Dr. Tex Landis: The Importance of Being Earnest

 

Dr. Landis

The highlight of Tex’s day in college was peering through the small glass window of his box in the mailroom and finding a handwritten letter from his girlfriend back home, a thousand miles away. She wrote to him nearly daily; he replied about once a week. He was busy, and trying to find his way in the world. 

His father (William Landis) served as a flight surgeon in the military so the family moved around a lot. They were in Texas when he was born. Christened William, he immediately acquired the nickname “Little Tex.” The family can trace its roots in Lancaster County, Pennsylvania to the  1700s. So after spending time in Texas, they returned north to settle in a rural farming community outside of Marietta. Tex recalled that “you couldn’t see any neighbors” then. But there were streams to explore and plenty of interesting animals for a young boy with a curious mind to watch and “rescue.”   

He was happy. But when he was in the fifth grade someone had the nerve to build a house across their field, blocking his grand view of the natural world. How close was it you ask? It was nearly a quarter of a mile away; maybe within hollering distance, if the wind was just right. Tex was peeved.  

Lancaster County landscape (Credit: Wine-Searcher.com) 

But it wasn’t as bad as all that. You see, the man and his wife had two daughters and the younger became the letter-writer, and then Tex’s wife. So what seemed at first to be not so good became “one of the greatest blessings.”  Interesting lesson learned.  

Dr. William “Tex“ Landis told me he is very grateful for the people in his life, particularly his parents and his wife Desi (who sat next to him during our interview). His quietly stern father wanted his son to be bigger, tougher, and stronger than he was. His mother was unfailingly supportive. Together, they set safe boundaries for their four children (with four dogs) on the five-acre farm. 

As noted, Tex found particular pleasure in tending to wounded or abandoned animals he might come across. The list included a sparrow, a crow, a few rats, and even slithery snakes. His first job (at age 12 or 13, and for 25 cents an hour) was in a pet store. He liked the work and even thought he could have a career maintaining aquariums.

But it was not all nature. The house was full of books, and Tex would often pick out a Time-Life volume to read in bed. He did very well academically and dutifully learned to play the violin and (the ever-popular) clarinet. But he “lived” for sports, especially soccer and wrestling. He was pretty good at both, and they were formative; soccer taught him the importance of teamwork and wrestling gave him confidence and taught him to seize an opportunity (to make his “move”) when it is presented (since the steadily-ticking time clock might run out before he’s offered a second chance).

High School  

His 1975 Donegal High School wrestling team was undefeated and he lost only two matches. He is remembered (even 50 years later) for his quick recovery from a misstep that could have been terribly embarrassing. As he ran out to the center of the mat his foot caught the mat’s edge and he nearly fell face forward. But instantly, and without conscious thought, he did a flip and landed securely on his feet. Everybody watching was impressed; Tex was relieved.

A few "interesting" wrestling moves and holds-ouch! (Credit: scientificwrestling.com)

But let’s get back to Desi. Early on, young Tex wasn’t interested in either of the neighbor’s girls when they came over to skate on the Landis’s frozen pond or to swim in the pool. But by his junior year in high school, things looked different. At 16, in his underpowered 1951 Chevy pickup (that struggled to climb steep Chickies Hill Road by the Susquehanna River), he asked Desi for a date; would she go to the prom with him?  She accepted, of course, and their romantic relationship began. But it was soon time to decide on a college and a possible career.

At that point, Tex was still interested in pursuing marine/aquarium work and was still intensely sports-oriented. He realized that there were, as he said, some “dysfunctional” elements at home ( his successful family-physician father liked to drink) and he had to get away to grow. 

College

He decided to go to the Florida Institute of Technology (Florida Tech) in Melbourne. He would study biology. Maybe, he thought, he could even play soccer as a “walk-on.” 

Things were shaky at first. Tex drove down to the school in his Vega and briefly lived in the small car until he found a place to stay. The school’s admission policy was very liberal but the coursework (designed for nearby NASA scientists) was demanding and only 36 members of his freshman biology class of 300 graduated. As in high school, Tex was driven to excel, deciding not to settle for anything less than an A. He put his mind to it, worked hard, and finished at the top of the class. 

Olin Physical Sciences Center at Florida Tech (Credit: newsfit.edu)

(Why did he push himself? Tex innocently recalled that his drive to be the best “wasn’t discouraged” by his parents. His wife, as a somewhat more objective outsider, rather saw that it was “strongly encouraged.” Rashamon, once again.)

Questioning

Yet Tex craved more than worldly academic and athletic success. At 18, that critical time of questioning, he was thinking deeply about who he was, where he was going, and what might be his purpose in life. A key moment, perhaps “the key moment” in this quest occurred when a friend spoke passionately of the Bible and Christian Faith. This resonated with Tex and he eventually felt a strong need to “believe the Bible and to trust God.”  The beginnings of a maturing spiritual faith, the internal mandate that would guide his inner life.

As Tex studied the sacred texts, especially the succinct ethical sayings in the "wisdom" book of Proverbs, he realized that "serving God through serving others was a noble cause.” Actually “the cause.” How that might play out for Tex would take time; despite much success in college and finding the recognition he sought he still lacked a clear direction.  

As he made his way through his studies he began to feel that God was truly looking after him and protecting him. He liked “biology stuff” and his bio mentor asked if he ever thought about medical school. Tex reflected on his father’s work and saw that it was good. So he decided to pursue a medical career of his own. He took the few additional required courses and applied to medical school. He was accepted at the University of South Florida in Tampa while still in his junior year.

University of South Florida Medical School (Credit: health.usf.edu)

He proposed to Desi over Christmas during his senior year in college and they were married a week after graduation in June 1979. When Tex entered medical school ten days later, he and Desi “had nothing” (not even a kitchen table) but they were happy. She worked to support them while he studied and they had “enough to survive.” 

Medical School

During his intense three years of medical school (no summer breaks), Tex played intermural soccer for a while, but the rest of his time was “totally about study.” Again, he pushed himself and yet he was surprised when his friends told him that he, once more, graduated at the top of the class. He had enjoyed general hospital work and the challenges of the ICU and decided to pursue a career in internal medicine.

His advisor (who did not know him at all) didn’t like his plan to look at community as well as academic programs for a residency, and firmly recommended he stay at the University. Desi’s family was “relational” (Tex’s was not) and since both families resided in Pennsylvania Dr. Landis decided to leave Florida do his internal medicine training close to home.

As he looked at community programs in York and Reading, and at Geisinger, and the academic programs at Jefferson and Penn, he wanted to find “the best director.” By that time, Tex had learned that who he worked with became the most important factor in his education. The people were decisive.

Reading Hospital (the way it was) (Credit: Tower Health)

When he met with the illustrious, humane, and humble Dr. Eugene (Pat) Hildreth in Reading Tex knew he had found what he was looking for. Dr. Hildreth (as my husband, who was also trained in internal medicine in Reading before studying neurology, reminded me) surely had an unmistakable strong moral presence.

Residency and a Scare

So Tex began his General Internal Medicine residency in West Reading in 1982. He (like many other eager trainees) sought to emulate, to, in a sense, imitate, “The Chief” at first, but eventually (as others did before him) found his own style. Dr. Landis remarked that he was “extremely” influenced by Dr. Hildreth. And he liked the idea of being a general internist, treating the whole patient, rather than specializing in one organ system or discipline.

According to the American College of Physicians (of which Dr. Hildreth served as president, one of his many prestigious leadership roles): "Internal medicine physicians are trained to handle the broad and comprehensive spectrum of illnesses that affect adults, and are recognized as experts in diagnosis, in treatment of chronic illness, and in health promotion and disease prevention.”

In his third year of the residency, Desi (who already had a daughter) became pregnant again. But in the seventh month, she was at home when her water broke, the protective amniotic sac ruptured. At 32 weeks, it was a bit too early to deliver a baby safely since the so-called artificial surfactant that would help the immature lungs function better wasn’t available yet. Desi needed to be rushed sixty miles to Hershey Medical Center where they could do the delivery and take care of the fragile preemie.  

Hershey Medical Center (Credit: OnwardState.com)

Aware of the seriousness of the problem, Tex (who was working) left the Reading hospital and headed to Hershey to meet his wife for the birth. Losing the usually calm demeanor that he had when tending to critically ill patients, his heart pounded wildly as he imagined the worst, the potential future health issues. 

He drove as fast as was safe, but it wasn’t helpful; the baby came into the world in the ambulance on the Pennsylvania Turnpike. When he got to Hershey his newborn daughter was in the NICU on a ventilator. Things were quite rough for a while. But Tex found that simply talking with the neonatologist immediately calmed him. Another lesson; the anxiety and fear that inevitably accompany illness can be softened by compassionate empathic communication.

(Tex and his wife were reluctant about having a third child but their obstetrician in York, Dr. Leslie Robinson helped them work through their fears and all went well. However, his faith was severely tested–but sustained him–when, years later, his first grandchild died shortly after birth. This was, he said, “the saddest day” of his life.)  

Dr. Hildreth

Tex chose to stay in Reading for a fourth year as Chief Resident. The one-on-one mentoring relationship he enjoyed with Dr. Hildreth (whose patients he managed while Dr. Hildreth was away) greatly boosted his confidence in his abilities as a physician. And, foreshadowing things to come later in his career, his experience managing other physicians, learning what it meant to be a leader, was “rewarding and challenging.”

After that, Dr. Landis hoped to stay in Reading for practice but there were few good opportunities. While deciding what to do, he got a call from Dr. Ben Hoover in York. Would he like to interview for an unexpected opening for a partnership position with Brockie Internal Medicine? Tex was interested. He was suitably impressed by Dr. Hoover, liked the idea of becoming a partner rather than an employee, and joined the group. 

(Over the years, he learned a lot from Ben about taking care of patients as people, but also about the business of a thriving medical practice.)

Practice and Another Scare

With his Brockie partners, he did 75% inpatient work at the York Hospital (managing patients on the general floors and in the ICUs) and spent 25% of his time in outpatient practice (office, nursing home, and home visits). Dr. Landis cultivated an easy rapport with the busy ER physicians who called him in to admit patients. He was tireless and enjoyed the increasingly heavy and complex workload. Yes, he kept a positive attitude when his spirit could have easily been tested as the stresses of the ever-larger inpatient practice mounted.

But there was another more important test. When Desi was 37 she had a suspicious breast lesion. After it was biopsied, Tex reviewed the tissue slides with the pathologist. The lesion was a cancer. He came home prepared to tell his wife. As he hugged her tightly he could hear their hearts beating together; without words, she knew the ominous result. Tex had to devote more time to his family and a bit less to his career. The painful experience helped him become a more sympathetic (and empathic) physician. And a better husband, and father. 

New breast cancers by age; noting the need for earlier screening
(Credit: National Cancer Institute)

Back to the practice with Brockie. The inpatient demands were balanced by the less-stressful and more personal outpatient work. This part of the practice was emotionally rewarding for nearly 20 years as Dr. Landis developed warm friendships with his patients, and he and they experienced mutual abiding trust. But running back and forth from the office to the hospital (though it was only three traffic lights and less than a mile away) became cumbersome, especially as caring for the patients became more complex, highly technical, and increasingly time-consuming.  

Trust

Regarding the importance of trust in healthcare settings, Tex told a brief personal story in which it was abruptly lost. His wife had seen a specialist for heart problems. There was a significant abnormal finding on the CT scan. This was not addressed during the visit, even after direct questioning. No explanation for her symptoms was found and she was sent on her way. 

The official record of the encounter included a detailed physical exam, an exam that Tex knew was not done. Dr. Landis could no longer trust that physician with his wife’s health; he sought a second opinion for her problem. He is discouraged by the increasing lack of trust he sees within our health system. 

What are the elements of trust? In a 2023 article in The Hospitalist about building trust the writer notes that “trust consists of a belief that a person will behave in certain ways; an abstract attitude toward a proposition that someone is dependable; and a feeling of confidence, reliance, and security that the other person cares. And that to trust someone is to become vulnerable and dependent on the other person’s intentions and motivations.”  And that “as difficult as building trust can be, it comes down to two simple things—listening closely and caring about others.”

Hospitalists

By 1996, as an answer to the technical difficulty of tending to sicker and more complicated patients in the hospital while maintaining an efficient office practice in the era of so-called managed care (actually managed payment), the term “hospitalist” was coined. A general internist could decide to be a hospital-based specialist, with a full career devoted to doing complex inpatient medicine.  

The new idea caught on quickly in both community and academic centers. A ”large nationwide study of over 3,600 hospitals in 2005–2006 found that hospitals with hospitalists had higher quality of care in terms of diagnosis, management, and counseling/prevention for three common inpatient conditions: acute myocardial infarction, congestive heart failure, and pneumonia,” (Kulkarny and Wachter, 2024). 

Hospitalists have been active in teaching roles, in taking care of patients without housestaff, and in broad leadership positions developing diagnostic and therapeutic protocols and guidelines, and in enhancing communication among the increasing number of individuals involved in a patient’s care. Good communication, Tex emphasized, is vital, and a skill that can be learned; it requires sharply focused and sustained attention and awareness. And a commitment to getting it right, through practice.

As Dr. Landis foresaw the coming hospitalist movement he embraced it fully and became one of the first dedicated hospitalists at the York Hospital. The novel position was soon accepted by the general staff. In time, Dr. Landis took on more responsibilities. He served as the Medical Director of the WellSpan Hospitalists and in this “challenging” leadership position he managed 120 practitioners across several hospital sites. Expectations were high and could not always be met. But Tex has had an enduring belief in the still-evolving project.

Stepping Down 

By 2017, his full-time position (the highest clinical post in WellSpan) took a toll personally and professionally and (with a successor in place) he stepped down from his directorship. Tex has continued to fill in by doing strictly clinical work when it’s needed. As a result, he now has much more time to spend with his immediate and extended family.  And as he and Desi sat at the Thanksgiving table with ten members of their family Dr. Landis realized that “everything that was really important” for him was “right there, and the best thing” in his life. 

(Incidentally, before I send these tales out into the world the doctors profiled review them. My hope is that there is enough trust between us to allow the stories to be told faithfully and with compassion.)  

References and Selected Readings:

1. Collins, Thomas R. "Rebuilding Trust: A Top Priority for Hospitalists." The Hospitalist, November 14, 2023

2. Kulkarni, Shradha A., and Wachter, Robert M. "The Hospitalist Movement 25 Years Later." Annual Review of Medicine, Vol75; 381-390 2024.

3. Maxwell, John C. How Successful People Lead; Taking Your Influence to the Next Level. Center Street, New York, 2013. (Tex was influenced by Maxwell's popular teachings.)

4. Allport, Gordon W. The Individual and His Religion: A Psychological Interpretation. The Macmillan Company, New York, 1950. ("It is religion's peculiar secret that it brings to the individual a solemn assurance unlike anything else in life, an ever-present help in trouble, that makes next steps easier no matter what mesh of circumstances may entangle the life." p. 158)

By Anita Cherry 7/28/24

Toby (2010-2024)

Dr. Todd Butz Sometimes Gives His Sheep Animal Crackers with Their Grain

 You are here for a reason...  

                                                                102-year-old Holistic Physician Gladys McGarey, M.D.

Todd Butz, M.D.

Todd began life in a small rural town on the outskirts of the borough of Marietta in Lancaster County. The girl who would become his wife, Barb (seven years younger than him), lived about a mile away “as the crows fly.” His parents and her parents had purchased land from the same local farmer. And though one of his brothers was best friends with her brother, Todd didn’t meet Barb until he was already practicing medicine. 

This happened in 1994 at a 150th-anniversary banquet for their Catholic church. Todd’s mother had insisted that her four kids (including Todd’s two older brothers and his younger sister) attend, and  Barb was there. She and Todd married three years later.

 Dr. Todd Butz told me that he has been “fortunate, lucky, and blessed” as he had a lot of good people in his life and great parents. His father (in the family sign business) was of quiet, stoic German stock, while his mother (an R.N.) was an animated and passionate Italian.   

He believes that “creativity is what life is about” and early in his training he combined German technical insight and Italian passion with his family’s interest in sports to invent a unique exercise machine. It is worth telling this story in some detail.

You see, Todd was doing a Sports Medicine fellowship with Graduate Hospital in Philadelphia when he had a “crazy idea.”  He imagined a device to exercise “the torso” as he felt swimming did. Something to work the abdominal, hip flexor, and lower back muscles. Something that would allow for a prolonged session at a moderate aerobic intensity.  

He dreamed up a contraption that he called an ABDO-Cycle. You sat in it and it used a weighted flywheel with steady resistance to permit the user to perform repeated abdominal crunches and back extensions for minutes at a time. 

Barb on the ABDO-Cycle

Todd spent years (and a lot of money) on his idea. He tried to do the patent work himself but had to get an attorney (who charged him $10,000 to eventually use many of Todd’s own words). A friend’s father, an entrepreneur, helped him find an engineer to build a prototype. But the investor wanted substantial equity in the (proposed) company and Todd didn’t like that idea. 

Time passed, and after a prototype was finally fabricated, he decided to shop it around himself. A professional and talented graphic designer (it was Barb) produced a finely detailed brochure complete with a model (Barb, again) using the machine. The major fitness companies nibbled but didn’t bite. Dr. Butz said that he learned a lot about life from this experience. More than he learned, he noted, from college. 

(The model--the machine, not the girl–still resides in his attic. The girl is in the house proper.) 

It is not surprising that Todd’s creative drive would result in a piece of exercise equipment since he was part of a sports-oriented family. His dad had played football at the University of Florida and Todd and his brothers were in all the usual team sports from a young age. 

His mother (though not an athlete herself) was a fierce motivator (and a pretty good cook). He said that while she wouldn’t put direct pressure on him to do things, or to perform, she had her way. For example, he can still hear her saying (when he was away in medical school), “We have supper on Sunday and I made a lasagna and two dozen meatballs.” He knew what she really meant, and he could hardly fail to show up.

So after a childhood wrapped up in team sports and with no particular academic direction, Todd decided to go to the University of Delaware for football. While there, he first toyed with the idea of being an athletic trainer or a physical therapist. But when he watched the team doctor on the sidelines he decided to aim higher. 

University of Delaware football field (Credit: University of Delaware)

So he quietly squeezed in the needed premed courses. He didn’t tell anyone about his lofty goal until he was accepted to Hahneman and was on the wait list at Thomas Jefferson Medical College, both in downtown Philadelphia. 

Where should he go? He took advice from his knowledgeable football coach (who became a cardiologist). Todd waited a bit, got in to Jeff, and joined the coach, Joseph Bering, who was already there, two years ahead of him. 

He initially loved it in Philadelphia. But after two years of studying the basic sciences in the middle of a busy noisy city, he missed the peaceful countryside. So when he took a few clinical rotations at Geisinger Hospital in Danville in rural Northeast Pennsylvania, he was comforted by the calm environment, where he could see “cornfields and sunsets” again.

Sunset and cornfield (Credit: SimonSkafar)

During medical school, Todd’s evolving interests in sports, exercise, and preventive medicine led him to take an enlightening rotation with the famed Dr. Kenneth Cooper (who coined the term “aerobics” in 1968) at his clinic in Dallas. Dr. Cooper (who still works out five times a week at 93) was onto something that resonated with Todd.

Dr. Maddrey

Back in Philly, looking for a career path, Todd methodically crossed off one specialty after another (“Not this, not this…”). He finally settled on internal medicine, maybe cardiology. When it was time to look for a residency the Chairman of Medicine at Jefferson, the illustrious liver specialist Dr. Willis Maddrey, urged him to stay there for a life in academics. But Todd didn’t want that, he wanted to move back home.

In 1990, Lancaster (quite close to home) only had Family Medicine programs, so he ventured a bit farther away and looked at York Hospital’s Internal Medicine residency, York would be okay, still less than an hour’s drive from his home. 

As soon as he visited, he was impressed. He loved the congeniality as the doctors and nurses talked to one another face-to-face instead of communicating coldly on the patient’s chart, as they did in Philly.

Instantly comfortable in this atmosphere he thought, “This is where I want to be."

Todd had a happy experience as a resident. He believed he had outstanding training with a long list of wonderful physicians as he took specialty and general internal medicine rotations. (This was when almost all the attendings taught on a volunteer basis and gave freely of their time despite busy private practices.) 

After three years in York, Todd’s interests led him to the one-year Sports Medicine fellowship with a Graduate Hospital affiliate on the Main Line near Villanova. The staff at the large center served as the team doctors and therapists for the Phillies, Eagles, Flyers, and 76ers as well as Villanova athletes. They also did executive physicals, stress testing, and cancer screening. 

At the end of that year, Dr. Butz was again offered the option of staying in the Philadelphia area but chose to return home instead. (By the way, he had not yet met Barb.)  

Dr. Landis

What could he do? Thinking outside the box, he had an idea for a position in York. Over a steak dinner, he and Dr. William “Tex” Landis of the Brockie Internal Medicine group sketched the plan on a napkin. From his experience as a resident, he knew the practice and the physicians well. He proposed (that is, invented, created) a brilliant role for a single guy: he would admit and manage the Brockie patients (including new patients coming through the busy ER) at night. 

This would allow the overworked internists who were running back and forth from the office to the hospital and taking night-call to count on getting regular sleep. The idea was accepted, and Dr. Butz did this full-time for five years. And it was during this nocturnal phase of his career that he met and then married Barb.

But as the night schedule became too stressful to maintain, and thinking ahead, he had other plans. So in 1999, he went half-time with the enlarging WellSpan system and started a preventive medicine clinic across the river near Lancaster. At that time, before the Affordable Care Act changed things, preventive services, he noted, were generally not covered by insurance.

He did stress-testing and calculated VO2max (how much oxygen you can use during exercise) using Dr. Cooper’s data, and other stuff like that. Nearly 25 years ago, Dr. Butz counseled interested people on the importance of a balanced diet and regular exercise. He advised them to stop smoking, to get enough sleep, and to be better at managing life’s inevitable stresses. 

Todd thought that it was “crazy” that “we wait for people to get sick and then pump them with pills.” He knew that prevention of illness was a much saner approach to long-term health. Dr. Peter Attia, writing in his 2023 bestseller Outlive, calls this (not so new) idea “Medicine 3.0.” 

(In his book, Dr. Attia carefully explores the best science and emphasizes the age-old appeal of a personalized nutrition plan to prevent cardiovascular disease and diabetes and the complications thereof. He is especially enthusiastic about the remarkable ability of regular aerobic activity and strength training to delay the onset of a wide variety of diseases and to meaningfully extend our “healthspan,” not simply our lifespan. And he eventually recognizes that achieving emotional health often requires prevention.)  

While Dr. Butz was a resident, he had given a Grand Rounds presentation to the staff entitled (quoting a phrase often attributed to Hippocrates around 2,500 years ago) “Let Food be Your Medicine.” He is still keenly invested in this idea and feels that “we do best on fuels that our remote ancestors ate.”  

As we sat and talked, Todd mentioned the decades-long “Seven Countries Study” spearheaded by Ancel Keys. First published in 1978, the observational study of middle-aged men was started in 1958 near the height of the heart disease epidemic. Serum cholesterol, blood pressure, diabetes, and smoking were clearly seen as risk factors for coronary disease. And it suggested that certain dietary patterns played a role.

Location of cohorts (often in villages) in the 7-Countries Study

The nutritional aspect appeared to be the amount of saturated vs. unsaturated fat in the typical diet. The countries with a lot of saturated fat in the diet (e.g., Finland) tended to have way more heart disease than those with much less (i.e., Japan). Part of the war on heart disease became a war on saturated fat and cholesterol in the diet.

So as we became increasingly health-conscious and weight-conscious, we became fat-conscious. And in the 1980's the American food industry responded. Since saturated fat was “bad” they would use sugar to replace it in prepared foods and snacks to keep them tasty (and to keep us buying). 

We ate less fat. But a lot more sugar. Yes, a lot more sugar. And as we took more of our calories as “added sugar” (most often in surgary drinks) we ingested more calories overall. The prevalence of obesity and type 2 diabetes nearly doubled from 1980 to the early 2000s and has continued to rise. We became fatter and sicker, rather than thinner and healthier.  

The shocking increase in obesity from 1987 to 2021 (Credit: CDC)

What happened? Table sugar (sucrose) is 50% glucose and 50% fructose. Glucose is used immediately as fuel. Fructose is metabolized differently than glucose and if it is excessive it is stored as fat (to survive a cold winter with sparse food supplies). It is put away first in muscles, and then in the liver. Too much eventually leads to insulin resistance, diabetes, an increase in LDL and a decrease in HDL cholesterol (made in the liver), elevated triglycerides, and chronic inflammation.  

Part of the problem for us is that sugar is enticing and rewarding, and, therefore, potentially addicting. It produces momentary pleasure, a desire for more of it, and uncomfortable withdrawal symptoms when it is no longer available.  As Gary Taubes states in (probably rightly) calling sugar a drug of addiction: it makes children happy, at least for the period they’re consuming it…(but the) downside is that they “will come to expect another dose, perhaps to demand it on a regular basis.” (p. 31) We get hooked early.

(A childhood memory: Uncle Sol sold candy. I looked forward to his visits and I can recall the excitement at seeing the long thin red licorice “shoelaces” or “lariates” he brought with him. I twisted, braided, and knotted them in anticipation of their chewy sweet taste. The pleasant sugar high was soon followed by a disheartening letdown; I wanted more. I knew early on that sugar affected me strongly and I gave it up nearly altogether in my teens, in the early 1970’s.)

(Don't they look good?)

Dr. Butz said that the massive decades-long Keys study can be criticized for “cherry-picking” the data (leaving out countries that were initially to be included, 20 countries in total) and ignoring or downplaying the role of high sugar intake in heart disease. 

The truth, said Todd, is that no correlation could have been established between fat consumption and heart disease if the data from all 20 countries were used.  Nevertheless, Keys and his colleagues championed a diet low in saturated fat to combat heart disease (by lowering, it turns out, the all-important serum LDL cholesterol). The possible role of too much sugar and simple carbohydrates was ignored.  

Anyway, enough about sugar. Let’s get back to our main subject, Dr. Butz. He ran back and forth to his Lancaster clinic for three years until the commute became too much for his soon-to-be growing family. So, for their protection, he put his preventive medicine practice and the soaring ABDO-Cycle dream away and took a hospital position with good benefits.  

Dr. Van Wyck

As Todd returned to WellSpan full-time in the fall of 2002, he helped Dr. Rita Van Wyck do inpatient medical consults for the psychiatrists (where he learned a lot about mental health). And as the local family practices were one-by-one bought by the system he helped Dr. Douglas Rubelmann admit patients from the different groups. He also did some moonlighting for the Brockie physicians who had been greatly disappointed when he left his night-coverage position with them. 

Recounting this part of his journey, Dr. Butz told me, with a quick laugh, that he “seemed to do the things that other people didn’t want to do.” And he quickly added that he likes new challenges.

But over the years, the easy fellowship at the hospital that so impressed him began to erode. The expanding health systems became more corporate, industrialized, and impersonal. Todd said that doctors are, by nature, independent. So they were easy isolated targets, sitting ducks, as the art of medicine was lost to a business with multiple layers of managers setting and enforcing policy. Physicians gradually became “disengaged.”

Morale declined, so that simply walking through the hospital corridors became a gloomy experience. Dr. Butz recalled one of the corporate solutions: the 5/10 rule, a take on the “Ritz-Carlton 5/10 Way” designed to improve customer satisfaction. 

The idea is simple. If you are ten feet from someone in the hospital you make eye contact and greet them with a smile. If you are within five feet you smile and say hello. Mandated civility to improve the bottom line, sort of like a high-end hotel.

So Dr. Butz took on a new challenge in 2014 after Dr. Jonathan Whitney asked him to help with so-called case management as a physician advisor. In the late 1990s Medicare and private insurance companies, to reduce spending on healthcare overall, labeled some in-hospital services as “outpatient status.” They could reimburse the hospital much less for this than the same service deemed as “inpatient.” There had to be a clear justification for “inpatient status” or such additional payments would be denied. 

According to a 2016 Report on Medicare Compliance newsletter:

To comply with the two-midnight rule (for a justified admission), Todd Butz, physician adviser at WellSpan Health in York, Pa., is trying to get physicians on the same page, free of considerations that are beside the point. That means placing patients in observation or admitting them as inpatients because that’s the appropriate level of care, regardless of the impact on copays or skilled nursing facility admissions, or the hospital’s worries about revenue, patient-satisfaction scores or readmission penalties.

Dr. Whitney and Todd sometimes had to call out insurance companies when it was felt that their decisions about payment were wrong. Dr. Butz reviewed pediatric, obstetric, and surgical cases as well as internal medicine encounters, so he had to broaden his medical knowledge significantly, and he liked that challenge.

He did this for more than four years for WellSpan and then decided to work as a self-employed consultant for a hospital in Maine that sought his specialized expertise. Todd did this for another five years until Optum came to Maine and his services were no longer needed.  

So in May of last year (2023) as he felt “out of balance” he chose to take a break from the grind of working seven days a week. He needed to “unwind.”  At age 60, as “the next chapter has yet to be written,” Dr. Butz has been spending more effort on his farmette a few miles south of his home. He and his wife and their two teenage children can “unplug” in the peaceful environment that is like a “time machine.”

There is an 1850s log cabin with enough steeply banked ground to need a few sheep to keep the grass and weeds down. He stops by to feed the two ewes daily; they like Animal Crackers (this English delicacy was first made in the US at Stauffer’s in York in 1871, where they still turn out a million daily) along with their grain. 

The Butz's quiet rural retreat

He also has a good-sized and varied organic vegetable garden and he planted ten young fruit trees (already bearing fruit). He is paying careful attention to nutrition as he tries to adhere to a version of a low (starchy-) carbohydrate diet that includes beef from pasture-raised cattle and “lots of eggs” (scrambled, and always with onion) laid by happy free-range hens. He makes his own butter and yogurt, and he enjoys snacking on olives and tree nuts instead of chips (despite the fact that York County is the unofficial potato chip capital of the entire world).  

Returning to a regular exercise regimen, to routine physical activity, he often starts his day with a long meditative swim at the York JCC, where we sometimes cross paths and chat. 

What have we learned from Dr. Butz? Prevention of illness makes more sense than waiting to treat entrenched disease. We can start improving our food choices by cutting back on starchy carbohydrates, sugar, and calories. The Mediterranean diet is a good model, and buying fresh local produce or even growing some of our own vegetables is preferred to mindlessly consuming highly processed packaged food. Regular exercise is essential for good health; we need to keep moving and stay strong. So it might be time to brush off the old ABDO-Cycle, stationary bike, or treadmill collecting dust in the attic.  And we should, following Todd, not be afraid to take chances, to be creative, to try something new. And it is good to feel connected to the land.

Dr. Todd Butz and his family

Readings and References:

1. Anon. "Guided by Pocket Card, Doctors Are Coaxed To Keep it Simple With Two-Midnight Rule." Report on Medicare Compliance, Volume 25, Number 34, September 19, 2016. (Explaining Todd's foray from direct patient care.)

2. Attia, Peter, M.D. with Gifford, Bill. Outlive: The Science & Art of Longevity. Harmony Books, New York, 1993. (Synthesis of a lot of fascinating deep technical information, but quite readable and recommended highly.)    

3. McGarey, Gladys, M.D. The Well-Lived Life: A 102-year-old Doctor's Six Secrets to Health and Happiness at Every Age. Atria Books. New York, 2023. (The "mother" of holistic medicine in 1978 addressing the health of the brain, body, and, especially, spirit. You can watch her YouTube interview.) 

3. Nozowitz, Dan. "Why are So Dang Many Potato Chip Brands from Pennsylvania?" Atlas Obscura. October 24, 2017. (Is it the climate? The soil? The German ancestry?)

4. Taubes, Gary. The Case Against Sugar. Alfred A. Knopf. New York, 2016. (A strong argument that we need to pay attention to.)

By Anita Cherry  (04/21/24)

Soaring Hawk in Flight in Florida (Photo by SC)

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)