Tuesday, February 13, 2024

Dr. Razvan Vaida Advises: Be Present and Feel Your Emotions

Human beings may be induced to sacrifice everything they hold dear and true including their sense of self for the sake of being loved and approved by someone in power and position of authority.         George Orwell, Nineteen Eighty-Four

Dr. Vaida
Dr. Razvan Vaida is a psychiatrist in York. He was born in 1970 in socialist Romania. His parents separated when he was two or three and divorced when he was four. After that, he, his mother, and his older brother moved from Bucharest to an apartment in the periphery of the city. He saw his father (an engineer) once a month on a Sunday (the single day of the Soviet communist weekend). They would go out to eat or watch a movie. Sometimes he spent the night.

A few years after the move, two of his maternal cousins, eight and ten years older than Razvan, came to live with him and his mother.  She was also an engineer and taught high school engineering and electronics. The cousins became father figures. 

Razvan felt shame and embarrassment growing up without a father, and divorce in Romania carried a heavy social stigma with it. It was painful, and whenever his father’s name came up in conversation Razvan would be vague. The young boy learned early on to disguise, to hide, his emotions. 

Dr. Vaida told me that this struggle was “one of the big reasons” he ended up studying and practicing psychiatry. He feels that “most people (working) in mental health have some kind of problem they want to master or questions they want answers to.” Of course, he hasn’t yet found all the answers, but he has no second thoughts about his career choice. 

Communism Under Ceaușescu

Communism itself was bad, but life in Romania under Nicolae Ceaușescu became especially harsh in the early 1980s. There was strict rationing of food (to the edge of near-starvation), gas, heating, electricity, and other necessities to quickly repay massive loans from Western nations. The loss of political freedom, with severe restrictions on acceptable speech, led to a “suffocating environment,” recalled Dr. Vaida. 

Long breadline in Romania in the 1980s 
(photo from mcgarmott.medium.com)

The “doublespeak” of Orwell’s chilling novel of totalitarianism and brainwashing, Nineteen Eighty-Four  (published in 1947), was very real to him. The truth in Romania could only be spoken quietly and only in small safe circles to avoid the secret police, the Securitate, and their many willing neighborhood informants.

(Romanians developed dark humor to cope. One saying went like this, said Razvan: "We pretend we're working. And they pretend they're paying us."

His mother did private tutoring after her day of teaching and she often didn’t come home until nine o’clock. His cousins picked young Razvan up from pre-school, and by the second grade, he was already a “latch-key kid” who took two or three buses for the hour-long trips to school and back home. He remembers answering the phone and taking messages in the evening for his mother while she was away. There wasn't a lot of money. 

Frigid Bucharest street scene
with an overcrowded bus in the 1970s
(photo by Andre Pandele)

By the time Razvan was ten, his cousins left for college and he had to fend for himself. He learned to be independent. And he sensed, even at this age, that he would live and die under oppressive communist rule. This was simply the way his life would be.

Razvan's MGF
Dr. Vaida said that if you have not lived within communism it is impossible to fully understand what it meant. For example, his mother’s family was given only two hours to leave their comfortable home in Bucharest. The home that was built by her father. He had been a high-ranking commander in the Air Force during World War II (and a two-time four-man Olympic bobsledder) and he sometimes piloted a plane for the popular King Michael I before he was forced to abdicate in 1947. 

Since Razvan’s mother’s family was comparatively well-off she was forced to spend a year washing dishes before she was allowed to go to college. His dad was luckier; he came from a simple background, as they had a small farm, and there were no punitive measures. 

Human Biology Clicked and The Fall of Communism

When Razvan was  11 or 12 he became intensely interested in human biology. It “clicked,” and he knew from then that he wanted to be a doctor.  There was fierce competition for the six-year medical degree programs so he, like everybody else with the same lofty goal, “memorized” the 11th-grade biology text in anatomy and physiology. Yes, he committed the entire book to memory.

He was accepted to the prestigious Carol Davila University of Medicine and Pharmacy. But he had to serve nine months in the army first. 

Intense studying at Carol Davila (photo from The Global Research)
But in 1989, when Razvan was 19, something completely unexpected happened; the fall of communism in Eastern Europe. 

Crowds of Germans began dismantling the Berlin Wall on November 9th. The uprising in Romania began in December in Timişoara. And the regime of the dictatorial cult of personality finally ended on December 22nd after two days of violence during which about 1,000 protestors were killed. Three days later Ceaușescu and his wife Elena were court-martailed, convicted, and executed by firing squad. This was a “tense” but “interesting” time said Dr. Vaida, with irony.     

Military crackdown on December 17, 1989 in Timişoara, Romania,
(photo from Fortpan)

Dr. Vaida didn’t have much to say about his medical school experience other than that he enjoyed it (and that he had a thousand classmates). But when he took his rotation in psychiatry in his sixth and final year something, again, ”clicked.”  He said to himself, “That’s what I want to do.”

His Interest in Psychiatry

The hospitalized patients he saw with severe psychiatric illnesses were fascinating (but they were also shocking). He thought that studying them would give him the opportunity to “know what makes the mind tick.” And that he might find answers to nagging questions about himself; about his emotional difficulties, including his reaction to the divorce of his parents, and his lifelong introversion. He could know himself. He decided to finish medical school with a thesis on anxiety.

While things in Romania would change after the revolution Razvan knew that such change would be slow. Looking to escape, he received a nudge from one of his brother’s classmates who had gone to his medical school. And since his brother had already traveled abroad and eventually moved to the U.S., Razvan could follow his example.

He flew to Budapest for the first step of the USMLE, the exam required of foreign medical school graduates who hope to practice in the States. He passed and applied for a psychiatry residency. He sent applications to "a few dozen" programs and waited. No replies. Without a scheduled interview for a residency, without a job offer, he could not get a visa. He had to stay put for a while.

His girlfriend at the time was a psychiatrist teaching at one of Bucharest's state-run hospitals, where individuals with severe mental illness were often hidden away and forgotten. Razvan spent a lot of time with her over the next year. He said that this was “kind of an (unpaid) internship.” He said it was also “nice to have time off to relax" after the rigors of medical school.

Lonely forgotten patient in a Romanian psychiatric asylum in 2004
(photo from darrinjamesphotography.com) 
The next year, not wanting to take a chance on missing out again, he filled out applications for every single program in the U.S., all 200. It was a lot of paperwork, he said, and he gave the box of applications to his brother’s friend to mail when she got to the States for her psychiatry residency in Texas (it would have cost way too much to send them from Romania).

Residency in Philadelphia

This time he got several replies. It was October 1997 and he was ready. The interview at Einstein Medical Center in Philadelphia (on Old York Road) went well and the program director offered him a position on the spot. He could start in July. But there was a problem: his required English exam had expired. He had to return to Romania for the exam given in June and he missed the orientation sessions for the new residents.

The transition to a new country with an unfamiliar culture was “rough.” First of all, he had no Social Security card and no place to live. A colleague took him in for a few months and the commute to the hospital by bus and subway took an hour. That first year was stressful and difficult, and he struggled academically. 

Ionic columns in front of Jefferson-Einstein Medical Center 
(photo from Jefferson Health) 
Things were much better by the second year, especially after he was fixed up with the young woman who would become his wife. They were brought together by an Indian attending who guessed that a Chinese woman from Louisville, Kentucky would be just perfect for a lonely introverted resident from Bucharest. Why, of course, she would! 

After Residency, On to Kentucky and Marriage

When Razvan finished the residency in 2002 on a J-Visa he could either return to Romania for two years or work in an underserved area here for three. He chose the latter and was assigned to a medically barren small town in eastern Kentucky, Hazard, in Perry County. Mary said she would not join him “without a future.” So they got engaged.  And they would need to have two weddings: one here and one back home. His mother would be happy to organize the affair in Romania.

Kentucky was “very stressful.” Dr. Vaida was sometimes the only psychiatrist for four counties and he was “always overworked.” He didn’t like the job, but he enjoyed the warm welcoming people of Appalachia. 

Downtown Hazard, Kentucky (photo from VOA by Ashley Westerman)
Razvan and Mary got married in Philadelphia In May of 2003. His mother came in for the wedding but his father (long since remarried and with two daughters, making things awkward) didn’t attend. Afterward, Dr. Vaida and his wife took his mother to see their home in Kentucky. 

At the time, his mother taught and practiced the “hands-on” stress reduction and relaxation technique of Reiki. She was also involved with various spiritual groups from around the world. While here for the wedding, she decided to head to a healing-energy meeting in Boulder. 

Sadness

Several mornings later, as Dr. Vaida and his new bride were at home, somebody knocked at their front door. It was a police officer. He told Razvan to call a phone number in Colorado. The number was to the coroner. Razvan’s mother was struck by a car the night before and she had passed away. (A visibly saddened son retelling this story became very quiet, and he took several slow deep breaths as he again felt the shocking trauma of that awful day.) 

Razvan flew to Boulder to see his mother at the mortuary and he and his brother (a statistician at the Harvard School of Public Health) made arrangements to return her body to Romania. The airline tickets that had been purchased for the planned second wedding in August were used, instead, for his mother’s funeral.

Peaceful Romanian countryside (photo from Eye View)
Following the three years in Kentucky, Razvan looked around for a position close to his wife’s mother and brother in Downingtown just outside of Philly. WellSpan’s offer in York was the best and he took an outpatient position.

Practice

When I asked him about professional influences, Dr. Vaida could not recall having a mentor to guide him on his medical journey. You see, without a father, he had been forced to rely on himself. He admitted to me that he “may have some issues with authority, with authority figures.” He said he never learned how to “negotiate” such uneven relationships.

In his adult psychiatry practice, he typically treats patients with major depression, bipolar disorder, chronic anxiety, panic disorder, social anxiety, and borderline personality disorder. He occasionally sees individuals with substance abuse disorder and he sees a good number with the painful and disorienting effects of remote trauma, patients with post-traumatic stress disorder (PTSD). In this disabling condition, in the wise words of addiction specialist Gabor Maté, “the past becomes the present” and rational thinking goes offline. 

In a 2014 interview with our local TV station, Dr. Vaida said that a study had shown that specific RNA markers found in blood could reliably distinguish people with major depressive disorder from those without it. He hoped this would lead to earlier and more biologically based diagnoses and personalized precision therapies, even prevention. 

Still image from the 2014 video interview
 about a possible blood test for depression (from Fox 43)
Ten years later, that hasn’t happened, and the psychiatrist's bible, the Diagnostic and Statistical Manual (the DSM) remains purely descriptive. But researchers are getting steadily closer to understanding the complex biology of major depression and several other disabling psychiatric conditions including bipolar disorder, schizophrenia, anxiety disorders, and borderline personality disorder.  

Dr. Vaida manages most of his patients with medication, but he also stresses the need for lifestyle modification including a focus on a healthy diet, regular exercise, and relaxation techniques (such as yoga or tai chi) along with psychotherapy.  He said that he spends about 10% of his practice doing talk therapy but that he would like, someday, to be able to do more. 

The Effects of Trauma

Razvan and four other psychiatrists from his training program have weekly online meetings to “discuss different things.” Trauma, he noted, is the “thread that goes throughout” the stories their patients tell. 

Some of the most challenging patients he treats are those with what has been (somewhat poorly) called borderline personality disorder. These people have often suffered repeated abuse as children. They have low self-esteem, experience very poor relationships with others, and have difficulty regulating their emotions. There is likely a strong genetic predisposition to develop this condition after experiencing early-life trauma, and there are gender differences in how it shows up. 

The sufferers may experience chronic anxiety, depression, and full-blown PTSD, and they may engage in self-harm (including cutting and multiple suicide attempts) and substance abuse. Medication (treating the symptoms) is not very effective unless the remote trauma (the crucial underlying problem) is fully addressed. 

These misunderstood individuals utilize a lot of medical and psychiatric services and are often poorly served by the health system. Dr. Vaida feels that he connects well with them and he said that it “does wonders if you are able to be there and listen.” Many difficult patients can do quite well following comprehensive treatment.

(One of his friends in New York has adopted the NeuroAffective Relational Model (NARM) to treat “attachment, developmental, and relational trauma.” This compassionate labor-intensive approach uses body-mind mindfulness to promote self-regulation of the body and nervous system. Dr. Vaida is intrigued by this idea explored in depth by Dr. Bessel van der Kolk in his best-selling book The Body Keeps The Score.)

For the past two years, Dr. Vaida has been cutting back his hours as he found that more of his time was “spent on things that are not related to patient care.”  He notes that this time-waster is due to “pressure from insurance companies.” The stress of checking lots of little boxes in the electronic record and writing extensive treatment plans that nobody reads is, he is certain, affecting his health negatively. 

After Hours

He likes to read but he unwinds by watching movies, most of which deal with emotions.  He said that viewing 1984's dark vision of the future "brought back memories." He exercises regularly and he likes to swim. In fact, I first encountered Razvan at the York JCC pool during the second year of the pandemic while doing early morning laps (he does smooth flip turns).  

Frame from 1984: Winston (John Hurt) writes in his forbidden
diary while carefully avoiding the watchful eye of Big Brother
(from FilmScene)
His family? Razvan’s son is 17; he loves math and physics and wants to go to MIT. His daughter is 15 and her career path is still wide open. Both kids love music. His wife worked as a therapist when they were dating but since Kentucky, she has taken care of the household and family stuff. 

After 20 years in psychiatry, Razvan remains, he said, “fascinated by human emotions, human behavior, what makes people do what they do...and feel what they feel.” He believes in “the goodness of people” and that “good prevails over evil.” His unexpected freedom from communism, from tyranny, and from the sometimes oddly seductive lure of Big Brother “was a miracle,” and that makes him optimistic. 

Dr. Razvan Vaida, the hopeful psychiatrist, said that “the solution is to be present and to live every moment and every feeling that you have without having to escape.” That may take some practice.


References and Suggested Readings

1. Orwell, George. Nineteen Eighty-Four. Plume/Harcourt Brace and Company, London, England, 1983. (Original copyright 1949.) (We seem to be headed in that alarming direction.)

2. Roseberry, K., Levey, D. F., Bhagar, R., Soe, K., Rogers, J., Palkowitz, S., Pina, N., Anastasiadis, W. A., Gill, S. S., Kurian, S. M., Shekhar, A., & Niculescu, A. B. (2023). "Towards precision medicine for anxiety disorders: Objective assessment, risk prediction, pharmacogenomics, and repurposed drugs." Molecular Psychiatry, 28(7), 2894-2912. (Dr. Niculescu had done similar work on major depression in 2021; he emigrated from Romania.)

3 Stroescu, Vlad. "My Three Lessons as a Psychiatrist in Romania." Psychiatric Times, October 3, 2019. (If Razvan had stayed in Romania...)

4. Van der Kolk, Bessel. The Body Keeps the Score: Brain, Mind, and Body in the Healing of Trauma. Viking. New York, New York, 2014. (Essential work on understanding and treating PTSD.)


By Anita Cherry (2/13/24)


An Orange Tulip (photo by SC)




Monday, December 25, 2023

Dr. Earl Bernstine, Child and Adolescent Psychiatrist: Coming Home

 

Dr. Bernstine 
Being raised in a physician’s family in a small semi-rural Pennsylvania town In the late 1950s seemed idyllic. The doctors worked together. Their families socialized together and traveled together. And their children went to school together. The two hospitals in town were quietly run by practicing physicians and surgeons (with just a few administrators). And the doctors could live comfortably within a few blocks of the hospital.  

There was no worry about access to medical care. No worry about doctor or hospital bills. It was good. But the subject of this story sorely missed having time with his father. You see, his father, Dr. Earl L. Bernstine, a general surgeon, worked “twenty-hour days.” He “covered everything” from the emergency room, to trauma, to orthopedics, to whatever came along.  The surgeon’s son, Dr. Earl W. Bernstine (one of a long line of Earls--no Dukes, as far as I can tell), is a recently retired child and adolescent psychiatrist. He was kind enough to stop by to tell me his winding tale.  

Earl L. (the surgeon) was, himself, the son of another Earl, Earl H. (a pharmacist).  After he served in the Navy in Word War II, he did dental school for a year before transferring to Thomas Jefferson Medical College for a medical degree. He did his internship year in Williamsport, where his family lived, and where his son, Earl W., the future psychiatrist, was born. 

He then moved the family to York (wisely equidistant from his wife’s family in Philadelphia and his own) for a surgical residency at the York Hospital. The busy practice that followed left him very little time to spend with his young son.

Earl W. (from here on referred to as simply “Dr. Bernstine”) decided early on that he didn’t want a medical career like his dad. Having “missed” his father terribly, he wanted to make sure he had time to be with his own children. Though some of his high school classmates whose parents were doctors went into medicine (and even returned to York to practice) he purposely steered away from the health field and his hometown.

On to the University of Denver

After struggling in high school, he went to the University of Denver to do political science or practice law. Dr. Bernstine, as a visual learner, had trouble memorizing facts and had to read things over and over; his dyslexia had not yet been diagnosed. On the other hand, he was quite good with numbers. His calculus professor and statistics expert George Bardwell told him that his math notes were “very elegant,” and encouraged him to further his math studies. 

View of The University of Denver (from the university)

Dr. Bernstine told me that he “could see numbers in shapes and colors” and “squeeze them through an equation” in his mind (whatever that could mean!) to get the right answer. Realizing his gift, he thought briefly of becoming a theoretical mathematician.

While in Denver, using his skills with numbers, he worked on several local Republican political campaigns (though he was a Democrat, they didn’t mind). He had success and considered doing this as a business.

Return to Pennsylvania

But after two years in Colorado, he decided to return to Pennsylvania. He went to Dickinson College to finish a degree in political science. As a student, he stayed in the family cabin in nearby Pinchot, taught alpine skiing, and “had a motorcycle.” 

Entrance to Dickinson College campus (from The Edvocate)

He wanted to support himself financially and he started helping out in his father’s office. As he talked with patients scheduled for minor surgery he saw that what he was doing quickly relaxed them. He realized that this simple act of communicating had an immediate positive effect.

Some of Dr. Bernstine’s skiing buddies were, he said, “male nurses” (an unusual job for men at a time when gender stereotypes were strong and there was widespread homophobia in York). Nursing could be a reasonable career option, he thought.

And in 1979, in the close medical community, York psychiatrist Dr. Kirk Pandelidis offered Dr. Bernstine a test job as a nurse’s aide on the locked psychiatric unit at the hospital. On his first day there, contact with the struggling patients (including one man who asked him if he had brought a screwdriver with him since everyone there had a loose screw) showed him that “we’re all people.” We all hurt; we all cry. He said to himself, “I can do this!”

Through this brief experience, Earl felt, he said, that “the mind is so fascinating.” 

Now to Upstate New York, Way Upstate

Anyway, he left York again, this time for nursing school in upstate New York, just twenty miles from the Canadian border.  He was one of only three male students. During the summer off he worked on the psychiatry ward in York. He was put on third shift, a time when the visitors and the attending doctors were gone and the nurses took care of most things. 

Snow-covered SUNY Canton Bridge (Photo by McCluskey Photography)

When it was quiet, he could study psychiatric diagnosis or pharmacology (psychiatrists, he noted, would soon become “neuropharmacologists” primarily providing medication management rather than in-depth analysis). The opportunity to observe patients for eight hours, seeing how they responded (or didn’t) to medicines, and what side effects occurred, was far more educational than the books (that Earl, a dyslexic, had trouble with). 

Dr. Bernstine graduated from the two-year SUNY nursing program in Canton in 1981, and he and his girlfriend (with whom he had been living) “parted ways.” Where would he go next? His classmates were recruited to work in Lubbock, Texas. But a few of his friends in Denver lived in Houston, and he thought that city would be “more fun.”  

Though he had no particular interest in treating kids, he landed a job as a staff nurse on one of the first long-term inpatient adolescent psychiatric units in the country. He said that he learned a lot, and as he progressed from staff nurse, to charge nurse, and then to nursing supervisor he gained much confidence. 

Nurse-Bernstine soon concluded that as the on-call attending psychiatrists at night would sometimes rely on his observations and suggestions to determine the patient’s acute treatment, he might as well become doctor-Bernstine and do this himself (and get paid for it). Yes, he was ready for medical school.

Now on to Houston, and Medical School

So, at 25, he applied to several programs in Texas. He was accepted to The Texas College of Osteopathic Medicine (TCOM),  where they were looking for students with
good interpersonal skills. The “campus was beautiful” and the work was “challenging.” 

Dr. Bernstine told me that he was taught that osteopaths have a “different way” of looking at things compared to allopathic (M.D.) doctors (like his father). He said they view all things in the body as parts of a complex system, not in isolation. And that “everything is connected,” he said.  He feels that this broad perspective is especially needed in understanding disorders of the mind.

TCOM (Photo from TCOM)
After five years at TCOM (you see, he and a few classmates had taken an additional year of school beyond the required four), it was time for an internship and residency. 

Back to Pennsylvania Again; Internship and Residency

Feeling the pull to return again to Pennsylvania, he did a rotating internship year (1990-1991) at the small York Memorial Osteopathic Hospital (where his intimate knowledge of the importance of being “nice to the nurses” came in handy).

Following this, he started a psychiatry residency at Hershey Medical Center under sleep researcher Dr. Anthony Kales. But Hershey didn’t fully accept his D.O. year and he had to do another six months of internal medicine first, including taking nightcall. 

That being done, Dr. Bernstine did three years of psychiatric training at Hershey. This included work in psychotherapy and six months at the Harrisburg State Hospital, formerly called the Pennsylvania State Lunatic Hospital. The sprawling facility housing (yes, simply housing) incurables not capable of living in society closed in 2006 as patients across the country had been slowly “deinstitutionalized” after the very first-ever effective psychiatric medicines were developed in the 1950s and after President Kennedy signed the Community Mental Health Centers Act in 1963.

Dr Bernstine wanted to do general psychiatry, but there was more politicking. You see, Hershey needed to fill their adolescent fellowship slots. And since Dr. Bernstine had insight and skill with kids they “strong-armed” him into taking one of the positions. It turned out that this was a surprisingly nice fit. 

Now to York for Practice

Dr. Stevens
Following his two years of subspecialty training, he once more returned to York. This time to practice.  By then, the child and adolescent psychiatry unit at the York Hospital (on 6 South), conceived and developed by the late multi-talented Dr. Bryan Stevens, was, according to Dr. Bernstine, “phenomenal.” It was the best he had ever seen. He and his two “great” partners and the capable support staff provided the troubled kids with the full range of treatments including family, recreational, and group therapies. Sometimes for many months.

But as they required more staff to meet the growing demand for services the costs mounted. Insurance reimbursements (traditionally poor for mental health anyway) did not keep up. Management began cutting. And cutting more. Eventually, the understaffing compromised care too much, and the unit had to be closed.  (It was reconstituted later on the 2nd floor of the hospital, but it wasn’t the same.)

Over the years, Dr. Bernstine and his partners treated the full range of child and adolescent psychiatric problems. They “covered everything,“ doing both inpatient and outpatient work, unlike in the current system, where you generally do one or the other. He was a WellSpan outpatient psychiatrist from 1996 until his retirement in 2023 and he spent 13 years as a staff psychiatrist at a facility for long-term treatment of adjudicated adolescent male substance abusers. 

Autism and Asperger's Syndrome

I asked him if there was a type of patient that he especially liked to take care of. Without hesitation, he said he enjoyed and was good at connecting with the so-called “Aspies,” the kids with what used to be called Asperger’s syndrome, but is now viewed as the mild end of the broad complex autism spectrum (or, better yet, wheel). We will spend some time with this.

The case study report of four young boys meticulously described by Dr. Hans Asperger in 1944 in Vienna out of more than 200 “difficult children” that he had studied over ten years at the University Paediatric Clinic was his post-doctoral thesis. 

Hans Asperger (on the left) working with a student in the early 1930s
(photo from Pictorial Press)
The boys appeared to be locked up in their own worlds. They were cut off from the environment and, especially, their social surroundings. While non-verbal and verbal communication were impaired, spontaneous language itself could sometimes be precocious (but disconnected). Odd stereotyped repetitive movements were seen and the boys were often awkward and clumsy. 

But special exceptional talents, such as the ability to manipulate large numbers or remarkable feats of memory might emerge. And (writing in Austria during the German leader’s failed effort to eliminate all undesirables from society) Asperger stated that if these individuals had “normal intelligence” and were treated by an “absolutely dedicated and loving educator”  they could find suitable work and “have their place in the organism of the social community,” (Draaisma, p. 313).

(An aside: Well-known Aspergerish autistics likely include Sir Isaac Newton, Charles Darwin, Albert Einstein, Emily Dickinson, James Joyce, Ludwig Beethoven, Bill Gates, Steve Jobs, Thomas Jefferson, Stanley Kubrick, Anthony Hopkins, and Jerry Seinfeld, among many others who have created our world.)     

The autistic’s deficits in social interaction, behavior, and communication may be profound but can sometimes be so subtle that they are viewed simply as personality oddities. In addition to the core features, the kids may have sleep problems, gastrointestinal and eating disorders, seizures, anxiety or depression, immune system disorders, and cognitive impairment (apart from that tied to language). And all of these problems may exist to various degrees, as on the proposed autism wheel.

The new nuanced complex autism wheel,
going beyond the simple linear spectrum
(from ablelight.org)

While we can only guess what’s going on in the mind (the inner experience) of the severely autistic child, those with lesser degrees of autism can introspect and can occasionally tell the psychiatrist (and us) something about what they are thinking and feeling. 

(The autistic Temple Grandin said that when she was young she screamed because she couldn't talk. And she thought that it was the tone of the voice, not the words, that carried meaning.)

Dr. Bernstine found that he could connect with the Aspies by showing interest in whatever interested them and that he could thereby gain their trust. He observed and listened carefully and learned to “talk Aspie” (speech that may be monotone, emotionless, robotic, repetitive, arrhythmic, or too loud, etc.).  Once the child trusted him he could address specific remedial problems.

This lifelong and varied disorder of brain development and interconnections is much more common than previously thought. It is dependent on a wide variety of poorly understood genetic, epigenetic, and environmental influences (but not the MMR childhood vaccination).  

But aggressive and sustained loving treatment may eventually allow the “neuroatypical” child to adapt to the outside so-called "neurotypical" world. A world, to them, that is “relentlessly unpredictable and chaotic, perpetually turned up too loud, and full of people who have little respect for personal space,” (Silberman p. 471).    

Dr. Bernstine was careful to absolve the parents (especially the mother) of any blame at all for their child’s condition (the once-popular “cold mother” theory of autism having long since been abandoned). 

Neurologist Dr. Oliver Sacks, champion of neurodiversity before there was such a word, writing movingly about autism and the remarkable animal behaviorist Temple Grandin, said: 

And yet the parents of an autistic child, who find their infant receding from them, becoming remote, inaccessible, unresponsive, may still be tempted to blame themselves. They may find themselves struggling to relate to and love a child who, seemingly, does not love them back. They may make superhuman efforts and to get through, to hold onto a child who inhabits some unimaginable, alien world, and yet all their efforts may seem to be in vain. (Sacks, p. 248-249.)

Connecting compassionately with frightened tired parents and their autistic child requires lots of skill, as the therapies are arduous and progress is painfully slow. But there can never be too much therapy for these vulnerable children, said Dr. Bernstine. 

Elements of Psychiatric Practice

Dr. Bernstine said that timely diagnosis of autism or any of the mental problems that begin in childhood and adolescence is vital. In addition to autism, these problems include major depression, bipolar disorder, anxiety disorders, conduct disorders, learning deficits such as dyslexia, a variety of eating disorders (not just being a picky eater), substance abuse, and gender identity issues, among others. There is plenty to keep the doctor busy.

There are, as yet, no blood tests or imaging studies that can be relied on to confirm most disorders managed by child psychiatrists. So the diagnosis mostly remains a so-called clinical one and may take time to establish with certainty, as the needed DSM-5 criteria gradually emerge. 

As physicians observe the patient and collect information from the parents and other family members, the child’s teachers, psychologists, social workers, and other sources (speech, occupational, and physical therapists, etc.), they must also explore the social and cultural contexts to provide a reasoned diagnosis and a comprehensive treatment plan. And as Dr. Bernstine had advised me, “Everything is connected.” An effective child psychiatrist finds the connections. And he is an able communicator who can reassure parents and work well with a diverse team. 

Dr. Bernstine enjoyed his varied practice over the years within the growing WellSpan Health System. But after he went through therapy himself during the divorce from his first wife he gained insight into “what makes you a good physician.” After that, he decided to change his practice; he limited the number of new patients he would see and set aside time daily for emergencies; he decided to protect himself.

Outside Interests

Toward the end of the interview, I asked him about his interests outside of medicine. He said he likes outdoor activities such as hiking, bike riding, fishing, and skiing. He walks his three dogs regularly, sometimes at a small hilly county park adjacent to his neighborhood close to the hospital (where I first met him on a daily morning walk as he introduced himself). He has a busy family life, with a son ( Earl J.) from his first marriage, and three adult children of his wife's.

Dr. Bernstine and his family

He joined (of all crazy things) a really good York-Lancaster rugby club when he was 52 (the other members, he said, were half his age). He didn’t play much initially, but he went with them to Nationals as a trainer that first year. He was a starter after that; he was a “small” guy, but he was fast and could reach in to steal the ball from the other team. But it was hard for him to master the intricate playbook. 

Through the intense (and dangerous) sport of rugby, Dr. Bernstine lost 60 pounds and kept it off. Despite better nutrition, he had a heart attack three years ago and needed a stent. He is okay now and is looking forward to an active retirement. 

What about less physically demanding pastimes? He said he doesn’t read a lot of books but he thought a minute and then mentioned The Alchemist by Brazilian author Paulo Coelho. This short worldwide bestseller tells a story that is a variation on the ancient folk-tale theme that the treasure you dream of, that you seek far and wide is, in the end, found at home. I like that.


References and Readings

1. Coelho, Paulo, (Translated from Portuguese by Alan R. Clarke). The Alchemist; 25th Anniversary Edition. HarperOne. New York, 1993. (Twists, turns, and trials when traveling from Andalusian Spain across the Sahara desert to the Egyptian pyramids and back home.) 

2. Draaisma, Douwe, (Translated from Dutch by Barbara Fasting). Disturbances of the Mind. Cambridge University Press, Cambridge, UK, 2009. (Detailed background stories of 13 conditions bearing the names of those that first clearly identified and described them...Parkinson's, Alzheimer's, Tourette's, etc.) 

3. Sacks, Oliver. An Anthropologist on Mars; Seven Paradoxical Tales. Alfred A. Knopf. New York, 1995. (Another one of his remarkable explorations into the unending mysteries and strengths of the human brain and spirit.)

4. Silberman, Steven. Neurotribes; The Legacy of Autism and the Future of Neurodiversity. Penguin Random House. New York, 2015. (A lively easily-read "tour de force" history of the condition, its modern understanding, and its immense but often unrecognized societal impact.) 

5. Valentine, Vikki and Hamilton, John. "Exploring Language; Temple Grandin on Autism & Language"  NPR July 9, 2006. (https://www.npr.org/templates/story/story.php?storyId=5488844)



One of my husband's favorite trees in York's Reservoir Park in the spring
(Photo by SC)



By Anita Cherry 12/25/23

Sunday, October 22, 2023

Dr. Rita Van Wyk: A South African Advocate for Social Justice

Dr. Rita Van Wyk
I recently learned about the legend of the 
Lamed Vavniks from a Rosh Hashanah sermon streamed from New York’s Central Synagogue. According to a Talmudic story, there are (at least) 36 righteous people living among us at any given time upon whom the continued existence of human life depends. We don’t know who they are. They, themselves, are not aware of their critical role in the world. And anyone you meet (even you) may be one of them, perhaps for only a fleeting moment. 

As we sat together, Dr. Rita Van Wyk began the interview with her story of being a two-year-old during the polio epidemic in South Africa in the mid-1940s. She paused to ask how much time she had. “As much as you want,” I replied. (Knowing that the stiff new chair she was sitting on was not the most comfortable one in the room.)

Rita had the “ascending” form of the dreaded disease, she said. As it traveled up her body and the chest wall muscles were affected she couldn’t breathe. She had to be encased in an iron lung to save her life. The prognosis was poor for many such toddlers, and her working-class parents were coldly informed that she “might be a vegetable” if she survived. (Use of Jonas Salk's polio vaccine  would have to wait until 1955.) 

Children affected by paralytic polio (from polioeradication.org)

She soon regained the ability to breathe on her own, but she wasn’t the same. Her right leg was severely weakened and she couldn’t walk. What would happen to her?

Rita had two much older brothers. Her parents hadn’t planned on another child, and taking care of a daughter with serious neurological and orthopedic problems was a burden they couldn’t handle. You see, girls in South Africa (as elsewhere, it seems) were supposed to be pretty and lively so they could marry up. This was more important for a family from “the wrong side of the tracks.” But Rita was a burden; she was saddled with problems. So she was sent to “The Hope Home For Crippled Children.” (“Hope” was the founder’s wife’s name, not what they were offering.)

The Family

What was her family background? When Rita’s Afrikaner father left school after the tenth grade he was recruited to work for DeBeers overseeing the experienced black mine workers. Later, during the war, he learned Morse code and joined the Air Force as a radar operator. After the war, he worked in civil aviation. He eventually became the manager of the Johannesburg International Airport. After Rita’s mother finished the eighth grade, she toiled in a sewing factory. In time, Rita’s parents’ combined salaries gradually lifted them out of poverty. They were able to hire an Indian housekeeper who taught Rita how to cook. Curiously, Rita’s father “never” actually called her by her name; for him, she was always “di-da-di di-di da di-da!”

At the "Hope Home," there was grueling physical therapy, with very little reading, writing, or arithmetic for the youngster with a curious mind and (as Dr. Van Wyk later learned) attention deficit hyperactivity disorder. 

The "Hope Home and Convalescent Center for Children"
on exclusive Westcliff Ridge overlooking Johannesburg
(from hopeschool.org.za)

rBut her “Auntie Sis” (the oldest of 11 children and a teacher) stepped in and was a blessing. She taught the bright little girl how to knit, crochet, and embroider. Keeping Rita’s hands busy in a “well-rehearsed and well-controlled manner” had a “fantastic effect” on her “frustration, restlessness, and impatience.” 

She picked up things quickly, and when she graduated from the "Hope Home" (and School) at 11 the standard exam placed her in the tenth grade. She wasn’t really prepared; her interpersonal social skills were poor and she was “unsophisticated.” And as she was still relying on bulky crutches to get around she would certainly get in everyone’s way, she thought. Yes, she felt awkward. This isn’t going to be good, she said to herself.

High School and Beyond

But rather than wallow in self-pity, Rita would “bust everyone’s balls” and excel. Her goal was to know (get this) more than the teacher. So she studied the published curriculum before class to try to stump the teacher with a tricky question. That was her “adaptation” to the situation, she told me; shove the despair aside and be brilliant.

As the paralytic polio left her right leg weak and shortened she had a series of orthopedic procedures to try to improve her gait. At one point, her foot became infected and she developed gangrene. The surgeons wanted to amputate it but her parents refused to give them permission. The wound slowly healed but she ended up with a “really painful scar” and a limited range of motion. So Rita still has a shorter right leg and is unable to push the foot down, she has no “plantar flexion” she said.

After high school, Rita took the national exam for college matriculation and “did really well.” By that time, she had already decided on a career in healthcare. But where would she fit in? The physical therapists who worked on her were “mean and bullying” and burned out by the heavy workload during the epidemic (no good). The nurses had to take orders from the doctors (not her style). The doctors gave the orders that others followed (perfect). 

It happened to be that Rita’s family doctor’s wife was also a physician (quite unusual at the time) and it was she who became a role model for the strong-willed teen. Dr. Wagenaar had dedicated herself to helping people who could not afford medical care. These disadvantaged souls were the native black Africans, the victims of apartheid (the Afrikaans word for “apartness”). 

Apartheid

Starting in 1948, (and until 1994 when it was peacefully and democratically ended) there was a legally mandated separation of people. Where you could live, where you were actually forced to live, was determined, in essence, by the color of your skin; whether you were pure black (of African heritage), white (mostly European), or colored (mixed). The blacks were compelled to return to their ancient tribal lands while the whites alone would populate the modern prospering cities. (Another category, Indian, was added later.) The effect (if not the stated goal) of this creul system was to continue to exploit the majority indigenous black population for the economic benefit of the very small minority white ruling class. And there was fear.

Cautionary sign during apartheid in South Africa
(from history.com)
The poor displaced individuals that the compassionate white physician treated in a makeshift clinic in her garage were black. Grateful patients rewarded her kind services with a few precious tomatoes or a nice bunch of bananas, said Rita, who thought that this type of medical practice was “fantastic.”

Thus inspired, learning by example, Rita came to feel that those who have much must give to those who have nothing. But when she enthusiastically shared this idealistic insight about social justice with her family they branded her as a “bloody communist,” she said. She soon decided to get away from her “nasty bush family.” She would henceforth be “self-reliant.” And she would “never get married,” fearing that a husband would try to control her (fat chance, I think).

(It wasn’t until quite late in the interview that Dr. Van Wyk disclosed that she had been witness to repeated domestic violence, including extreme physical violence, in the chaotic household of her childhood. And that her mother suffered from a severe undiagnosed mental illness.)

Medical School and A Year of Obstetrics

Anyway, Rita received acceptance from all of the medical schools she applied to and chose to attend Pretoria University (on a full scholarship). The program, like the others in South Africa and parts of Europe, ran over six years. She did not say much about those years (actually, nothing) so they will remain a mystery. She did let on, however, that she was one of only three women in her class of 117 (and she suspects that one was a feminized male with an extra X chromosome, a Klinefelter’s).

University of Pretoria (from up.ac.za)
As she was finishing up medical school in 1969, her friend Johann wanted to go to the U.S. and he urged Rita to join him in taking the ECFMG exam (the American test for graduates of foreign medical schools). Johann knew that she absolutely loved Indian food and after he offered her the enticing bribe of an authentic Indian dinner, she agreed. 

She passed the exam easily, so she was, she thought, “good enough for America.”  However, she had no real interest in going to the States but rather liked the idea of possible training in England. She decided on a year of internship in obstetrics (the miracle of fetal growth and birth being, she thought, “the most exciting thing in medicine”. (Though Rita, at 21, decided never to have children of her own.)

Going against her earlier vow to remain single, she got engaged to be married, but this fell apart early during her training.

Politics Intervened

She had put away her dream of foreign travel for practice when she stumbled into some political trouble. It was July 4, 1970 (exactly two months after the shock of Kent State). “all eyes were on America,” said Dr. VanWyk as 350,000 of President Nixon’s staunch pro-war supporters rallied in D.C. at the Lincoln Memorial for the so-called “Honor America Day.” But thousands of idealistic young people waded into the iconic Reflecting Pool in protest.  (The previous day, counter-demonstrators had drowned out a Nazi rally speaker who blamed America’s troubles on blacks and Jews.)

So Rita and a group of her liberal Jewish friends, interns, decided to do a peaceful sit-in. They would argue for fair and equal salaries for their black and Indian counterparts, for a show of South African social fairness. The expected press coverage didn’t materialize, but the chief hospital administrator did appear, and he simply handed out pink slips. Everyone was fired; Dr. VanWyk was out of a job.

By sheer luck, Rita already had a passport and a visa. Her less fortunate colleagues were denied such documents, and because they didn’t complete their internship year, they could not practice medicine in South Africa. Perhaps she could go to America where there is “equal opportunity and no racism” to “polish” her education before returning to South Africa to be “the poor people’s doctor” thought Rita. (She believes that this “escape route” was “divinely inspired.” )

Travel to the States

One of her brothers was a PanAm pilot and lived in (of all places) Lancaster, Pennsylvania.  She would stay with him and his family for a while and travel around by Greyhound bus. However, her brother’s friendly neighbor was the Director of Medical Education at Lancaster General Hospital and he had an urgent problem that Rita might help solve. 

It was July, the start of the year for interns and residents. Well, wouldn’t you know, one of the 12 prospective interns had finked out at the last minute? The eager South African visitor without a job was informed that she could fill that slot if she got an Immigrant visa. Rita was interested. Strings were pulled and the work visa was granted. But her gratitude was mixed with guilt as life fell into place so easily for her.  

She quickly found that 1970s medicine in the U.S. was different from that back home. She was accustomed to “wild rough and tumble hands-on bush or jungle medicine” where “you do what needs to be done.”  For example, her first delivery as an intern had been in a South African leper colony.  Where people with the ancient disfiguring disease are discriminated against, shunned, removed physically from society, and feared. It was two hundred miles from the nearest hospital. No matter what the situation, it was up to her ”to get the baby out,” she told me.

Batsutoland Leper Colony (from leprosyhistory.org) 

Whereas in her new position, she was “fearless and confident,” having been tested in the field, in the veldt, her fellow interns were (let’s just say)…not.  They understood the more esoteric academic matters while she had hands-on experience. (Though she had to admit that she struggled with medical English, Afrikaans being her native tongue.)

After Lancaster; Obstetrics and then Planned Parenthood

After the internship in Lancaster, she later began an OB/GYN residency at the York Hospital just thirty minutes west. But, sadly, everything she had learned in South Africa, everything she had loved about obstetrics, was absent.  She was trained to make eye contact with vulnerable human beings, with women carrying their unborn children. The American-educated residents made “eye” contact with the beeping flashing electronic fetal monitor. 

Even the attendings whom she considered to be kind and “real mensches” typically looked at the monitors in the labor hall, not the women ready to deliver. While she appreciated that monitoring assured better outcomes, the impersonal aspects of the experience did not satisfy her deep need to help people. She couldn’t continue like this. She had lost interest in modern de-person-alized obstetrics.

So she changed direction and worked for Planned Parenthood, pretending to be Dr. Wagenaar treating the mostly non-white and poor clientele. She was quite happy there until the issue of pregnancy termination “became a big deal.” Though she believes that women have the right to choose, she could not deal emotionally with late-term suction abortions. Nevertheless, Dr. Van Wyk stayed with Planned Parenthood for eight years. The work eased her internalized “collective (white) guilt very much” she noted.

She Doesn't Like the Cold

But each year she was “dying” with the Pennsylvania cold winter, where readings below freezing are typical for months. The average winter temperatures in Johannesburg don’t dip below freezing at all, and the daily highs are usually in the pleasant 60s. You see, she said, one of the residual effects of polio may be intense cold intolerance. 

Typical late effects of having polio as a child, or the post-polio syndrome, include progressive muscle weakness, fatigue, and pain. In addition, the ability to regulate one’s core temperature may be impaired as a result of damage to the body’s thermostat in the hypothalamus. The limbs originally affected by polio may feel especially cold as surface blood vessels don’t function normally in response to the ambient temperature. People like Rita may need to dress in multiple layers because it feels to them as if it’s 20 degrees colder than it really is. They need heating pads, warm blankets, and long underwear.

So her body “craved the dry desert heat” of South Africa. Arizona might come close to that, she thought. So she applied to work in the Indian Health Service (again, assuaging her guilt regarding white privilege). But they didn’t need more obstetricians, they needed general medicine or pediatric help.

Dry South African Veldt

Dr. Van Wyk was up for a mid-career change and she decided to take up family medicine to make her way to the warm dry Southwest. She got a residency position with the York Hospital program and as she progressed through the rotations she found that enjoyed her time in psychiatry the most. She said, affectionately, that she loved “being around crazy people.” 

(Her therapist has told her that because she grew up in such a crazy family she feels at home in that setting, though she had to escape.)

When Rita Met Chris

Throughout her busy three-year residency, she remained free and unattached. But one fateful day she “looked into a pair of blue eyes” belonging to the “most interesting human being” she had ever met. The “really smart, quirky” and “painfully shy” intern (14 years her junior) was Dr. Christopher Due. They connected and were good friends for about a year before they “stopped being platonic and wanted to be together forever,” Rita gushed (sort of). 

And so they got married. A Unitarian Universalist minister officiated at a Bed and Breakfast in Muddy Creek Forks in the southern part of the county. She wore a peasant-style wedding ensemble, a top, and a long skirt, that she fashioned herself from “Aunt Lydia’s” crochet yarn. They could now move west. But Chris wanted to stay near his “nurturing, supporting” family, so the inviting Arizona desert was out. They have been married for 35 years and were looking forward to another trip to South Africa after the interview.

A Muddy Creek Forks Landmark

More Career Changes

With her family practice training finished, and a persistent urge to minister to the poor, she took a position with the (oddly-named) York Health Corporation in downtown York. Once again, many of her patients were non-white, and had little money, soothing her conscience regarding privilege. She loved working there. But (surprise!) that would not be the last phase of her varied career.

It turned out that the head of Psychiatry at the hospital, Dr. Kirk Pandelidis, wanted input from their primary care physician when a patient was admitted to the Psychiatry Service. Dr. Van Wyk, drawn to psychiatric patients, offered to do this on weekends for those without a personal doctor. 

The psychiatrists liked her work, and the part-time job became a full-time position. She would do the admission histories and physicals and follow up on any relevant blood work or imaging studies. Rita said that she “loved being the medical liaison on Psych for 21 years.” Little by little, she learned about the wounded spirit. How early painful experiences left their marks. And she felt useful and appreciated. 

In fact, she enjoyed listening to the patients so much, even those with full-blown psychoses or those with a tricky personality disorder, that she even considered doing a psychiatry residency!

We Stopped After a Text

(At this point in the interview, my husband Scott received a text. Former family court judge, The Honorable Penny Blackwell, who had been lingering with progressive parkinsonism with dementia, had passed away. We stopped talking and sat in silence for a few moments; the energy in the room was drained. We thought of her husband, Dr. John Sanstead. Jack, now retired, was my internist for years. He would gently hold my feet in his hands during a routine exam. He cannot be replaced. Dr. Van Wyk noted that in their periodic discussions on general medicine during her residency, Dr. Sanstead taught her some of the most important things she needed to learn to take care of patients skillfully.)

Family, Mental Health, Climate Change, Spirituality, and Racism

After this sadness, we talked a bit more about Rita’s dysfunctional family and how living through that helped her understand troubled psychiatric patients from impoverished and deprived backgrounds. And how, as a young child who couldn’t walk she would sometimes be placed in her seamstress-mother’s wicker basket of fabric scraps. And how her Auntie Sis showed how to sew the scraps together in a quilt to turn “trash to treasure.” (She still collects the discarded material from others when she attends retreats for serious quilters.)

We talked about how mental health services are woefully underfunded. We talked about how primary care physicians, including her internist-husband, are not allotted enough time to adequately take care of their complicated patients. We talked about the fact that the “main thing” in the clinic now is the ever-present computer. And how the system can wear you down and change you if you give in.

Rita's attempt to understand mental illnesses graphically
(scribbled in her copy of Psychiatry for the House Officer)

We talked about Rita’s despair regarding critical climate change spelling the possible end of humanity. And that while things may appear hopeless “there is always hope,” she said, but she “could be totally wrong.”

And we talked about spirituality. She believes that photosynthesis, whereby plants (she loves plants) receive light energy from the sun and store this as chemical energy for growth as they release oxygen proves, beyond any doubt, that there is a God. And she told me that she’s been a member of the Unitarian Universalist Church/Congregation of York since 1978, spreading “love and kindness, and understanding.” And that racism exists and hurts.

You see, there is increasing recognition of the importance of so-called social determinants of health and well-being. These are (according to the WHO) “the conditions in which people are born, grow, work, live, and age, and the wider set of forces and systems shaping daily life.”  

Racism, that is, bias against, and discrimination of, people on the basis of perceived but non-existent differences, is one of these determinants. It profoundly impacts physical and mental health. It must be addressed openly and honestly. It is present in South Africa and it is present and pervasive here. We need people to fix this. We need the Lamed Vavnicks.    


References and Suggested Readings

1. Paton, Alan. Cry, the Beloved Country. Charles Scribner's Sons. New York. 1948.  (The famous sad South African novel.) 

2. Rubin, Rabbi Lisa, "One of the 36." (Rosh Hashanah sermon on the Legend of the Lamed Vavnicks who "exemplify kindness, selflessness, and humility, 2023. (Click to watch the wonderful video.)

3. Tomb, David A. Psychiatry for the House Officer: Second Edition. Williams and Wilkens, Baltimore, 1984. (My husband had this small book--Rita's discarded copy!-- in his collection.)

4. Sima, Richard. "Racism takes a toll on the brain, research shows: The chronic stress of structural racism and discrimination damages brain circuits and mental health." Washington Post 2/16/23. (Link to the story)

5. Wilkerson, Isabel. Caste: The Origins of Our Discontent. Random House, New York, 2020.  (A broad exploration of the dangerous worldwide problem.) 




One of my 15 thriving African Violets


By Anita Cherry (10/22/23)