Dr. Kenneth Brein: Seeing More Clearly

Kenneth Brein, M.D.

Ken’s mother helped support the family with a thrift shop in Germantown. Her youngest son had an ear for music, so when she acquired a slightly-cracked Gibson guitar for twenty-five dollars one day, she lovingly handed it to him. He was ten years old. He practiced. And practiced. And by the time he was in the seventh grade his band, “Celestial Fire,” was performing somewhere every weekend. It was the early ‘70s and they played “everything you heard at Woodstock,” said Ken. It was his life. That is, his life apart from his early interest in science, math, and physics. Yes, Dr. Kenneth Brein confided to me that he was “the nerd” in the family. But he was a nerd with a guitar.

He did well at Harriton High in Lower Merion just outside of Philadelphia, and he thought he’d be a scientist. His father (who, said Ken, joined the Army after graduating from Overbrook High but then struggled in a variety of businesses) recognized his third son’s potential. His often-whispered advice to Ken? “Be a doctor, be a doctor...”

But when Ken finished high school in 1974 near the top of his class of 250 his plan was to study science and engineering, not medicine. He applied to four elite schools and when he visited Princeton’s 500-acre bucolic campus it was “a gorgeous day in April.” When he toured Penn in West Philadelphia, it was a gloomy rainy day. So, Princeton it would be. 

Princeton University in the spring (from the Fulbright Commission)

PRINCETON AND PENN

While in central New Jersey, Ken refined his interests and decided to study biomedical engineering. But the course offerings were limited. He took whatever he could, and for his senior thesis he wrote the complex math for a theoretical model of blood flow  (a fluid, but with cells floating in it) through the small tubes of an artificial lung. Ken was (once again) advised to go to medical school. 

So he applied to a number of medical programs, received acceptances, and chose Penn (despite his weak first impression of the area). He enjoyed learning biology and doing medicine but seemed to lose interest in research. And as he progressed through the various rotations, he didn’t develop a feeling for a particular specialty. But one day, he was given a nudge. This happened when he was visiting his mother and her second husband George at their apartment on leafy Rittenhouse Square in downtown Philadelphia.

WHY OPHTHALMOLOGY

Dr. Zubrow

His mother’s personal physician and good friend, the highly-esteemed cardiologist Dr. Sidney Zubrow (who lived in her building) called her. He said that he wanted to see Ken. Dr. Zubrow, said Dr. Brein, was “the old-fashioned internist” who knew everything about his patients. The wise older clinician gently asked the young student how things were going in medical school. He asked him what he was considering doing in his career.

Ken thought for a bit. Maybe he’d go into Hematology-Oncology, he said, having recently done an intense rotation in that.

“Try something else,” said Dr. Zubrow flatly.

“Maybe Cardiology?” (Surely, Dr. Zubrow would be happy with that answer, thought Ken.)

“Try something else,” was the cryptic response.

“Maybe Infectious Disease?”

“Try something else,” came the reply once more.

By that point, the perceptive medical student began to catch on.

“Oh. Well…ophthalmology looks pretty good,” offered Ken.

“That’s a good one,” said Dr. Zubrow.

“Maybe Dermatology?“ Ken guessed as he was guided along.

“That’s a good one.”

The attentive pupil was “getting the message, loud and clear.” And when the time came to decide on the next phase of his training, a residency, Ken chose to study the many diseases of the eye. He would have loved to have gone to the Will's Eye in Philly but was content to be accepted into the ophthalmology program at the University of Pittsburgh. So, after medical school, and a year of internship at Pennsylvania Hospital (where a portrait of Dr. Zubrow is prominently displayed) he and Jessica took the turnpike (called “America’s First Superhighway” when it opened in 1940) 300 miles west. Wait a minute! Did I forget something? Who’s this Jessica? 

UPMC Presbyterian Complex in Pittsburgh (from UPMC)

HOW KEN MET HIS FUTURE MATE

Well, during the Christmas break the first year of medical school Ken took the train to Manhattan to visit one of his college roommates. When it was time to head back to Philadelphia he boarded at the busy Penn Station. He realized that he forgot to bring a book or a newspaper to keep him occupied for the hour-plus trip. What was he going to do? As he made his way down the aisle of the crowded car he spotted an empty seat next to a pretty girl. Somehow, he had the intuition that she was from Long Island and returning to Penn (no, she was not wearing the U of P red and blue). He thought they might hit it off.

So he sat down next to her, but she made an expression like ”you're invading my space.” He would have to play his cards right. So Ken, trying to be optimistic and trying to impress, reeled off his credentials (you see, he didn’t have a guitar with him). After chatting for a while, he asked her to dinner. But Amy (that was her name) was on her way to Penn to see her (quick stab in the heart) boyfriend. However, “I have a sister you might like,” she said. So she gave Ken Jessica’s phone number. What did he have to lose? He decided to give her a cautious call and soon wined and dined her, taking her to the fancy “La Terrasse” French bistro on the Penn campus. I guess it worked out, as they married and have three adult children and six grandchildren. 

Watercolor of the well-known Locust Walk at Penn (by elliemoniz.com)

AFTER RESIDENCY, WHERE TO PRACTICE?

Though Jessica would have been happy to stay in Pittsburgh after Ken finished his three-year residency, and he was offered an opportunity there, he wanted to be closer to the Jersey shore, to tiny Ventnor City, a two-square-mile vacation spot of many soothing childhood memories. So as Ken searched for a place to practice through print ads in the journals, he learned that Dr. Charles Letocha (also a product of Princeton and Penn) in York was looking for a partner. After a series of letters (yes, actual handwritten letters) back and forth, careful Chuck finally decided to meet Ken (and Jessica). They clicked right away, and Ken moved to York and joined the private practice in 1986. 

As a clinical ophthalmologist, Dr. Brein focused his energies on perfecting his skill in cataract surgery, addressing the clouding of the lens in the eye that is the cause of half of the world’s blindness. But a type of blindness that can almost always be cured.  

CATARACTS

Let’s talk about the cataract. The clear crystalline lens focuses incoming light to the fovea at the back of the eye, the area of the retina with the highest density of light-sensitive cones serving color vision. With age, (and UV light exposure) the proteins in the lens change and coalesce and the lens becomes progressively opacified, letting less and less light pass through. Though attempts to stick a sharp needle into the eye (ouch!) to push the clouded lens out of way go back as far as the fifth century BCE in India, the first “modern” cataract surgery was performed by a French surgeon in 1747. Serious complications were not unusual, and vision after the procedure was poor; thick heavy “Coke bottle” glasses were needed to see clearly in the absence of a lens. 

So physicians used to wait until there was a nearly complete loss of vision before removing the severely opaque lens. But advances in surgical techniques eventually made the procedure much safer. And Dr. Brein said that cataract surgery was revolutionized by Dr. Charles Kelman in 1967.  He devised a procedure termed phacoemulsification. With this, a thin ultrasound-driven needle inserted through a tiny incision breaks up then and then sucks it out. This is a very safe technique. It is the standard now, though it took a while to catch on (like most bold innovations in medicine). 

The development of the plastic artificial lens in 1974 by Dr. Harold Ridley in London to replace the worn-out body part provided a much more satisfying vision outcome for patients. And when the foldable plastic lens was invented in 1980, the incision required to insert it became even smaller and less traumatic.

Phacoemulsification and intraocular lens implant (artwork by Christine Cote)

For experienced surgeons, like Dr. Brein and his partners, cataract surgery became extremely controlled and consistent. And it is claimed that nearly 98% of patients can expect a successful outcome, a truly remarkable statistic for any surgical procedure. Complex lenses can now correct a variety of refractive errors, like astigmatism, etc. Over his satisfying 31 years in practice, Dr. Brein was able to deliver better sight to many thousands of individuals in York. 

HE HAD TO STOP DOING SURGERY

But Dr. Brein had to stop performing the extremely delicate surgery after he developed nerve injuries affecting the strength and coordination of his right hand. He underwent surgery for median and ulnar entrapment, but recovery of dexterity was slow and he did not want to expose his patients to the risk of a slip-up (fear of such things during his practice would sometimes keep him up at night) so he put away his scalpel. He still saw patients for refractions and for the diagnosis of the many ailments that can affect the eye, but he could no longer offer them his surgical expertise. He was okay with that, but then something else happened.       

ANOTHER BLOW

This next part of Ken’s story is particularly difficult to take in. And it was painful for me to hear. It happened five years ago. 

It was a routine day at his office. For a few weeks, Ken had been experiencing what he thought was right-sided tooth pain spreading into his cheek. He did what many doctors do (and shouldn’t): he diagnosed himself. He assumed that he had developed maxillary sinusitis. But when Ken spoke with his wife from the office he sounded confused. It was clear to her that something serious was wrong. Jessica told him in no uncertain terms to stay put. That she was calling for emergency medical services. She then spoke with one of his partners, Dr. Matt Bilder, and said, “Make sure he gets into the ambulance.”

A head CT scan in the York Hospital ER showed that Ken had a right frontal lobe mass, an angry-looking mass compressing and distorting the brain. There was swelling and an ominous “midline shift.” He had to be admitted to the ICU to be monitored and watched closely. Later that night, he was wheeled away for an MRI.

Well, it turns out that Dr. Brein had created his Wellspan Health account a week before. With this part of the electronic health record, a patient can use their laptop or their phone to view their test results, any time of the day or night, wherever they are, even when they are in the hospital. So, lying in the ICU, with several IVs dripping and devices beeping and flashing and keeping time, alone in the darkness, he picked up his iPhone and cautiously opened his portal. There was a message: “You have a new test result.” The report of the MRI was already posted!  Ken paused briefly, then opened the document. The radiologist felt that the mass was a tumor, “most likely a glioblastoma.” Ken, was very aware of the terribly grim statistics for survival after the diagnosis of a GBM and thought, “I’m dead.”

Images of a frontal GBM with a midline shift (from David C. Preston)

“How were you able to deal with this?” I asked.

Ken waited for a moment, and then replied: “I have not said this before, but I think I went into denial.” 

You see, when he was an intern in Center City Philadelphia he had taken care of a woman dying of this rapidly progressive untreatable tumor. So while he knew “intellectually” that he had received a death sentence he quickly determined that this harsh decree would not cripple him emotionally. 

“Do you think you should have been allowed to view that MRI report, to be faced with such a grim diagnosis when you were alone?” I asked (but already knew the answer).

“No. I don’t think I should have been put in the position to see the test results at that point,” he answered. Sure, one of Ken’s doctors did come in the following morning to talk about his MRI and to explain things, but the psychic punch of facing imminent mortality had already landed; he said his “whole world was turned upside down” in that instant. 

He recalled that early in the AIDS pandemic when there was no cure (there still isn't), and no effective treatment, the results of the testing for the HIV virus were to be given to the patient only with the help of a counselor. “That would have been helpful for me,” he said.

So, as a student of science and mathematics, Ken looked carefully at the dismal survival curves. While almost all patients died within two years (many in the first year), there was a tail of the curve to the right, an exceedingly small tail, but a tail nonetheless. In fact, it has been reported that about 5% of adults with a GBM survive five years and nearly 2% make it to ten years. He could, statistically, find himself in those tiny groups (higher physics and mathematics informed him that even exceedingly unlikely things do eventually happen).  

GBM survival curves with different dosing of Temodar
(from Bin Huang 2021)

FOLLOWING THE DIAGNOSIS OF THE BRAIN TUMOR

After standard treatment with radiation and chemotherapy with Temodar, Ken’s oncologist in York found an ongoing trial of immunotherapy at Duke that appeared promising. Fortunately, Ken met the very strict criteria for the study. In that, they produced a personalized vaccine by harvesting some of his own white blood cells and exposing them to a specific antigen found in GBM tumors but not in normal brain tissue. They then injected these reactive cells into Ken’s thigh so they could find their way to the lymph nodes in his groin. Once there, they could generate T-cells to attack and destroy tumor cells carrying the targeted antigen. It seemed like a long shot, but it made sense to Ken to try; he had nothing to lose and everything to gain.  (Two reported studies from Duke were very small, but 4 of 11 patients in one group and 2 of 6 in the other were alive at five years compared to 0 of 23 historical controls.)

Five years on, and after regular trips to Durham, and a bunch of noisy MRIs Dr. Brein, remarkably, has no evidence of recurrent disease. There is no talk of cure or even remission, he said, just no visible disease at this time. The “sword of Damocles” is still dangling precariously over his head, he noted. 

Dr. Ken Brein chanting Torah on Yom Kippur 2022
 By Jewish tradition, it is on this holiest of days that God decides
 each person's fate for the coming year, who will live and who will die.
(Rabbi Marshall Klaven, Jessica, and daughter Courtney are looking on.)

WISDOM GLEANED

“Have you changed over the past five years?” I asked (again, knowing the answer).

“ How can you not?” he replied.

Early on in his journey, he was given the simple advice to “make every day count.” At the end of each day, he and Jessica ask each other these few questions: Did we do something good today? Did we have fun today? So Ken tries to do what he enjoys. And he believes that his positive, attitude allows those around him to feel better, as well. For example, Ken has had the opportunity to meet with others coping with brain tumors like his. He discovered, somewhat to his surprise, that he could connect easily with them and that he could be compassionate in light of their shared experience. And he often imparts the wise counsel he received after his diagnosis. This has been rewarding. (Ken’s father, having lost a leg in an auto accident, helped console Veterans who had similar traumas.)

THE MUSIC

As Ken tries to follow his own guidance, (forced) retirement has had a “silver lining,” he said. It has allowed him to pursue his life-long interest in music in more depth. When Ken began playing the guitar he followed the popular rock and roll track. This served him well for many years. But when he, by chance, listened to a jazz album one day not too long ago he was struck by the colorful sound. There were different chords and chord progressions and complex harmonies. And there was an emotional element that intrigued him.

So he studied music theory; that there are specific patterns of sound frequency and rhythm that are especially pleasing to us, and moving. He studied the mathematics and the physics that result in, literally, “music to our ears.” 

(My husband reminded me that there is no music or sound "out there," and no color. These are the private experiences the brain produces as it processes different wavelengths of energy detected by various sense organs. The tree that falls in the forest does not make a sound if is not perceived, it just disturbs the air.  And he reminded me of Duke Ellington’s famous comment about music; "If it sounds good, it is good.") 

Ken became serious about this and studied jazz guitar technique and theory (mostly online) with master guitarist and teacher Martin Taylor.

Music theory: The complicated (mathematical) circle of Fifths

Jazz music originated in the African-American communities of New Orleans in the late 19th and early 20th centuries. It evolved from Blues and Ragtime.  Jazz (according to masterclass.com)  “rarely uses three-note triads that define pop, country, and folk music. Nearly all jazz chords feature the seventh chord tone, and many include tensions like ninths, elevenths, and thirteenths.” And (importantly) improvisation (promoting creativity and flexibility) is an...element that “unites nearly all forms of jazz.”  

Ken is grateful to have been part of York’s “Unforgettable Big Band” for the past five years as they perform swing and classic big band music for appreciative audiences. He said that he has learned a lot from these talented and  “professional musicians.”  But he has been toying with the idea of playing solo jazz guitar in coffee house-type venues. And he might even try his hand at the intricate fingerwork of classical guitar.

AND MORE

Not content with sixteenth notes and syncopated rhythms and the physics of scales and harmonics, another one of Dr. Brein’s current interests is (wait for this…) cosmology, the study of the origin and development (and eventual running down) of the entire universe. Modern cosmology builds on insights about the curved fabric of space-time and elusive gravitational waves envisioned by Albert Einstein (a resident of Princeton in his later years). Remarkable insights that revolutionized our concepts about the nature of reality. (This, alone, should be enough to keep Ken plenty busy.)

And when he’s not with Jessica, or the rest of his family, or with his bands, or playing golf (where, he noted, you “keep your own score”), or fooling with one of his many guitars (including his first one), or reading stuff by Brian Greene or other cosmologists, you might find Dr. Kenneth Brein carefully covered up on the beach in Ventnor enjoying the peacefulness of the rolling ocean waves and the gently setting sun, the celestial fire sustaining life on Earth.

The quiet, soft, Ventnor City beach (from Shawn R. Smith)

References and Suggested Readings:

1.   MasterClass. "What is Jazz: A Guide to the History and Sound of Jazz." accessed at https://www.masterclass.com/articles/what-is-jazz (A succinct overview; but a start.)

 2.  Batich, Kristen, et. al. “Once, Twice, Three Times a Finding: Reproducibility of Dendritic Cell Vaccine Trials Targeting Cytomegalovirus in Glioblastoma." Clinical Cancer Research 2020 Oct 15;26(20):5297-530. (A report of the encouraging, though limited, experience at Duke, one of a number of centers looking for a way to shift the survival curve in GBM to the right.)

3.  Greene, Brian. Until the End of Time: Mind, Matter, and Our Search for Meaning in an Evolving Universe. Alfred A. Knopf. New York, 2020. (Not just physics and math, but a far-ranging erudite exploration of what it means to be human and concluding that "in our quest to fathom the human condition, the only direction to look is inward." p. 326)

4.  Davis, Geetha. "The Evolution of Cataract Surgery." Missouri Medicine 113(1): 58-62 2016.

By Anita Cherry 12/16/22

 volume21, Article number: 424 (2021) 

Dr. Paula Jacobus: A geriatrician who thinks for herself

Dr. Jacobus 

She was the oldest of five children and she had crooked teeth. Her siblings also had crooked teeth. And after visits to the orthodontist, twenty-five miles each way, her teeth were much better, though still not perfectly straight. But the before-and-after plaster dental castings were on display for all to see. The young girl, Paula Jacobus, was affected by her experience. And she enjoyed the treat of her father taking everyone out for lunch afterward. So she thought of becoming an orthodontist; she believed that she “would be good at it.” But this was the 1960s in a small town in rural western Pennsylvania; not so fast…

When she informed her high school guidance counselor that she “wanted to be a dentist” she was quickly advised that she could, as a girl, be a dental hygienist instead. She did not want to settle for that. But Paula lived in Kane, Pennsylvania, with a population of five thousand and there were no advanced placement, or AP, classes; she had to “fight” to take physics, humanities, and higher math to get into a good college.

Paula is now Dr. Paula A. Jacobus, a fellowship-trained geriatrics specialist.

Her college-educated mother (1930-2013) taught high-school English, and her father (1927-2000) was “a good car salesman” and businessman whose own college studies were cut short when he was drafted during World War II. They were both concerned when Paula, their firstborn, was two and still not talking. They were afraid that she was slow. Afraid that she would be below average. 

They realized that the Catholic school classes were much too large for a single nun to provide individualized teaching, so Paula (and her siblings) went to the public school a block from home. It turns out that Paula was not slow, of course, just careful. And of the 160 students who graduated high school with her, Paula was one of only ten who went on to further education.

Postcard rendition of the Kane business section
at some time between 1930 and 1945
(from Wikimedia Commons)

 (Paula wasn't the only one in the family drawn to a career in medicine. Her sister Susan is an oncology nurse in Ventnor, N.J. and her sister Judith practiced medicine for 20 years before deciding to become a Catholic nun; she lives in, get this, St. Malo, France. Judith is her "Sister sister.")

Before we get to her unusual college experience, let’s see how the future geriatrics expert was drawn to the elderly. As a child, she spent a lot of time with her Italian grandmother. “Nonna was a wonderful cook,” said Paula, but she could not read (any language). So when she lovingly “read” a picture book to the kids she made up a story. And she left out the violent parts; the cat, for example, did not catch and eat the mouse.  

And Paula’s first job as a teenager, at 15, was to stay with an elderly woman who simply needed someone to help her get up at night. At 16, she served as the chauffeur for her 96-year-old neighbor, two doors away, who had purchased her cars from Paula’s father’s auto business. She had her own room in the woman’s home, a definite luxury for a girl with four younger siblings. Paula said, simply, that she “always liked older people.”

Okay, back to her formal education.

College

When it was time to apply for college, small-town Paula didn’t actually have a lofty or special place in mind.  And, as we have seen, the unhelpful school counselor didn’t provide meaningful guidance. 

So, how did she get to the very highly-regarded St. John’s College in Annapolis? “Purely by chance,” she said. She was in a humanities class and doing a report on education. Her father had a business trip to the area, and as she looked into the school’s curriculum she thought that it sounded “pretty weird.”  So she went on the trip with him. 

The "Old Library" at St. John's (from Wikimedia Commons)

She was intrigued by their educational approach. “It was the most amazing thing,” said Paula, because (unlike in her high school)  “everybody was there to learn.” And (this is surely unique) each student took exactly the same courses! As the daughter of an English teacher, she couldn’t resist.

You “start with Homer,” she said, “and over the four years, you read the classics,” the primary sources, in literature, philosophy, history, and the sciences. And discussed them, and picked them apart in small seminar settings. You also took two years of Greek and two years of French and some math. While at St. John’s you were forced to develop the skill and the habit of critical thinking, of thinking for yourself, she said.  

According to their website: “St. John’s students learn to speak articulately, read attentively, reason effectively, and think creatively.”  They "practice radical inquiry" and are urged to "establish habits of civic responsibility."

The noted humanist physician-turned-ethicist and teacher Dr. Leon Kass was one of Paula's important tutors. He was a “really really good seminar leader” and he took her (as a freshman) to the Kennedy Institute of Bioethics to “hang out.” Paula said, reflecting, that this “might have been a pretty significant influence” on why she ended up in medicine. She has read “most of his books.” She enjoyed the intense experience at St. John’s and graduated in 1978.

The 1978 graduating class at St. John's, Annapolis (from their website)
(If you can't immediately spot Paula, she's seated in the second row on the right.)

Transition to Medicine

After this broad liberal education, Paula knew that she still wanted a career in one of the medical fields. The only two doctor role models in Kane were husband and wife, Charles and Elizabeth Cleland. Elizabeth (affectionately known to the Jacobus family as “Dr. Betty”) had to give up her pediatrics residency when she got married (not pregnant, mind you, just married). Nevertheless, she was the one who took care of the kids in the small town as her husband tended to “the sicker adults.” Though Paula couldn’t (she was told) be a dentist, she could (it was clear to her) become a doctor. 

So she went to Bryn Mawr College for a year to take the required premed science courses she couldn’t get at St. John's. And in 1980, after a year off, she began her studies at the University of Pennsylvania Medical School (the country's first medical school). 

Things were pretty difficult at first, she said, as they crammed all of the basic science stuff into the first ten months and Paula had arrived with only “the bare minimum” preparation. However, in her clinical years, she quickly caught up with her more single-minded classmates. 

Penn's medical campus 1829-1871 at 9th and Market in Philadelphia
(from archives.upenn.edu)

While she was In medical school planning her future, she thought about doing something familiar, family medicine. But that new “specialty” was frowned upon at Penn. So she dropped that and considered going into either internal medicine or pediatrics. During her three-month Peds rotation at the York Hospital (affiliated with Penn, then), “three or four kids died.” She was shaken by that and concluded that pediatrics was “not the way to go.” 

Following Medical School

After medical school, Dr. Jacobus chose to come back to York for a three-year residency in internal medicine. She followed this with a fourth postgraduate year of her own design where she was especially influenced by (the also well-read) Dr. J. Wolfe Blotzer, the program director. Her make-shift “office” was adjacent to his, and they often sat and talked about what was on their minds. 

She had learned a lot during a three-month rheumatology rotation with Wolfe and even considered going into that specialty for a while before choosing to focus on the care of older individuals. (She lamented the fact that the intimate mentor-mentee relationship she was privileged to enjoy as a resident is no longer the way things are done.)

While at Penn, she was taught by Dr. Laurence Beck, a nephrologist who went on to do and teach geriatrics, so, when the time came, she wanted to go back to Philadelphia to train with him. She did that, but when she soon heard that “Larry was leaving” she applied to the highly-regarded UCLA fellowship for the following year. But it turned out that they had an unexpected opening and she was accepted for that current year. 

Dr. Reuben

Paula moved to California and was not disappointed, as UCLA “was a great program.” She rotated through “a lot of different places” including a rehabilitation center and "The Jewish Homes for the Ageing" where she witnessed “good quality nursing care.” She had “top-notch teachers” including Dr. David Reuben and Lisa Rubenstein.  She told me that it was "purely by chance" that she "got a way better education" at UCLA than she would have (in the much smaller program) in Philadelphia.

 Return to York

Dr. Jacobus returned to York with the idea of joining another physician in a new geriatrics program, but by then he had already changed his mind and gone into administration. So the staff waited anxiously for Paula for six months. Upon arrival, she had to go it alone and it was difficult. There were vexing personnel issues and she went through six different administrators in five years. 

Marta Smith, MPH, (with whom she is still close) was the sixth; they got along and “moved things forward,” but “not to where they should have been.” Dr. Jcobus realizes now that she “didn’t have the skill set to run a geriatrics assessment program” and that “it wasn’t meant to be.” 

So, as she was “pretty burned out” after six or seven trying years, she decided to stop doing just geriatrics. She had nothing specific in mind when she decided to talk to nephrologist-turned-general internist Cyrus Beekey for his advice. Cy, it turns out, was looking for a partner. Paula stepped in and worked with him in private practice “for quite a few years.” 

But, after a while, it became clear that “private practice (of internal medicine) was dying” (was being slowly choked off). Dr. Beeky saw this and joined the expanding WellSpan Health system.  Paula resisted and stayed independent as she continued to do general internal medicine along with some geriatric work in nursing homes. She was happy.    

But she had “health problems” along the way, including breast cancer at 43 and the development of diabetes requiring insulin. She didn’t let these setbacks slow her down and she only missed a single scheduled on-call stint. But years into her busy practice she began to worry about how her patients would fare if “something happened” to her and she wasn’t able to continue to take care of them. So Dr. Jacobus thoughtfully arranged for another well-trained physician, Dr. Heui Yoo, to take over her practice as she planned her “semiretirement.”

Retirement on Hold

In fact, she might have retired altogether (“Life is short; do what you want to do,” noted Paula.) were it not for (another) unexpected turn. Within days of setting things up to allow herself to wind down, Dr. Jacobus got a “cold call” from the large Lehigh Valley Health Network in Allentown about 90 miles from York. They were looking for another geriatrics specialist.

It turns out that she had interviewed with them in 1996 when they were searching for someone to head their geriatrics program. At that time, she would have taken over for a blind doctor “who was a wonderful physician,” she said. But another administrative job was not for her. (The sightless doctor was Dr. Francis Salerno, the same doctor who “saw,” as they trained together in Reading in the 1970s, that my husband would become a neurologist.) 

This new offer from Lehigh was appealing and suited to her skills and she applied. It took a while “to get on board,” but she eventually started there in March 2015. “It’s been a great place to work,” she said. She initially did half-days at the small Luther Crest Nursing Facility and half-days at the comprehensive Fleming Memory Center for individuals with (or concerned about) dementia. 

Lehigh Valley Hospital (from LVHN)

She has dropped back to part-time for the past three years, spending three days a week at the clinic. The work is “very easy” compared to what she used to do, and she has time for other pursuits (mentioned below).

As a Patient

She is not pleased, however, as she has seen the breakdown of the primary care model of coordination of medical services she experienced during her formative training years. She receives her own care through her employer’s system, and she said that she’s already had three different primary care internists in less than seven years. 

Her endocrinologist, for her well-controlled diabetes, has been stable and reliable, sure.  But when she needed a dermatologist for terribly itchy (undiagnosed) psoriasis she “couldn’t get past the front desk.” And even as a physician within the system itself, she was stymied when she needed to see a specialist or even when trying to see her regular internist for a week of gnawing belly pain that was due to a ruptured appendix.

And exactly a year ago, on her sixty-fifth birthday, 21 years after her initial shocking diagnosis of breast cancer, she woke up, rolled over in bed, and felt a hard lump in her breast. She knew that she had to have a diagnostic mammogram, but setting this up was needlessly difficult and she was “scared to death” for nearly three weeks until she got a study and it was determined that the lump was just scar tissue. 

These frustrating experiences were quite unlike what transpired when she was diagnosed with breast cancer more than twenty years ago. She had called Dr. Eamonn Boyle’s oncology office to make an appointment “for a new patient.” When they asked who the patient was and Paula told them it was she, herself, they said, “Five o’clock.” (As Dr. Jacobus recalled this story about her cancer, and that doctors used to take care of each other, her voice cracked and she cried softly.) 

Alzheimer’s Disease

Seeing that obtaining timely health care has become a problem even for physicians, I wondered whether improved treatment of Alzheimer’s dementia, the disorder she mostly sees now, makes up for that lack. Unfortunately, it doesn’t. Dr. Jacobus said that donepezil (Aricept) and the two other similar medicines for Alzheimer’s “might (at best) slow the progression by six months for 10-20% of the patients.”  She will prescribe them if requested, but she doesn’t “push” them, since she doesn’t see any “appreciable degree” of improvement. The same can be said for another medication for Alzheimer’s, memantine (Namenda). 

When Biogen’s anti-beta amyloid monoclonal antibody Aduhelm, designed to remove clumped deposits of the amyloid protein that are one of the hallmarks of the disorder (tau "tangles" being the other), was given approval earlier this year over the objections of the independent reviewers the phones at the memory center were “ringing off the hook.” 

But the enthusiasm for this treatment to slow or stop the dreaded disease process itself, not just treat the symptoms, faded quickly. As a result of the weak and inconclusive clinical data despite the evidence that amyloid was removed, and the seriously suspect accelerated approval process, this very costly medication with potentially serious side effects is currently available only in the setting of a controlled study. 

Enrolling patients has been painfully slow and might end altogether as the industry funding dries up and other promising treatments are pursued instead. And, importantly, not all researchers believe that trying to remove the amyloid plaques is the right approach, as the phosphorylated tau tangles disrupting nutrient transport within cells may be more critical.

PET scans showed that deposits of amyloid (in red)
were removed (from www.sciencenews.org)

PET Scans and the Diagnosis of Alzheimer’s 

What about making a diagnosis, one of the important tasks of the geriatric specialists at her center? Until relatively recently, Alzheimer’s was a so-called purely clinical diagnosis, made after other causes of dementia have been excluded. There was no definitive imaging or blood or spinal fluid test for the condition, and it was only diagnosable with absolute certainty at autopsy. 

Being able to see the accumulating amyloid beta deposits during life with special PET scans has aided research studies (as those for Aduhelm, noted above). But using any type of PET scan (there are several, each showing different things, but all are very expensive) for individual patients with dementia (or a suspected dementing process) isn’t precise, and may be misleading. Positive scans make the diagnosis of Alzheimer’s more likely and negative scans while reassuring, don't rule it (or other causes of dementia) out. Misdiagnosis is still not uncommon.

So Dr. Jacobus is currently “starting a quality improvement project about PET scans” at her facility. She said that of the five practitioners in the office, two don’t order them for patients: she and Heidi Singer, CRNP, (who was trained by Dr. Salerno). The other three do.  Patients and practitioners, she noted, both need to be aware of the limitations of imaging. 

But (and here’s an important point) “even if we can prove today that (our patients)  have Alzheimer’s, we’re not going to do anything to majorly impact that,” Paula said.  (As a resident at the York Hospital many years ago, in another lifetime, she was taught that “you don’t order a test if you are not going to do something about the results.”)

For an accurate diagnosis, it may be preferable, she noted, to carefully examine patients over time to see if their memory deficits or other cognitive or behavioral problems worsen, consistent with dementia, either Alzheimer’s or something else.

But sometimes patients and families want certainty, they want to know for sure what they are up against, and push for (what they hope will be) a definitive test. They feel the need to be their own advocates within the large complex regional health systems, a role that Dr. Jacobus, as a patient herself, understands.

In any case, in the absence of an effective treatment for the very slowly developing brain disorder (it likely starts decades before symptoms are detected), a major focus at the busy but understaffed center in Allentown is on education (as was repeatedly emphasized during her training years under Dr. Blotzer). And this group effort is carefully tailored to the specific needs of each particular family (As, in Tolstoy's Anna Karenina, “every unhappy family is unhappy in its own way”).  

More Technical Neurology Stuff  (with the neurologist's long-winded input, of course)

Scientists have not determined exactly what leads to the gradual accumulation of the toxic misfolded amyloid-beta and hyperphosphorylated tau proteins that damage the delicate synaptic connections between neurons and result in the death of the neurons themselves. They do know that the spread from the initial sites in the brain areas for forming memories (the hippocampi) proceeds along the connecting neural pathways.

Mathematical model of the spread of misfolded tau
through the so-called connectome
(from royalsociatypublishing.org)

Early-onset disease, seen in much less than 5% of patients, is caused by mutations in amyloid precursor protein and presenilin genes; the much more common late-onset disease is related to a multitude of interrelated factors, both genetic and environmental (as for most chronic disorders).

Research has shown that lipid metabolism plays a very important role in Alzheimer’s. Apolipoprotein E (apoE), through interactions with cell membranes, regulates the clearance of damaging extruded amyloid beta fibrils before they clump up. Carriers of one of the three forms of this protein, apoE4, have the early accumulation of amyloid beta deposits, substantially increasing the risk of developing Alzheimer's down the road. Carriers of apoE2 have a lower risk while the apoE3 is neutral.

The gene variant coding for apoE4 is found in about half of those with Alzheimer's; people with two copies have about a 60% likelihood of developing Alzheimer’s by age 85 compared to 10-15% of those without the gene variant.  And so, there are other important factors in play. 

Prevalence of Alzheimer's by age (in 2005)
(from ResearchGate)

It turns out that age itself, living a long life, poses the greatest risk of late-onset Alzheimer’s (as it does, for example, for hypertension, cardiovascular diseases, cancer, osteoarthritis, Parkinson's, type 2 diabetes, and cataracts). Up to 50% of those older than 85 may be affected by Alzheimer's dementia. The next most significant risk is having a parent with the disorder, especially a mother (who supplies us with our mitochondrial DNA). But the genetics is way more complicated since more than 800 genes may modify the metabolism of the amyloid precursor protein. 

The misfolded tau protein story is only beginning to be understood.

We are stuck with our genes (so far) but genes are turned on and off (through epigenetics) and there are modifiable risk factors for the feared condition. There is a significantly heightened likelihood of Alzheimer’s dementia in people with vascular disease, hypertension, and (especially) insulin resistance and overt diabetes. Mid-life central obesity, repeated head injuries, heavy alcohol use, cigarette smoking, lower educational level, social isolation, untreated depression, inactivity, poor diet, and hearing loss all increase the chance of developing dementia.   

In fact, it is felt that anything that influences the health of an individual through life and the rate of aging is a potential factor.

Buffers against developing substantial late-life cognitive impairment include adequate treatment of hypertension and dyslipidemia, a habit of regular exercise (the link is surprisingly strong), lifelong cognitive pursuits (learning something new; doing something new), getting enough sleep (allowing removal of toxic debris), mindfulness meditation (shown to lengthen the protective telomeres at the tips of our chromosomes ), and regular social engagement (our brains are shaped by other brains). 

And if you have more interconnections and more synapses to begin with you can lose a good bit and still function well. And, contrary to formerly accepted dogma, we have stem cells in the brain (and especially in the hippocampus) that can generate new neurons and supporting cells when stimulated to do so. 

Image of brain interconnections
(from the Human Connectome Project)

We can improve the chance of our brain aging well if we make the right choices early enough in life.

The Future?   

I asked about her thoughts on the future of medicine. Paula is particularly worried about the quality of care in rural areas. For example, her nephew in Kane was (accidentally?) shot recently by his girlfriend. He is now a T4 paraplegic and when he had “horrible” diarrhea the other week the diagnosis of C. diff (that was obvious to Dr. Jacobus when she heard the story) was missed in the ER as he was initially told he had prostatitis. And years ago, when her mother had a brain tumor, a benign meningioma, she had to make three trips to the local ER before her symptoms were taken seriously enough to result in a brain scan. 

What about telemedicine (for these remote underserved areas)?” I asked. “I don’t think that’s the way to go (for most things),” said Paula.

Looking at the other side of the medical encounter, another one of her nephews has just started an emergency medicine residency in Cincinnati. She is uneasy as she sees the shortened rotations and the lack of hands-on learning at her current institution. And she is uneasy as newer trainees seem to rely less on their clinical skills while they rush from patient to patient and “do a lot more tests.” This (over-) testing greatly increases the societal cost of healthcare, likely to the point soon, Paula believes, where it will simply be no longer affordable. 

As it is, we spend a lot more on healthcare per person than any other wealthy country. And the future burden to society to care for the rising number of people with Alzheimer's as our population ages is expected to be enormous.

She feels that doctors need to be mindful of this and aware that spending more time with patients can result in less need for costly studies and more efficient medicine.  (I found online that Dr. Jacobus has a master’s degree in public health, an MPH, from Loma Linda University in California; she failed to mention that credential during our interview.)

Paula feels fortunate that she can still take as much time as she needs in the office since many of her elderly patients are confused and lots of things have to be sorted out. For example, their long medication lists (one of her patients brought in 67 bottles, she said) need to be simplified. In fact, Dr. Jacobus tries to limit her patients to five essential medicines. And when they come back for a follow-up, having stopped potentially harmful unnecessary pills, ”they are (often) better.” This “deprescribing” is an important new tool for geriatricians. 

And as for general advice, she strongly encourages her patients, of course, to remain mentally and socially active and to exercise whenever possible. 

Outside Interests

What does Paula like to do when she not doing medicine? She enjoys quilting and belongs to several guilds devoted to that craft. She just finished a classic “attic windows signature quilt” to present to her boss (who is retiring). She made 32 “bright and colorful” quilts for Jessica and Friends, a local faith-based program for adults with autism and other intellectual disabilities. And she has made quilts for Camp Erin for bereaved children. (Her first purchase with her “own money” was, in fact, a sewing machine!)

She loves to travel and the experience of being in a different culture. She has been on every continent except Antarctica, sometimes with a group from Penn State York, and sometimes with her friend Marta. Paula has been to the 400-year-old Oberammergau Passion Play in Germany four times (it is performed once every ten years according to a promise made in 1633 when the town was spared the ravages of the Plague). She doesn’t know where she wants to go next. 

Paula and her new Berber friend in the sand dunes
of Erg Chebbi, Morocco, on 3/10/20
 (the day before the pandemic was officially called)

She has thought about doing international medical missions where she might help out for six months “or even a year” as long as she was in good health. Especially if she could go someplace where she could use her Spanish. But Paula also noted that there are underserved areas “even in the U.S.” where she would be needed. And, who knows? Something unexpected might come along to catch her interest. But for now, she still sees patients in Allentown Monday to Wednesday and is content with that. 

So...

When you are a young child with crowded misaligned teeth you need to find a competent orthodontist to straighten things. When you are a somewhat forgetful older adult with missing teeth or no teeth at all you need to find a well-read compassionate geriatrician to help guide the way. Preferably one who’s been a patient herself.

Suggested Readings:

1. "Alzheimer's Disease." from Wikipedia. (accessed 9/2/22) (A very good and complete resource with lots of science.)   

2. Cohen, Gene D, M.D., Ph.D. The Mature Mind: The Positive Power of the Aging Brain. Basic Books. New York, 2005. (A reassuring and easy read by the first chief of the Center on Aging at the National Institute of Mental Health, a psychiatrist.)

3. Pachana, Nancy A. Ageing: A Very Short Introduction. Oxford University Press, Oxford, United Kindom, 2016. (A nice overview by a psychologist.)

A braided Challah 

By Anita Cherry 09/10/22

Dr. Asuquo Inyang: "And that's how I became an anesthesiologist."

Dr. Inyang

The young boy often walked two miles from the family compound to fetch water. He thought of the outing as fun, since he could get a quick swim. One day, as the Nigerian third-grader was on his way home he heard gunshots.  He wasn’t aware of the brewing turmoil in his divided country and he wasn’t alarmed. So after he got back, he and his older brother innocently sneaked a bit of roast goat and chicken in the small family smokehouse. 

When they heard his father suddenly call out, “Everybody into the car!”  the two boys hurried to wash up. But their father’s life was in serious danger, the car was already crammed with other family members, and their dad had to drive off without his sons.  

The boys, running to catch up to the car, cried out, ”Papa! Papa!” When they were able to get close enough, their father urged them to hurry to the next town three miles away. They could meet up there, he said. As more shots were heard coming from the direction of his backyard, frightened and confused Asuquo ran and ran. 

You see, he was trapped between warring ethnic and religious factions at the start of the 1967-1970 Nigerian civil war. The young boy who would become Dr. Asuquo Inyang quickly realized that he had to be resourceful and adaptable to survive.

On a cold day in York at the end of winter 2022, Dr. Inyang sat with me and my husband in our home and recalled his early childhood and his roundabout path from the subtropical delta region of Nigeria on the Atlantic coast of West Africa to temperate Southcentral Pennsylvania to practice anesthesiology.

The Republic of Biafra including the resource-rich
Niger River Delta region (from Wikipedia)

The idea of becoming a doctor came early to Asuquo. Though his mother “always had a smile on her face,” she “was (also) always getting sick.” She was in and out of the hospital, and “nobody knew exactly what was wrong with her,” he said. So when he was about four and felt her suffering he reassured her that he would one day find a way to relieve her pain.

Looking back now, Asuquo believes that his mother struggled with depression and anxiety and that she had severe panic attacks. But his native language, Ibibio, had no word for depression; if you were withdrawn, they just said you were lazy. His mother was “sick for a long time.” The stress of this led to divorce and his father remarried. 

So, as it turned out, as his father sped away from their compound, he left Asuquo and his older brother (by eight years) behind for the three years of the war. 

The Civil War

Dr. Inyang explained that the conflict began with a military coup d’état by members of the (mostly southern and eastern) Igbo tribe in response to persecution by the (mostly northern) federal government. This was followed six months later by a counter-coup and a bloody anti-Igbo pogrom in which as many as thirty thousand men, women, and children were killed. Asuquo recalled the horror of seeing headless bodies. The southeasterners were mostly Christians educated in the liberal English tradition; the north was dominated by fundamentalist-leaning Islamists. The beleaguered Igbo (the “g” is silent) decided to secede from Nigeria to form the independent Republic of Biafra.

The two Inyang brothers, though from Uyo in Akwa Ibom State in the targeted southeast region, were not members of either of the specific warring tribes. Asuquo recalled that as they avoided being caught in the deadly crossfire they sometimes had to hide deep in the woods, in the extensive mangrove forests. 

Nigerian mangrove (from environigeria.com)

Asuquo is "haunted" by these memories. But he can also bring to mind a quieter life before the war. He remembers the weekends by the Atlantic with long dining tables filled with freshly-caught fish, crabs, and shrimp.  He remembers his mother taking him to the hospital by boat and seeing the tall ships.  He remembers worrying about his grades in kindergarten in Enugu when he got everything right and was upset and cried when the teacher simply wrote “good” on his chalkboard. And he remembers learning to read at five, before attending school, thanks to his two older sisters.

His father worked as an auditor for the government while his mother raised the four kids. Since Asukuo was the baby in the family he was treated differently than his siblings and was “pampered and spoiled.”  

But the pampering could not protect him from the war. He raced away from the family compound that day in fear while his brother stayed behind. As he searched for safety, he ran across a sympathetic countryman who warned him that his village was surrounded and that he had to turn back. He did, and found that his home “was like a ghost town.”

Nigerian federal troops moving against Biafran forces in 1967
(from the Associated Press)

Asuquo eventually located his brother and the two sought refuge at their “auntie’s house.” He had not eaten anything since the day before and he was terribly hungry. His brother got something from the kitchen, but he couldn’t find the salt. And the young boy, hungry as he was, “couldn’t eat without salt.”

But why did Asuquo’s father abandon his two boys? Because he worked in civil defense he usually wore army fatigues. Spotting that uniform, the nationalist Nigerians assumed he was a rebel Biafran separatist. So, his father was a wanted man.  And when the armed government fighters reached the family’s compound, thinking he must be hidden there, they began shooting. 

Dr. Inyang said that “every square inch (of the house) was riddled with bullets.” Somehow, Asukuo and his brother were able to avoid getting hit. From then on, he “couldn’t live anywhere” and couldn’t “associate with people.” The spoiled, pampered, nine-year-old had to rely on himself to survive.

Dr. Inyang told me that one time soldiers were chasing after him and his brother and cousin. They managed to get to their grandmother’s empty house but there was nowhere safe to hide, nowhere to be certain they were out of sight of the invaders. He “thought it was the end” and he waited for the inevitable. But wait, there was light coming from their grandmother’s bedroom! As the blood-thirsty men suddenly rushed towards that Asuquo knew that it was his one chance to escape. And he did. He ran and ran and ran. He ran as if, he said, he was “floating in the air.” 

During the war, the national Nigerian government, with the help of the British, blockaded Biafra. Food supplies were eventually depleted, and nearly two million people, half of them children, starved to death.  Those of us of a certain age remember seeing the news photos of the swelled bellies of the otherwise emaciated innocent young victims of deep hatred, of an attempted genocide, who succumbed to malnutrition with marasmus and kwashiorkor.

Casualties of the Nigerian Civil War
 (from Kent Gavin; Getty Images)

The weary Biafrans eventually gave up and the war ended on January 14, 1970. Asuquo’s immediate family survived but he lost cousins fighting for Nigeria, and cousins battling for Biafra. (In time, his father had joined the Biafran army. He still had enemies after the war, so he had to wait a while to return home.) 

The Beginning of His (Formal) Education

And upon his return, his father had a special book for his younger son, for his son’s next chapter. Asuquo’s father wanted him to pass the entrance exam to get into (at the time) the best high school in Nigeria, the school he, himself, had attended. His father knew that education was the way out and that, due to the war, his son had not been able to go to school for several years and needed to catch up. Asuquo listened; as he sat on the balcony of his stepmother’s small house he went over every question and answer five or six times. 

The Hope Waddell Training Institution, founded by Scottish Presbyterian missionaries in 1895, was the school that Nigerian kids dearly wanted to attend. But of the “thousands” of hopefuls each year, only 120 were admitted. Asuquo managed to be one of the lucky ones. While there, he studied science, engineering, and art. But everyone at the school knew that he wanted to be a surgeon and when somebody got hurt they called him.

Hope Waddell Training Institution
 (from heritageschoolsnigeria.com)

The next step after Hope Waddell was the university for medical studies and he took another competitive exam for that. The report of the test results was delayed because of suspicion of cheating. There was, it turned out, no evidence of fraud, but by the time the final results were posted the available university slots were filled. Asuquo had to retake the exam. 

He knew he did well, again, but when the report was published in the local newspaper his name was missing. His father, knowing his son’s talent and hours of hard work, went to see what happened. Their lame answer was: “There must have been a mistake, he scored the highest!” But, once again, by then, it was too late.

So Asuquo went to the College of Technology in Calabar. He led the class and once more took the medical school entrance exam and passed. He was relieved. He needed a break from book studies and took an extended ecology tour. When he returned home he found the “happy to inform you” letter that is anxiously awaited by physicians-to-be. But the date for the finalizing interview for his spot had passed! Asuquo showed up at the dean’s office anyway, but his pleading request for the required face-to-face meeting was quickly denied. 

He returned to Calabar, studied, and obtained the British so-called A-Level certificates (from Cambridge). With those, he could then go anywhere.  

His father convinced him to attend the beautiful University of Ife for his preliminary medical studies. Since he already had A-levels in most subjects (except math) and they were teaching basic O-level work he decided (unwisely) to skip classes and play basketball. He was quickly bored and worried that he was wasting his father’s money, so he returned home again.

The striking Israeli-designed University of Ife
(Credit: wallpaper.com)

Medical School and Beyond

But his father knew people, and Asuquo was granted admission to the College of Medicine at the prestigious University of Ibadan, the first university in Nigeria and part of the University of London. At last, he was on his way. (Whew!)

After going through the above, the prelude to his chosen path, Asuquo didn’t have much to say to me about his medical school experience other than that he wanted to show others that he was up to the task. And he did that. 

Main gate at the University of Ibadan
(from Abayomi Fawehinmi)

He graduated in 1983 and after his year of a general internship, he had to do a year of national service. For this, he spent three months in a rural setting before his secondary assignment at the University of Lagos as one of three campus doctors. Though he had limited time to socialize, this is when he met the woman who would later become his wife. 

After Medical School

After this, Asuquo and his best friend, Temitope Alonge, were the only two from their class to do postgraduate work in surgery. They did this through the Nigerian Overseas Doctors Training Scheme. 

It was widely felt that the British system provided the best clinical training. So after his companion went to England to master orthopedic surgery at the Postgraduate Medical College in Yarmouth, a seaside town twenty miles east of Norwich, Asuquo joined him. Their strong bond was unusual as they were “not members of the same tribe and didn’t speak the same (native) language,” said Dr. Inyang.   

Great Yarmouth (from BBC)

The two eager trainees had few possessions and little money, so they relied on each other and shared. For example, Asuquo had a stove and his friend had a refrigerator, and they carefully coordinated their meals and ate together. (Dr. Alonge is now the Chief Medical Director of the University College Hospital, Ibadan.)

Asuquo's wife

After his wife joined Asuquo in Great Britain there was great sadness as they lost their first child, a daughter, in 1991. She was “three years and four months” old and was having “some difficulties.” She was rushed by ambulance to the hospital, but she aspirated and could not be resuscitated. Asuquo was busy at the other end of the facility at the time. He was terribly shaken by his daughter’s death and could not talk about what happened for ten years. He still can’t look at photos of her. (There was even more sorrow later as they lost a son after a full-term stillbirth.)

After five years of general surgical training followed by intense work in cardiothoracic surgery abroad, Asuquo’s plan was to return home to Nigeria for practice. He had all of the proper credentials and was ready to go, especially after he was offered the position of Chief of Cardiac Surgery at the University of Lagos.

A (Very) Brief Return to Nigeria

But things were not good when he returned to Nigeria in 1994 to start his career. He discovered that “people were disappearing for no reason.” It turns out that there was another political crisis that, according to a New York Times report at the time, “deepened ethnic and regional cleavages in ways that all sides say could threaten Nigeria’s existence as a state.” 

There had been an unprecedentedly free and fair presidential election on June 12, 1993. However, the then-current military president (representing the conservative north) refused to release the voting results showing that the opposition leader (a moderateYoruba from the south) had easily won. He claimed that the voting was rigged. Workers in the rich southern oil fields protested and went on strike. World oil prices rose sharply and there was social and economic chaos. (Sound familiar?)

Celebrating "the real" Nigerian Democracy Day
(from Legit.ng)

The reminders of the frightening civil war through which Asuquo had miraculously survived were difficult for him and his young family to ignore. And as the economy had suddenly collapsed they were now so poor they could not afford to feed their children. So after only two weeks, he knew he had to leave and he boarded “the next plane back to England.”        

Back in England

Politically stable England would be good, he thought. But it turns out that the gentlemanly medical system was not always kind to outsiders. He was able to get a registrar position (above a house officer but below a consultant) in cardiothoracic surgery and worked under the unit chief whom he had previously trained. His goal of becoming an attending surgeon sometimes seemed nearly unobtainable, Asuquo said, because he “wasn’t British.”   

So he toiled as a senior registrar (sort of like a chief resident) in cardiac surgery in Leeds for eight years. His mentor in Leeds was the dapper and remarkably self-controlled Unnikrishnan R. Nair. The mentee, Asuquo, paid attention, mastered the difficult craft, and waited patiently for his turn to be promoted to a consultant-level position. After a good while, he was finally scheduled for the all-important interview. 

He and his wife were realistic about the slim odds of getting a permanent job, and they decided that he needed to have another option. He could, instead, come to the States, where there were more opportunities. So he signed up for another test, the three-stage US Medical Licensing Examination, the USMLE. 

Wouldn’t you know, at the last minute, the day for the critical interview in Leeds was changed. It was to be on the same day as the USMLE in Liverpool,  seventy miles away.  What to do? Dr. Inyang’s practical wife advised him to take the exam, the surer bet. Yet, he thought he could do the test and still make it home in time for the six-o’clock interview. 

So he finished the exam, “jumped” into his car, and headed northeast on the M62. But (you may have suspected this by now) there was a problem. A traffic tie-up slowed his trip and he didn’t arrive home until eight. It was too late. He told me (with some irony), that “they gave the job to a Pakistani guy.” 

Stopped traffic on the notorious M62
 (from hulldailymail.co.uk)

Asuquo was frustrated and decided then that he wasn’t going to stay in England. His faithful wife agreed, and said, “That’s what God wants. You never know. Let’s pray.”

"That’s how I ended up coming to the United States,” said Dr. Inyang.

On to the States

So he “applied to a hundred places” across the US  and waited. Looking around, he stumbled on a new program in New York at North General Hospital with Mount Sinai that needed trained people. So he contacted them. They were happy with his West African and Royal College of Surgeons qualifications as a heart surgeon and said that he could sit for the American boards after just two years of training in New York. This promise was “attractive” and he agreed to take the job.

But when he showed up at (the financially troubled) hospital Asuquo was informed that he actually needed to do the full residency program, with several years in general surgery before doing cardiac surgery.  By that time, he was stuck and had to accept the challenge.

He was on track, but the new program closed after only two years and Asuquo was in limbo once again; he was here on a work permit and suddenly had no work. He had to provide for his wife and two kids, so he “looked for any job anywhere.”

The Switch to Anesthesia

As he scrambled to find work and was getting nowhere, he finally got a break. You see, he was friendy with a woman in his program who had been offered two anesthesia residencies, one at Montefiore and another at Mount Sinai.  She chose Sinai, and she was with Asuquo when she called Montefiore to tell them she wasn’t going to accept their offer. Dr. Inyang was on it; he contacted Montefiore “as soon as she dropped the phone” and innocently said, “I hear you guys have an opening...”

Montefiore Medical Center (from Montefiore Health System)

He was granted a meeting for the next day. As he sat there anxiously and waited for the chance to present himself a man walked by a few times while looking at some papers. “Are you the guy for the interview?” he was asked. Asuquo replied, “Yes.” The man said he was in a hurry and had to catch a plane for a conference, so: “Do you want this job, or what?” The answer: “Yes, I want it.” And with that, he was hired.

“That’s how I ended up in anesthesia!” proclaimed Dr. Asuquo Inyang with a full Nigerian laugh (one of many during our meeting). Even so, he was still hoping that there would eventually be an opening somewhere, a place where he could return to doing heart surgery, his real passion,

He told me, by the way, that the reason his program closed down was due to the political fallout from Newt Gingrich’s 1994 conservative, Reagan-inspired,  “Contract with America.” This was an outline to shrink government (which it didn’t) and cut back a number of liberal government programs (which it did). 

You see, revealed Dr. Inyang, it was felt that the foreign doctors were “making life difficult for surgery.” So in 1997, the Balanced Budget Act act put a cap on the number of annual residencies the CMS (the Center for Medicare and Medicaid Services, the major funding source for medical training) would support. It froze the funding at 1996 levels. International medical graduates were disproportionately affected.

Anyway, though he really “didn’t like anesthesia,” Asuquo was relieved to have a job. In fact, even now, after years of putting people to sleep and waking them up safely and unharmed, he doesn’t think of himself as an anesthesiologist per se. Instead, he is a “surgeon doing anesthesia.” 

And since he had already done two years of surgery training here he could complete a full anesthesia program in just three more years. During the second, they offered him a job as an attending. He told me that he hadn’t thought of doing that, as he still had faith that he could find a surgical slot. So he needed to run this by his wife. The increase in pay was substantial, the growing family had more expenses, and, to be fair, it was an offer he simply couldn’t turn down. As his wife gently reminded him, it was time for Asukuo to no longer be a student.

(I realize that we have covered a lot of ground so far, and it's difficult to take it all in. You may need a short breather before hearing the rest of the story. That's okay. Just remember to come back.)

To continue, Asuquo stayed at Montefiore in the Bronx for ten years, where he “hustled” and worked at three hospitals. In his salaried position, he did mostly complex cardiac work.  At the other hospitals, to make extra money, he did trauma and routine general anesthesia.

View of The Bronx with Yankee Stadium
(from hotels.com)

Dr. Inyang likes to be busy and felt that he was the “hardest worker” in the department. So when the chairman deprived him of extra compensation, as he would not get a “penny in bonus” one year because (they said) he was making money elsewhere, he quickly handed in his resignation. It was early 2007.

After Montefiore

After that, he worked part-time in downtown Manhattan. But there was a sixty-mile commute through three counties from his home, from his family, in 97%-white Pawling (but Quaker site of the first action against slavery in the colonies in 1738 or so), due north of the city. One day, just before Christmas, while their live-in nanny had gone shopping in Poughkeepsie and his wife was in the Bronx getting her hair done by a stylist who knew how to do African hair, their three-year-old son was in daycare (he’ll be 17 in May) and had had an allergic reaction. 

They couldn’t get in touch with Asuquo’s wife or the nanny, so they called him. He was in the middle of a difficult case (the patient later died) and he told his chief that he had to leave to take care of his son. But as he headed north on the FDR Drive there was (as you might guess) an accident, and “gridlock.” It took him four harrowing hours to get home. His son was okay, but Asuquo thought to himself: “What’s the point of working if I can’t take care of my family?”

The 9.7-mile FDR: More snarled traffic with which to contend
(from Hiram A. Duran in "The City")

So Dr. Inyang, not afraid of change, submitted his resignation the next day. But after this, he was “depressed” and couldn’t think about work. He did nothing, nothing at all, for the next two months. His wife was working on her PH.D. in physical therapy and she started sending in job applications on behalf of her flattened husband. 

After New York, just York

It wasn’t long before he received a pretty good offer from a hospital in a small town in upstate New York. They picked him up in a fancy limo for the trip. The position itself looked okay but his careful wife did not like the quality of the school system, and (as a sort of deal-breaker) there was “no Black barbershop.” He needed to keep looking.

The next offer, another nice one with luxury transportation, came from a hospital in Kentucky. But after Asuquo sent his wife a few photos of the place she firmly replied, “The kids are not going there.”

The next interview his wife arranged was with Anesthesia Associates of York. There would be no Lincoln Town Car, no airport ticket, and no high-end lodging. He was informed that he could just drive down from New York himself! He did that, and they booked him a room at the no-frills Holiday Inn Express. Though he liked what he saw with the practice, his cautious wife had to visit York to see for herself.

Once here, she took an immediate liking to Dr. Arthur (“Jed”) Smalley, chief of cardiac anesthesia at the time; Dr. Smalley was “straightforward” and “down to earth,” (a was his wife). She felt the same way about the chairman of anesthesia, Dr. Doug Arbittier (and his wife). There was a sense of comfort and a belief that they would be treated fairly. And, importantly, the Inyangs could easily live within a 15-minute drive to the hospital, making it easy if Asuquo had to run home for another family emergency. 

So Asuquo accepted the position and started working here in York in October 2008 while his wife stayed in New York for a bit to finish her doctorate, to become Dr. Ekamma Inyang.  

Asuquo enjoys being in the operating room to keep abreast of “what’s going on.” But he admitted that the first few years here were terribly painful. You see, in New York, he worked in three places, but in York, he had only one job (imagine that!) and was “kind of bored.”  This changed one day when he bumped into Dr. Vasudevan Tiruchelvam (who, by the way, also did his surgical training in England). Dr. Tiru told Asuquo about going on a voluntary medical mission in Honduras; a “lightbulb went off.” 

Beyond York

Dr. Inyang realized that this could be his opportunity to do surgery, so he joined the small group going to beautiful colonial Gracias, Lempira. When he arrived, he saw that the people were suffering and that his skills were needed.  But this suffering brought to mind his precarious childhood experience in Nigeria during the war. 

Beautifully restored church in Gracias, Lempira
(from "Visit Centroamerica")

On his third day in Honduras, a young woman had a cardiac arrest during a C-section; there was no heartbeat and her EKG tracing was an ominous straight line. Dr. Inyang had been calmly preparing for his next case in another room when he was urgently summoned. He had to pull out all of his anesthesiologist’s resuscitation skills, and as nothing seemed to do much, things looked grim. 

But as he persisted the new mother’s pulse eventually returned, they finished the case, and the patient “woke up.” Everybody cried. Asuquo realized then that it takes the right person at the right time (and with the right skills) to save a life.  He has gone back to Honduras “again and again.” And he has expanded his mission work.

He and his kids (his wife was in New York at the time) were at a Chinese restaurant when they saw someone who they thought was the pastor from the Living Word Community Church in Red Lion. Asuquo’s son went over and asked the man if he was Pastor Steve Almquist. He was, of course, and he introduced himself. Asuquo’s proud son said his father was a doctor. And Dr. Inyang told the pastor, yes, that he was an anesthesiologist, a surgeon, and an echocardiologist. 

Years went quietly by, and one Sunday after church Pastor Steve came up to him and asked, “You are the doctor, right? We have a medical mission to Guatemala and we need doctors to help us there.” 

Dr. Inyang “didn’t know how to say no to Pastor Steve.” So, along with Dr. Ed Nelson, he started doing work in Guatemala. And he didn’t stop there. He also tends to the suffering in Nigeria for a week or two twice a year; in March he goes to his father’s hometown, Iyo, and in November he spends time in his mother’s home, the peaceful port city of Calabar. He has gone to the Philipines once and was scheduled to go back, but COVID-19 has delayed that. Through his voluntary mission work, Dr. Inyang has been able to make use of his surgical talents.

Over the years, he has learned to enjoy certain aspects of anesthesia care, especially the hemodynamic challenges of cardiac surgery, where he may use his skills in echocardiography. While working in the OR, he envisions himself as the “non-operating surgeon.” He said that his “heart is in hearts.” 

A Few Recent Advances in Anesthesiology

Dr. Inyang noted that there have been important advances in the practice of anesthesiology in recent years, making it safer and better tolerated by patients. With new techniques, drugs, and enhanced training, the mortality risk has declined from about 1 death in 1000 procedures in the 1940s to less than 1 in 200,000 recently.

For example, the feared so-called difficult intubation, with trouble placing the endotracheal tube accurately in the windpipe and thereby risking inadequate oxygen delivery to vital tissues, can be avoided altogether with routine use of direct video laryngoscopy during the procedure.

Also, the drugs used to induce and maintain the deep anesthetic state (exactly how they work, and how they affect consciousness, is still not fully understood, by the way) where the patient doesn’t move, experiences no pain, and has no recollection of the procedures are better, too. When Dr. Inyang started doing anesthesia the barbiturate thiopental was the standard for induction. This has been mostly replaced by propofol, the quick-acting IV sedative/anesthetic made infamous by Michael Jackson and his cardiologist.  Amidate also has a rapid onset of effect and is especially helpful in trauma cases as it does not cause a drop in blood pressure or an increase in intracranial pressure, two potentially serious complications.      

The parts of the brain affected by anesthetics;
 the sensory relay station, the thalamus, stands out 
(from Semantic Scholar)

 A new medication that he really likes a lot is dexmedetomidine. This, he explained, is an  “alpha2-receptor agonist” (whatever that is). It has sedative, anti-anxiety, and antihypertensive effects. But it is unusual in that it does not cause respiratory depression or compromise cerebral perfusion; patients don’t stop breathing and the brain is protected. This has allowed physicians to do a number of complex heart procedures, such as transaortic valve replacements, under sedation only.

Dr. Inyang also noted that there are better medicines the anesthesiologist may use to improve heart function to maintain circulation during surgery, so-called inotropes. And he said that a temporarily weakened heart can be helped along for a while by a mechanical left ventricular assist device (LVAD). In fact, they use the “Impella Ventricular Support System.” This consists of a tiny pump and motor inside a catheter that can, remarkably, deliver 2.5 liters of blood per minute to the body, nearly half of the normal resting cardiac output.

There are new non-invasive ways to monitor pressures and blood flow within the heart and the rest of the circulatory system. And the second-to-second cardiac output can be calculated fairly precisely simply by analyzing the waveform of the pulse in one’s fingertip.  

Dr. Inyang was careful to point out to me that his experience in the OR has shown him that “most organs (including the heart) recover after an insult if you keep maintaining circulation.” With support, the body often heals itself. This bears repeating: with support the body often heals itself. 

Much of his free time is spent preparing for the complex international medical missions since it takes about six months to put one together. He and his team usually do 100-200 surgical cases and treat 1000-2000 medical patients over just a few weeks. Dr. Inyang is currently working on getting sponsorship for a trip to his wife’s hometown.

And Asuquo is grateful for his family and is quite proud of his wife and his four surviving children (all with meaningful traditional given names). His older daughter (the only one who learned his native language)  resisted the pressure to be a surgeon and is an oncology resident at the University of North Carolina, Chapel Hill. His younger daughter (with whom he shares a birthday) is studying environmental engineering at Penn State. His older son (who “almost died” before he was delivered by emergency C-section at Einstein in the Bronx) writes software for  AT&T in Atlanta.  The younger son (Asuquo Jr.) plans to be an artist/animator.  Asuquo’s wife, as we have seen, found time to obtain her own doctorate. 

Proud Asuquo with his wife and their two sons and two daughters

So, the 5,500-mile trip from Nigeria to York, the voyage from being a frightened young boy in the middle of a civil war to a fully-trained cardiac surgeon to a seasoned critical care anesthesiologist and to a mature anesthesiologist-surgeon arranging international medical missions, was not straightforward (Asuquo told me that nothing about him is).  But the long winding journey, having been made, has finally allowed Dr. Inyang to stop running (though he hasn’t slowed down).

Happy Father's Day and Happy Juneteenth.

Suggested Readings

1. Achebe, Chinua. There Was A Country; A Personal History of Biafra. The Penguin Press. New York, 2012.

2. Cole-Adams, Kate. Anesthesia; The Gift of Oblivion and the Mystery of Consciousness. Counterpoint. Berkeley, California, 2017.

Reenactment of Dr. John Collins Warren doing the first surgery
without pain on October 16, 1846, as William Morton administers ether
to remove a tumor from the neck of Edward Abott.
(painting by Warren and Lucia Prosperi for MGH)

by Anita Cherry

June 19, 2022

P.S. "Doctors Without Borders/Médecins Sans Frontières (MSF) was founded in 1971 in France by a group of doctors and journalists in the wake of war and famine in Biafra, Nigeria. Their aim was to establish an independent organization that focused on delivering emergency medical humanitarian aid quickly, effectively, and impartially." (from the organization's website)