicine and decided to return to York County once more. 

After Medical School

On the first day of his internship in 1977, he was assigned to the ER. At midnight, (get this) the attending physicians in the ER left the hospital and went home (yes, they went home!). This meant that green Dr. Benenson, just weeks after graduating from medical school, was the only physician staffing the York ER till the morning. Luckily, he noted, he had the support of “an unbelievably wonderful registered nurse,” an LPN, and an aide. But he was the only doctor. 

During the day, when everyone was there, he was taught by ER physicians Drs. George Grossi, Lynn Jensen, and Dave Logan. When he finished his internal medicine residency in 1980, having rotated through the specialties, he still wasn't sure what he wanted to do.  So he stayed in York and worked in the ER.  He told me that  at that time “you did everything.” And “if you didn’t know about it you learned about it.” He spent a lot of time in "the reading room" (before the world's information was literally at the tips of our fingers).

A quiet Philadelphia hospital ER in 1970 (from The Philadelphia Inquirer)

Leaving the ER for Internal Medicine

In 1982, on the gentle urging of cardiologist Dr. Jay Nicholson, Ron decided to leave the ER and to practice general internal medicine (as he was trained). He thought about returning to the D.C. area, but you had to know somebody. Instead, he joined his colleague Dr. Fred Kephart and, with help from a block grant, they opened a practice in Red Lion. 

But Fred and his wife, Dr. Cynthia Patterson, were soon off to a medical mission in South Africa for nine months and Ron was left to run things “solo with one employee."

The practice started out slowly as he saw only thirty patients the first month. It gradually picked up. and Dr. Benenson had only two weekends off that first year. He saw patients in the office, took care of them in the hospital, visited them in nursing homes, and even did a few enlightening house calls. He enjoyed private practice but realized that he liked being in the ER "a little more."

Tracy (a York native whose grandfather, Dr. Paul Brown, was one of the founders of York’s Memorial Osteopathic Hospital), delivered their first child, Daniel, in 1984. By 1987 The “set- hours” and the “variety of patients” of regular ER work, and the opportunity for teaching were attractive and lured Ron back to emergency medicine; there was an open position at York, so he stayed.

Back to the ER

By that time, ten years after his solo night shifts, the nature of ER work had changed. It was evolving and adapting, reflecting the complexity of the often older and much sicker patients, and the major diagnostic and therapeutic advances in medicine and surgery of the late twentieth century.

A busy Brazilian ER during COVID-19 (from Researchgate)

The first full ER residency program had opened at the University of Cincinnati in 1970 and emergency medicine was recognized as a boarded specialty by 1979. The option to be certified without taking a two- or three-year ER residency ended in 1988.  Dr. Benenson, as an internist with previous ER experience, was, as they quaintly say, “grandfathered in” (an odd term). And over time, the ER, the emergency room, became the ED, the full-fledged emergency department.

Tireless Dr. Dave Eitel (1948-2012) had come to York in 1982 from Ontario, Canada, by way of New York to direct and develop York’s new academic emergency medicine residency program. Ron worked closely with Dave and served as Associate Residency Director from 1988 until 2001. Dr. Eitel was one of the co-creators of the still widely-used five-level triage algorithm for ER nurses, the Emergency Severity Index or ESI.

Triage 

Being sorted is the entry point into the ED experience. This triage (employed by Napoleon's Surgeon-in-Chief, Baron Larrey), deciding who should be treated first and who can wait (based solely on the seriousness of the condition) is critical when there are mass casualties, as in war or environmental disasters, or epidemics, and limited resources. It has become a pressing issue during the COVID-19 pandemic as intensive care units here and around the world have often been filled to near-capacity.

Triage: "Baron Jean Dominique Larrey (1766-1843)
Tending the Wounded [of either side] at the Battle of Moscow"
(painting by Louis Lejeune)

So when there are “surges” of the life-threatening viral infection it is important to identify those most in need of care. Dr. Benenson remarked that at academic meetings as far back as the 1990s there was talk of using artificial intelligence, or AI, in the ED to diagnose the cause of chest pain, often a tricky task. The use of AI has expanded and it is being introduced into the problem of triage to rapidly identify patients, including those with COVID-19, who will need intensive care urgently.

A study from South Korea involving nine million (yes, nine million) patients showed that “AI was capable of predicting [the need for] critical care at a confidence interval of 95%, outperforming the Emergency Severity Index.” AI was more sensitive in identifying such patients but it was less specific than the ESI, it was less discriminating. 

However, in the study, using ESI and AI together, combining (warm) human intelligence with (cold) artificial intelligence, was better than either approach alone. (We do better when the two sides of our brains, the left, and the right, connect.) 

The ED of the future?

So when Dr. Benenson playfully shared a vision he had years ago of the automated computerized ED of a future time, a vision where patients are loaded onto a moving conveyor belt to receive a nice cleansing bath, where they receive a venipuncture for analysis of blood samples and then a head-to-toe CT scan, he was only "joking." He was not entirely pleased as he sensed that things in the ED were moving in that direction, moving away from the fundamentals of a detailed history and meticulous physical exam (as he was taught and practiced). 

And now, in late 2021, one could add face recognition and an oral swab for rapid DNA sequencing to complete the mechanized near-future scenario. Powerful AI with so-called neural networks will process the mound of collected information and a machine will spit out a diagnosis and a treatment plan. Patients will be sorted and treated accordingly. 

Cartoon depiction of an automated medical future (from mathematica)

And all of this will happen before the patient is seen or touched. In this vision of the future, there will be little need for direct human contact. Little need for a Dr. Hornick or one of his mentees to ask four or five insightful questions before physically examining the patient to ease her fears.  

While there is no conveyor belt (this reminded me of the moving sidewalk in the 1962 TV cartoon  "The Jetsons"), other aspects of Ron's reluctant prediction are beginning to appear as more roles for artificial intelligence in medicine are identified.

The moving sidewalk behind George Jetson
(artist's cell from the 1962 show)

Improving the process

Dr. Benenson did not venture into the daunting and mysterious AI field himself. But as he took care of patients with all sorts of acute and not so acute problems that resulted in a visit to the ED at any time of the day or night, any day of the week, any day of the year, he also tried to improve the “process” of care by simpler means. Emergency medicine residency programs have long stressed the importance of academic research in addition to clinical doctoring. Dr. Benenson enjoyed this aspect of medicine, even as he stumbled into it almost by accident. 

A member of the group in the ER had done a “tiny study” on infections after mouth lacerations.  Ron casually submitted the paper to an annual Academic Emergency Society meeting. He was baffled when he was notified that it would be used at the plenary session, the opening session with everyone there, including about 400 ER physicians. There were eight presentations in all; his talk was the sixth. (Ron confided in me, with a soft chuckle, that he “didn’t even know what a plenary session was.”)

When he concluded his cautious remarks and his slides by saying that “more study is needed” this drew “a huge laugh” from the audience. This heady experience on the morning of Sunday, May 12, 1991, in D.C., was the birth of Ron’s interest in research.

(His talk? “An Evaluation of the Use of Prophylactic Antibiotics in the Management of Oral Lacerations” by Ronald S. Benenson, et. al., York Hospital. In the 105 patients, a five-day course of penicillin or erythromycin compared to placebo reduced the subsequent risk of infection from 19% to 8%. A simple study, but it was statistically significant and clinically meaningful.)

So, Ron made time for research and went to a variety of academic meetings. He didn’t publish a lot, but, for example, he and Dr. Marc Pollack reported on a protocol for evaluating residents breaking the sad news to the family when there was an unexpected death in the ED, and he worked with infectious disease specialist Dr. John McConville on a pneumonia algorithm to cut the time to giving antibiotics from six hours to 90 minutes after diagnosis. He joined with Dr. Jayaram Thimmapuram and others looking into factors affecting life-work balance in medicine and the widespread problem of burnout. 

Exhaustion (from Medical News Today)

Though he said that “in the ER every story is just a little different,” Ron tried to make the process of taking care of some common problems better and more efficient. And an algorithm, a series of unambiguous rules for diagnosis and treatment, he understood, would also speed patient flow through the terribly overcrowded ED. (Are they busy, you ask? A 2017 University of Maryland study revealed that from 1996 to 2010 ER visits accounted for 44% of all U.S. healthcare visits.)   

The ER doctor no longer sees everything

And as research advanced, the nature of the doctoring in the ED changed quite dramatically from when Dr. Benenson was almost on his own at night. He reminded me that he saw “everything” back then, from the sickest patients requiring immediate resuscitation to those with a minor sprained ankle, or those who needed a few sutures for a simple laceration, or those who just had a cold or a migraine or a bellyache. 

But now, he said, that breadth of experience is harder to come by as minor problems are routinely shunted (triaged) directly to the nurse practitioners or physician's assistants while the doctors tend to those with more complex and difficult conditions. 

And as in all other areas of medicine, there has been a progressive division of labor among ED physicians. Different problems are seen by different practitioners with specific fellowship training and special expertise. For example, emergency physicians may train further in the use of bedside ultrasound, toxicology, pain medicine, sports medicine, or surgical or medical critical care. No longer does a single attending see whatever comes through the automatic doors.

Modern ED floor plan and flow diagram (from Design Collaborative)

In addition, we, as patients, now have other options for where to go for acute medical attention, and the (overburdened) ED can be used more wisely. When the primary care office is closed or fully booked or when there is no primary care physician at all a trip to an urgent care facility is less time-consuming and much less costly than a visit to the hospital. 

In fact, it has been stated that 40% to 60% of ED patients could be seen just as well at urgent care centers. The benefit? The average wait to be seen in the ED is more than two hours, but only 30 minutes at an urgent care center; the ED cost averages $1,400 vs. $100-150 for urgent care, ten times as much.

Ron visits the ED as a patient

As a life-long athlete who has suffered common shoulder and knee injuries, Ron has made a few unplanned trips to the ED himself. However, one ED visit for a different reason was particularly eventful.  He had experienced prolonged episodes of chest discomfort and shortness of breath for a while, but since he could still play competitive soccer in an over-40 league he was sure it wasn’t serious. Until one day in 1999.  He was at the local athletic shoe store and Tracy just happened to be there when he had an attack. He was in pain and sweating profusely; she immediately drove him to the hospital. 

A cardiologist who was there seeing someone else in the ED spotted Dr. Benenson and recommended an emergency stress-echocardiogram. The technician doing the study watched the screen and saw that he had a leaky mitral valve. She asked him how long had he had the murmur. What murmur? It was news to him. The cardiologists treated him, and he was able to go until 2009, still playing soccer, before needing a valve replacement.

(Stubbornly, he didn’t give his soccer cleats away until 2017 when he was in India with Daniel, went after a loose ball, and pulled a muscle.)

Speaking of Daniel, Ron’s kids live together in Philadelphia. Rachel is an oncology social worker at Pennsylvania Hospital; her brother teaches English as a second language and walks dogs. To save on rent, Dr. Benenson purchased a house for them in trendy Fishtown.    

Fishtown street scene (from Philadelphia Magazine)

Looking back on his long career, Ron said that in York, “the practice of medicine has changed dramatically” from the time he started. Back then the hospital “felt like a family” and you knew pretty much all the consultants. This easy familiarity has gradually been eroded as medicine everywhere “has become more corporate.”  

Corporate. In his recent book about AI and the future of medicine, Dr. Eric Topol, cardiologist, and Editor-in-Chief of the physicians' website Medscape writes, for example, that much of the stress and burnout experienced by physicians today can be traced to arbitrary time constraints as a result of the pervasive corporate bottom-line emphasis on productivity. 

He leaves the ED again and focuses on research

So when Ron decided to leave the ED nearly eight years ago ("November 24, 2013, not that I remember," he quipped) he was "spent." Too much of his time was consumed with “more paperwork and more documentation” and “checking boxes (in the electronic health record) to establish the level of care.” And, as a direct result, and most importantly, "there was less time to see the patient." Ron was, he admitted, "burned out."

Physician (and nurse) burnout is becoming increasingly common. It might be less likely in the future, wrote Dr. Topol, with time-saving AI tools. But only if physicians learn to use AI and, in fact, all algorithms wisely, he noted. And with humane understanding of their limitations. He said that while artificial intelligence is really good at narrow tasks like pattern recognition, such as analyzing images produced by CT and MRI, skin lesions, or slides of biopsy tissue, it is less good with softer data. And it is not good at all, said Dr. Topol, when diagnosis and treatment require empathic understanding of a person. 

So Ron felt that he needed to change course and do something else. He turned back to his research experience and spent the last phase of his career working at the hospital’s Emig Research Center where he focused on teaching and mentoring. He especially enjoyed doing the journal clubs with the residents and attendings from different departments. 

He tried to encourage the habit of critical thinking and to provide a basis for understanding simple statistics as he and his colleagues carefully picked apart the latest research studies. He told me that “every article has its flaws” and that it is necessary to know if these are important.

The athlete gets hurt  

Though Ron, as we saw, eventually gave up soccer he has stayed athletic and he’s an avid cyclist. In July 2020 he was riding on the 14-mile Northwest Lancaster County River Trail with his good friend Dr. Dave Neuburger when he crashed as he was speeding up trying to avoid another rider. He fractured his clavicle and his pelvis, the “acetabulum” (the socket where the head of the femur rests), he said. 

Serene view of the Wrightsville bridge
from the Northwest Lancaster River Trail (from traillink)

Dave examined him carefully and called 911. Instead of going to the nearest hospital, as is the rule, Ron asked the ambulance crew to take him across the river to the York Hospital “where everybody knows your name.” After surgery to fix the fracture and ten weeks in a wheelchair he eventually got back on his bike. 

A nostalgic journey back in time, just before college

Apart from athletics, Dr. Benenson also enjoys film and music, so a story from the late 1960s. 

Ron and his friends, in two carloads, headed to the August 15-17, 1969 Woodstock Music & Art Fair, billed as an "Aquarian Exposition." After the car he was in blew a tire on the packed New York State Thruway he was able to make it to his great aunt Ida's house not far from the concert venue; everybody else (along with his clothes) ended up at Bethel, at  Max Yasgur's 600-acre farm. When Ron finally got to the site the crowd had swelled so much that they were no longer checking tickets, so he simply  walked in. (He kept the original program and his unused ticket.)

The peaceful sea of humanity ("kids" according to Max) at Woodstock 

Ron searched and searched for his friends in the throng of (possibly) more than 400,000 peaceful idealistic young concertgoers. That night he slept in a hut fashioned from bales of hay and, amazingly, he finally found his buddies behind the main stage the next day. (Contrary to what is often said, Ron was at Woodstock and remembers the music.) 

Leadership positions outside of the ED  

Anyway, getting back to Dr. Benenson's career, during his many years with WellSpan, he enjoyed serving on a number of important committees. He was vice-chair and (for seven years) chair of the Institutional Review Board or IRB for research studies. He was also chair of the Pharmacy and Therapeutic Committee, and the Pneumonia Clinical Effectiveness team. For a number of years, he was the only physician on the Medication Safety Committee. 

Ron has made time to volunteer in the community with Jewish Family Services (where he was board president until recently), and he and Tracy continue their work with several local food banks.

And as we finish

It was nearly two hours into the interview as we were winding things down that Ron’s phone rang. His daughter Rachel called to say they needed a new doorknob for their place in Philly. She asked him how many spare keys he wanted.  

At this, my thoughts drifted back to our nearly silent and totally useless doorbell. We could update it with a “smart” one with video and AI-enhanced face recognition. It would summon us to let us know that there is someone at the front door. 

And with its prior experience and advanced machine learning skills, it would quickly identify the caller and the likely reason for their visit. That would be helpful, sure, but I will need to peek through the blinds to see for myself who it is before opening the door. If it is kindly Dr. Ron Benenson again, I will gladly let him in.

Aquarius/Let the Sunshine In

When the moon is in the Seventh House/And Jupiter aligns with Mars

Then peace will guide the planets/And love will steer the stars

This is the Age of Aquarius...

(by James Rado, Gerome Ragni, and Galt MacDermot)

References and Suggested Readings:

1. Kang, Da-Young, et.al. "Artificial intelligence algorithm to predict the need for critical care in prehospital emergency medical services." Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine, vol. 28, no.1, 4 Mar. 2020.

2. Marcozzi, David, et. al. "Trends in the Contribution of Emergency Departments to the Provision of Health Care in the USA. International Journal of Health Services, 2018; 48(2):267-288.

3.  Topol, Eric. Deep Medicine: How Artificial Intelligence Can Make Healthcare Human Again. Basic Books. New York, 2019.

Photo by SC

by Anita Cherry 10/2/21

Dr. Suzette Song, orthopaedic surgeon, "couldn't imagine doing anything else" until one day...

Suzette Song, M.D.

She was three when she decided to become a doctor; she wanted to be like her father. She excelled in her studies, made it through an interview for medical school, and Suzette Song, the future orthopaedic surgeon, was on her way, on a clear path, at 16.

She described herself to me as a “pure-bred” Korean. But her Korean father was born in Japan while her mother, also Korean, was born in China. After medical school in Seoul, South Korea, her father came to the States for an internal medicine residency in Morgantown, West Virginia. He practiced general internal medicine and took qualifying exams in endocrinology, cardiology, and gerontology. He was still running into the ER in the middle of the night in his 60s. He did not encourage his precocious younger daughter in her quest to become a doctor. 

But when she continued to say that this was her goal he tried to nudge her towards a specialty where she wouldn’t have to work quite as hard as he did, perhaps ophthalmology, or dermatology.  She listened to her father, of course, but still thought she might be an internist, like him. However, she had to wait for that unforeseen experience that would present her with her own personal calling.

Dr. Song’s mother was a pianist and Dr. Song’s (slightly) older sister Mimi followed her lead and is a fine musician. As we talked through our protective masks despite being vaccinated against COVID-19, I saw Suzette’s expressive hands. I noticed her slender delicate fingers. I asked her if she played the piano, too. She told me, flat out, and without regret, that she has little musical talent. It was clear that her manual skills and her dexterity were to be employed elsewhere.  

Suzette said that she and her sister “looked different” than the other kids in their elementary school outside of Pittsburgh and that they were often victims of hurtful racist remarks. “Where are you really from?” was the nasty response after she said she was born in West Virginia. The adults in the mostly white community were, of course, no better. The experience of being “the other” made her “tough” and “defensive.” And determined. 

Some American history is important here: We proudly call ourselves a nation of immigrants but xenophobia and racism are deeply embedded in our story. In colonial times, in fact, Philadelphia’s own Benjamin Franklin felt that German immigration was a grave danger to the English way of life. And over time, with various waves of arriving immigrants, the "other” changes, but the newcomers are almost always viewed with deep suspicion, with fear. So, restrictions are devised. 

The Immigration Act of 1917 halted immigration from most Asian countries and the Act of 1924 completely excluded those from Asia aside from the Philippines, then a US colony. People from other Asian countries were not permitted to enter the US legally again until 1952. The Act of 1965 ended national quotas set in 1920 and favored the immigration of professionals. As a result, Asian immigration to the US quadrupled in the next five years. 

President Johnson signing the 1965 Immigration Act
(from the AP)

The flow continued, and Asian-Americans were the fastest-growing ethnic group from 2000 to 2019. And hate crimes, hate speech, violence, and discrimination against Asians, especially Asian women, are sadly common and rose sharply during the first year of the pandemic. Dr. Song told me that, yes, she has continued to experience this.   

Getting back to our story, very competitive combined educational programs, including the one shared by Penn State and Jefferson Medical College (now Sidney Kimmel Medical College), have allowed young highly motivated students to obtain both a medical and a bachelor’s degree without the usual four years of college. Suzette (as usual, it seems) was in a hurry; she wanted to do that.

When she and her parents visited the campus and were given the standard tour at Penn State their guide had been in the program for two years. He was engaging, and his pep-talk was encouraging. He was so engaging, in fact, that Suzette soon “fell in love” with him (with future doctor Kevin Muzzio) and they later married.

At Penn State, she excelled in the microscopic study of cells and, as a sophomore, she taught a graduate-level course lab in histology. When she needed the required research job at Jefferson she hoped to be in Philadelphia for the summer with Kevin. Happily, she was offered a position in the molecular biology laboratory and she rearranged her schedule.

Dr. Eric Hume
(Penn Medicine)

Oddly, the lab was situated, she said, “inside the orthopaedic surgery department.” The new chairman, Dr. Richard Rothman, wanted to focus on research, so Jefferson bought the University of Pennsylvania’s entire molecular biology laboratory. So, for the summer, at 16, Suzette worked there under Dr. Eric Hume, whom she called, “the ultimate mentor.” She said that “he loved fixing people.” His special field was biomechanics. He studied how living bone responds to physical stress, how it changes its structure according to loading, how it adapts to what is needed. 

One day Dr. Hume took Suzette into the OR to let her observe him doing a case.  He told her that in orthopaedics “you get to fix stuff that people understand.” And as she watched him work she was transfixed. Her reaction? “Ahhhh! This is awesome!”  And, at that exact moment, at that instant, before even starting medical school per se, she “couldn’t imagine doing anything else.” And supportive Dr. Hume encouraged her.

As Suzette went through medical school and made friends with nearly everyone in the class of 220, including the 40 in the combined track with her, she kept her sights set on orthopaedics. She knew that ortho residencies were “super popular and very competitive to get into.” And she knew that there were very few women in the field. She often thought to herself: “Can I do this? Can I pull it off?”

The odds were against her. After the 1972 education amendment to the Civil Rights Act, including the Title IX gender discrimination section, the number of women graduating from medical school increased, tripling by 1980. But many surgical specialties remained underrepresented. In 1970 less than 1% of orthopaedic surgeons were women. By 2001 the figure rose to only about 4%. This was in comparison, say, to obstetrics and gynecology where, in the same span, the percentage of women increased from less than 5% to more than 70%.  

US Orthopaedic Surgeons
by gender and year (from AAOS)

As she studied, she ran many of the orthopaedic experiments in the molecular biology lab. She got to know the orthopaedic residents at Jefferson and saw that “they were happy” despite their heavy workload. And she saw, she knew, that she could compete with them. 

After medical school, Suzette was readily accepted into the ortho residency at Jefferson. By her second post-graduate year, she and Kevin were (without her parents’ knowledge) living together. At one point they had the penthouse apartment at the Ben Franklin House across the street from the main hospital at Jefferson in downtown Philly. 

She told me that “the windows would rattle'' as the noisy medevac helicopters slowed to a gentle touchdown on the hospital’s rooftop landing pad. Living there, she could get up before four and walk to the hospital to have her rounds done before the mandatory six o’clock (yes, six AM) conferences.  

Famous ballroom of the restored Ben Franklin, setting of
the courageous last scene of the 2012 movie "Siver Linings Playbook"
(from Michael Bixler) 

During her five orthopaedic residency years, Dr. Song had two special foot and ankle mentors, Drs. Paul Hecht and Keith Wapner. After her training at Jefferson, including at the Rothman Orthopaedics Institute, she did a year-long foot and ankle fellowship at the highly-regarded Hospital for Special Surgery in Manhattan (currently the nation’s top-ranked orthopaedic hospital according to the “US News and World Report”). She took the bus between New York and Philadelphia weekly to be with Kevin.

Paul Hecht, M.D.

But why did she decide to study the foot and ankle? She liked sports orthopedics (and really loves sports) but didn’t want to give up her Friday nights and Saturdays sitting on the sidelines waiting for someone to need her skills. Total joints were “too much inpatient work, too much rounding.” She simply didn’t like “hand” and she “didn’t want to do tumors” or spine (as many at Jeff did).

She saw the foot and ankle as a “biomechanically-based” functional unit with easily visible outcomes after surgery. Outcomes that her patients would immediately see and appreciate. Suzette (having, she admitted, a big ego) also liked the idea of becoming an expert and of being recognized as such by her colleagues. Yes, a subspecialty fellowship in foot and ankle was ideal.

Kevin was on his own track in academic medicine as he sought to be an internal medicine program director. As he attended conferences in the field he got to know some of the people in York (only about 100 miles from Philadelphia) running the medicine program, including Drs. Wolfe Blotzer and John McConville. 

Meg Figdore, M.D.

He was impressed by what he saw and took a position with the York Hospital. He started in April 1999 while Suzette was still training in Manhattan (at that point she needed to take the train to Lancaster to be with him).  She started her practice in October, only six weeks after giving birth to her first child, her son Ryan. (Ryan was carefully delivered by her steady Jefferson classmate and friend, Dr. Meg Figdore, despite ominous signs of fetal distress). 

Dr. Song said that her practice was busy from the start. As the new expert in the region, she was frequently asked to see patients with complex foot and ankle problems that needed additional surgery after a procedure elsewhere didn’t solve their problems. She often saw 40-50 patients a day.

A third of her practice, she told me, had to do with so-called posterior tibial tendon dysfunction. This “really strong tendon” runs behind the inside of the ankle and, amongst other things, maintains the foot’s natural arch. If the tendon is weakened by wear and tear (often hastened by obesity) or disease (such as diabetes, vascular insufficiency, or inflammation) “the whole foot falls apart, resulting in all sorts of structural problems,” she said.  The end result is now termed "adult acquired flatfoot." 

Illustration of adult acquired flatfoot
(from Todd Buck)

If this is diagnosed and treated early, surgery can be avoided. But if the problem progresses to complete collapse of the arch accompanied by constant pain surgery is needed, typically a combination of selective reconstructive and bony realignment procedures, or in severe cases partial foot fusions. 

When the ankle joint is damaged by severe arthritis causing chronic pain and instability the ankle may be fused with hardware (called arthrodesis) or replaced by an artificial joint.  It turns out that the ankle has been a particularly difficult joint to mimic with a prosthetic due to its complex mechanics and motions, but recent advances have made this more suitable as an option.

Radiographs of ankle fusion and joint replacement
(from seaviewortho.com)

Why are the ankle and foot so complicated? The change from walking on all fours to upright walking on two feet by our remote human ancestors evolved over eons. But the precarious bipedal gait of humans was likely present more than three million years ago as suggested by the fossil remains of one of our most famous relatives, the upright-walking but still-small-brained “Lucy,” (Austraopithicus afarensis). 

Reconstruction of Lucy
(My, what big hands you have, grandma!)
(from the National Science Foundation)

The grasping ape foot, fit for climbing trees, had to become, little by little, more rigid and stable, but also elastic to allow efficient and safe walking on two feet. So, foot and ankle anatomy and function are quite complex: the human foot’s thirty-three bones, twenty-six joints, and over a hundred muscles, ligaments, and tendons need to work together to keep us from falling flat on our faces.  

So, for 14 years Dr. Suzette Song, as part of the growing Orthopaedics and Spine Specialists group (then OSS Health) with their doctor-owned hospital, was “a pretty busy and productive surgeon.” She was the “only female (surgeon) in a big organization.” But she figured out the system, and worked within it to make her own practice run more smoothly, more efficiently (sometimes too efficiently, perhaps, as some of her patients, older women, felt that she talked too fast). 

Suzette had two more children after Ryan (again, with Dr. Figdore’s help), and everything was good. 

But she had no advance warning as something was to happen that would change her life forever. 

It was the end of February 2014. It was a routine Saturday. She was a bit feverish and her stomach bothered her. No big deal. She waited for something to ache, like having the flu. That didn't happen over the weekend, and she was baffled. Early Monday morning, still sick, there was repeated vomiting and she felt dizzy. 

So she called her secretary to cancel her hours for the day. Dr. Song felt poorly but really wanted to avoid the ER. She implored one of the nurses at OSS to come over to her house to give her IV fluids. Yes, she would feel better, for sure, when hydrated. But the experienced nurse saw that Dr. Song looked terrible: her blood pressure was unrecordable, she couldn’t think clearly, and at this point, her skin started to really hurt!  A trip to the busy ER was unavoidable.

Shortly after she arrived at the hospital her husband, who had been working there, made his way down to the ER to see her. Suzette’s blood pressure was dangerously low and she was in a lot of pain. Morphine would drop her pressure further, so she told them (yes, she told the staff) where they could find some (expensive) IV Tylenol (it wasn’t used).  They thought at first that she was septic. She had stat lab work and her liver enzymes were through the roof. She was sent for a CT scan of the abdomen. 

CT image of an acutely-failing liver full of nodules
(looking from below)
 (from Eurorad)

As things moved along swiftly she was told that she needed a nephrologist (her kidneys were failing), a GI specialist (for the liver thing), and a general surgeon (in case her belly needed to be cut open). She knew she was in deep trouble. 

Yet Suzette, the skilled surgeon faced with a crisis, thought methodically. She figured out in her mind who might be on-call and who would be the best doctors for her, and she made her choices known. When critical care specialist Dr. Richard Murray arrived at her bedside, she realized that she was really sick.

Kevin had never seen such high liver enzymes and he knew that his wife had life-threatening hepatic damage. A decision was made quickly: she needed to be transferred immediately to a center where she might, just might, be lucky enough to get a liver transplant before all hope was lost. Time was of the essence. When Kevin told his wife that she would be sent to Hershey by a medevac helicopter her response was: “What’s Hershey?” Her brain was failing.

Dedicated MEDEVAC helicopters to transport the wounded

were first used by the US during the Korean War, a "forgotten" war.

From 1950 to 1953 three million lives were lost, mostly civilian.

Virtually all of Korea's major cities were destroyed. 

(photo from "Olive-drab")

Dr. Song had “acute fulminant liver failure” (of unknown cause) and she needed a new liver without delay. Without it, she would certainly die. In fact, at one point as she was in the Hershey Medical Center ICU and intubated and on a ventilator and “couldn’t breathe,” she thought she was drowning. She thought that she “must be dead” already. And as she was getting chest physical therapy, as they pounded on her back to prevent pneumonia, she felt that she was being tortured and was in hell. (She thought she had been good; maybe she misunderstood the criteria for descending into hell, she wondered.) 

"The Damned Cast into Hell" painting by Luca Signorelli
(photo by Steven Zucker from smarthistory.org)

By Wednesday Kevin had to start planning her funeral. He contacted family and friends so that they could say goodbye to his wife. As she vaguely recognized the faces of those who made the trip to Hershey, people from widely different eras of her life, she was sure that she slipped into the hereafter. Why else, she thought, would all these people be at the same place at the same time?

She had been placed on the top of the transplant list, and by Thursday night they had found a donor liver. But it wasn’t certain that the organ would be suitable or that Dr. Song would even survive until surgery the next morning. It was a very difficult night for her family and friends, as they waited and waited.  And after Suzette underwent the delicate, meticulous, and long surgery (pioneered by the famed Dr. Thomas Starzl at the University of Pittsburgh in the 1980s), she didn’t wake up for a week. Would she be okay?

The damaged liver is removed and the new liver is

put in place and is carefully attached to arteries and veins. 

The surgery may last more than 12 hours.

(from transplantliverindia.com)

After three weeks in the ICU and time on dialysis for kidney failure she was so weak that she “couldn’t even roll out of bed,” she said. Her “right arm was mostly non-functional at first” and she had to “learn to walk.” She went home after seven weeks in the hospital. Her continued recovery was agonizingly slow. She was on three drugs to prevent rejection of the new liver, drugs that suppressed her immune system and increased her risk of infection. It was scary; she felt “vulnerable” as a patient. 

Dr. Song had to be hospitalized several times the year following the transplant and resuming her demanding surgical practice wasn’t possible. Even now, in 2021, seven years later, she still fatigues easily, has some weakness and loss of dexterity in her hands, and has tingling in her hands and feet when she’s tired or hot or cold. She had to find another way to continue her career. So, “plan B.”

As we have seen, Suzette had long had an interest in the “process” of her medical practice and tried to find ways to do things better. With the help of her (all male) partners at OSS, she was able to take this interest to a “system” level. But she said she had to learn new skills, skills that were somewhat foreign to surgeons, administrative skills. Skills such as listening, collaborating, and knowing how to “get people on board.”

She has the title of Vice President of Medical Affairs but spends most of her energy “on big projects” and “workflow stuff.” She tries to learn from previous mistakes. Though Suzette “absolutely misses” being in the OR her work now is rewarding as she can “help a lot of people” rather than just one patient at a time. For example, if she helps to lead process improvement on even one step of a total knee replacement at OSS she can have an effect on the lives of a thousand patients a year, she said.

The OSS Orthopaedic Hospital in York, one of ten various 

OSS facilities in the region

(photo from OSS) 

She carefully coordinated things at OSS, and also with the large WellSpan and UPMC systems during the early confusing months of the COVID-19 pandemic as clinical information changed nearly daily and governmental restrictions and mandates were imposed on healthcare facilities. 

(Though Dr. Song has received two doses of one of the mRNA vaccines against the SARS-CoV-2 virus her anti-rejection medicines blunt her immune response and she likely remains susceptible to the virus. So she continues to wear a mask, and a personal air purifier and ionizer dangles from a delicate cord around her neck for added protection and peace of mind.)       

And in her newer role, her second career, and over time, and from her own experiences, she has learned to view things from the standpoint of the patient. When she took her mother to see her mother’s oncologist, Dr. Amir Tabatabai, he gently asked Mrs. Song if she would allow him to examine her. Suzette was moved by this simple act of asking permission. She sensed that this is a way medicine could be practiced: focusing on the patient, unrushed, unhurried, slower. And she saw that medical care could be standardized without being dehumanized, she told me. 

Kevin

So, after practicing an intricate orthopaedic subspecialty for 14 years, Dr. Song nearly succumbed to acute liver failure of unknown cause. A fortuitous organ transplant saved her life, and she embarked on a new vocation, helping steer her male-dominated orthopaedic group toward being better at what they do. But efficiency, she clearly sees, is secondary to taking the time to address the needs of the patient as a unique person. It might be said that she has embraced the goals of a good internist, of a good doctor, somewhat like her father.   

By now, it was late in the afternoon, and after a few hours of telling me her story, it was time for Suzette to return home to Kevin. It was Sunday, and he would be making Korean grilled steak.   

Readings:

1. DeSilva, Jeremy. First Steps: How Upright Walking Made Us Human.Harper Collins. New York, 2021. (The author makes the case that "bipedalism could have evolved only from a lineage that had developed the capacity for tolerance, cooperation, and caring for one another."  He watched a foot and ankle surgeon at work and was impressed. The skilled orthopod was Dr. Paul Hecht!) 

2. Jensen K. Henry, MD, Rachel Shakked, MD, and Scott J. Ellis, MD. "Adult-Acquired Flatfoot Deformity" Foot & Ankle Orthopaedics 2019, Vol. 4(1) 1-17  (Review of the foot problem that made up a substantial portion of Dr. Song's surgical practice; from the departments of Orthopaedic Surgery at the Hospital for Special Surgery and the Rothman Institute, places she knows well.)

 

"Grey Coat and Pink Hangers" (photo by AC)

by Anita Cherry 6/27/21