(A surgeonÕs memoir)
* * *
Title of the Hebrew original:בחרתי
בכירורגיה
ISBN 965-294-139-5 דב
ויסברג
3rd edition (***)
Copyright Dov Weissberg © 2009
All rights reserved. No parts of this publication may be reproduced, stored
in a retrieval system or transmitted in any form or by any means, without permission in writing from the copyright holder.
Dov Weissberg, M.D.
11 BeÕeri Street
Rehovot 76352, ISRAEL
Telephone 972-8-946-6194
Fax 972-8-946-8065
e-mail dovw@post.tau.ac.il
www.dovweissberg.com
- the first surgeon in the family,
and to my daughter Dorit, who continues
in the tradition of medicine
Preface |
|
9 |
Chapter 1. |
The first steps |
15 |
Chapter 2. |
From Rambam to America |
34 |
Chapter 3. |
Training program with a curriculum |
45 |
Chapter 4. |
Mississippi |
68 |
Chapter 5. |
The interim period: Toronto and New York |
98 |
Chapter 6. |
Shmuel Harofe Hospital |
121 |
Chapter 7. |
Struggle at the Wolfson Hospital |
141 |
Chapter 8. |
Widening of horizons |
159 |
Epilogue |
|
186 |
Preface
This is a book of memoirs. Its building elements are stories from my life, my experiences. Some touched my very soul and influenced the most important decisions in my life; others carry a simple message or a moral.
Many people contributed to my professional career: teachers, pupils, colleagues, patients under my care and my family. I owe all of them a debt of gratitude and would like to express my feelings of appreciation and thanks for their contribution. Among these, my wife Milka and my children Yifat, Dorit, Limor and Avishai occupy the most prominent place. They gave me all their love and support, and accepted with patience and understanding the harsh reality that kept me busy and usually away from home. They encouraged me to write this book and helped me to edit the material.
Throughout the entire text
I tried not to offend anyone. For the most part, I believe, I succeeded;
although criticism could not always be avoided. If, in spite of my efforts,
some individuals will take offense, I ask for their understanding and
forgiveness.
* * *
I do not remember
whether I ever consciously ÒdecidedÓ to become a doctor. This decision must
have been inborn, although there were at least two factors that helped strengthen
it. One was my mother. She was a strong-willed woman, with a legendary power of
persistence. It was clear to her, even before we were born, that both her sons
(my younger brother and I) must and will be physicians. Any other turn of
events was out of question. Any thought that we may, perhaps, choose some other
profession or occupation, simply did not cross her mind.
In pre-war Poland it was
difficult for Jews to be admitted to universities, particularly to medicine.
Many were rejected because of Ònumerus claususÓ – limitation on the
number of Jews that were permitted to study at universities. Friends asked my
mother: ÒWhat if they will not be permitted to study in Poland?Ó To this my
mother had a ready answer: ÒThen I will send them to England or to Switzerland.
Here or there, they will study medicineÓ. Such were her dreams. But life
refused to cooperate. Instead of studies in Switzerland, came World War II and
the Holocaust (Fig. 1).
Fig. 1. It was clear to my
mother that her sons will be physicians.
The second factor was my
uncle Joseph (J—zek), my motherÕs younger
brother. He was not accepted for studies in Poland and studied medicine in
Italy. J—zek was a charming person, friendly and full of joy. He played the
guitar and the violin, painted (some of his paintings decorated our walls),
sang beautiful Italian songs, and in a most entertaining way, explained secrets
of the human anatomy or of the Italian language. Everybody loved him. I was
attracted by his company and, as a matter of fact, saw in him a prime example
of an ideal human being. Whenever he came to Poland for vacation, I had a real
holiday.
I believe that somewhere in
the depth of my subconscious, this self-identification with J—zek, my love and admiration
for him were of crucial influence in my decision to become a doctor.
During the war and the
German occupation, in his assumed new identity as a Polish-Christian, J—zek became a member of the
Polish underground movement Armia Krajowa. He participated in the Warsaw
Uprising and, regrettably, was killed in September 1944. He was awarded the
Polish Cross of Valor (Krzyż Walecznych) posthumously. To him I dedicate
this book (Fig. 2).
During my studies in high
school, my mind was already made-up. I wanted to study medicine. Nothing else
would do. For the time being, the general term ÒmedicineÓ sufficed, without
further analysis. However, at that time I read several books about famous
physicians and their discoveries. A particularly fascinating one was Paul de
KruifÕs ÒThe Microbe HuntersÓ. Dramatic descriptions of tropical diseases and
the excitement surrounding the discovery of microbes and parasites, all these
brought me dreams about a career of science and exploration. Why shouldnÕt I
become part of the wonderful worlds of discovery? Why couldnÕt I be one
of those who uncover these worlds and thus save thousands of lives? Later,
during bacteriology studies at the University, I saw this exciting field in an
entirely different perspective. Bacteriology appeared to me a boring routine of
inoculating colonies of microorganisms on agar plates and growing cultures;
plenty of dull routine and very little drama. I enjoyed studying anatomy,
histology and pathology and at some time even considered making them my career.
But bacteriology and parasitology, as seen closely, did not attract me. I
studied enough to pass the examinations, but a career of preparing culture
media for microorganisms had no appeal to me.
Fig. 2. My uncle J—zek (Dr. J—zef Klinger) and his Cross
of Valor.
A dramatic change took place
at the outset of my clinical studies. Contact with patients, listening to their
histories and examining them, and finally, clinical analysis and treatment
spoke directly to my soul. All remnants of my dreams about research and
discoveries vanished without a trace. It is impossible not to relate this
change to my teacher, Professor Moshe Rachmilevitz, chief of the Department of
Medicine in Hadassah. He engraved his unmistakable mark on studentsÕ minds: the
understanding that there is need for clear thought and simple logic (Òclinical
logicÓ – his favorite expression). In particular, he taught his pupils
how to distinguish between the clinically important and the insignificant.
ÒRetain the important and dispose of the rubbishÓ. Moshe Rachmilevitz taught me
to love clinical medicine. During my studies under him, there was almost no
doubt in my mind that in the future I will be an internist.
Surgery was different. I
was not nearly as attracted to it as to internal medicine. As a surgeon, it is
now embarrassing for me to confess, but after the period spent in the
Department of Medicine, my rotation through Surgery was rather dull. This was
not due to the nature of surgery itself, but rather because of the way we were
taught. On Medicine, every student was in charge of a number of patients, had
to participate in their diagnostic workup, try to diagnose the case and suggest
treatment. On Surgery, the students were supposed to admit patients, obtain
their clinical history, do complete physical examination, and then present them
at the bedside rounds. During presentation we were asked questions supposed to
arouse interest and to help in our studies. But in contrast to Medicine, the
clinical workup was limited, and entirely in the hands of physicians. Students
could ask questions and received instructions. But the feeling of being part of
the team was missing. Our role was passive. My function as a student in the
Department of Surgery did not stimulate a desire to become a surgeon.
This changed completely
upon my return to the Department of Surgery two years later, as an intern. All
patients on the service were now under my care, and I had to suggest their
diagnostic workup and treatment. Participation of interns in operations was
very limited, and usually not beyond holding retractors, sometimes for long
hours. However, if I prepared myself beforehand by reading relevant material, I
understood what was going on and the procedure itself was interesting.
Moreover, in Surgery I
could immediately see the results of treatment, and they were much more
definitive. On the medical service a patient discharged after treatment for a
congestive heart failure can return two weeks later with the same problem.
Feeling of disappointment is then unavoidable. But a patient, who undergoes
resection of a gallbladder full of gallstones, does not return with the same
stones and the same pain. Surgery is much more dramatic and decisive, features
that befitted my taste and temperament. My rotation as intern in the Department
of Surgery was therefore crucial in choosing the field of medicine appropriate
for me.
1
The first steps
During my internship at Hadassah, an
accident occurred that critically influenced my entire professional future.
Friday morning, 18 January 1957, on my way to the Hospital, I slipped in the
rain and fell. I felt instant pain in my left hip and could not get back on my
feet. People on the street helped me, and I continued slowly, limping all the
way to the Hospital. I started my routine work - drawing blood samples, preparing
patientsÕ charts for rounds with the Professor, and similar chores. While doing
all this, my limping became more obvious and arose general attention. Dr.
Shlomo Rogel, at that time a medical resident and later professor and
well-known cardiologist in Jerusalem, insisted that I get a radiogram. Finally,
against my wishes, he sent me to the radiology department. The radiogram showed
fracture of the femoral neck. I was not permitted to get up from the table. I
was immediately transferred to the Emergency Room and was operated on that same
day. Dr. Makin, chief of the orthopedic division, fixed my broken bone using a
Smith-Petersen nail that remained in my body until the hip replacement 46 years
later. During the operation a number of complications occurred. As a result, I
remained in the hospital for a whole month, and in a convalescent home for
another month. For four months I was not permitted to use my left leg, and had
to walk on crutches. The curriculum of my internship was modified, to enable me
to be in ÒeasierÓ departments during this difficult period.
Just at that time several
resident positions became available in the Department of Surgery and a tender
was announced. The candidates were interviewed in the Lecture Room of the
Department of Surgery – the famous ÒshackÓ in the yard of the Ziv
Building. Not doubting that my chances were excellent, I applied for the job.
Judging from my student record and my performance as intern, there was no doubt
in my mind that my residency position was assured.
When the judgesÕ decision
was announced, the results amazed me. I was not accepted. The shock was beyond
description. I felt that a great injustice had been done to me. I did not
understand what had happened and could not accept the verdict. True, all the
candidates were good, and the number of positions was limited, but still, the
fact that of several available openings not one was offered to me, did not make
sense. To me it seemed a terrible distortion of impartiality. For the next 29
years, long after recovering from the shock, the puzzle did not stop mystifying
me. In 1986, when I had already been Chief of the Department of Surgery for 15
years, I happened to visit Professor Theodor Wiznitzer in Tel Aviv. We were
drinking coffee and telling stories. In 1957, when the candidates for the
position of resident were interviewed in Hadassah, Wiznitzer served there as a
senior surgical resident. During the interviews, he entered the shack several
times with some information for the senior surgeons and stayed for a while in
the room. In this way he had an occasion to overhear some of the reasoning in
favor and against the various candidates. When the candidate – Dov
Weissberg – entered the room limping and supported by crutches, all the
favorable impression from his good work as intern was forgotten in an instant.
The judges saw only the limping intern supported by crutches, and nothing
beyond. ÒCan this disabled young physician be a surgeon?Ó was their only
thought. My fate was decided once and for all. From this moment on I had no
chance to be accepted for a residency in Hadassah.
Had I been accepted in
Hadassah, my career would probably have developed differently than in fact
happened. Had I been... But whatever happened, had happened and it was
irreversible. The senior surgeons remained my friends and through letters of
recommendation and phone conversations helped me obtain a residency position.
But not in Hadassah. This was the way that led me to the Rambam Hospital in
Haifa, Department of Surgery B. Chief of the department, Dr. David Erlik (later
Professor Erlik, founder of the Abba Khushi School of Medicine in Haifa)
himself went through surgical training in Hadassah and all the senior surgeons
there were his friends. Their recommendation was enough to ensure being
accepted to his department. Indeed, this time there were no difficulties, and
the tender was a simple formality. Because of my recent fracture, my military
service was postponed for one year, and I could start the surgical residency
immediately after my internship (Fig. 3).
Fig. 3. The Graduation; the author first from right.
One day in January 1958,
just before the end of my internship, I went to Haifa for an interview with Dr.
Erlik. He showed me the hospital and invited me to see some operations. The
schedule for that day included a porta-caval shunt, a major and new operation
at the time. Dr. Erlik was the first surgeon in Israel to have performed this
kind of operation successfully, and it was interesting to see him do it. I
stood behind him and observed. One of the side-lamps obscured part of the
operative field, so I shifted it slightly to the side. While I did this, the
lamp hit the main headlight suspended from the ceiling, covered with a special
opaque pane. The pane broke with great noise and shreds of glass fell in all
directions. It was pure luck that no glass fell into the open belly. I wanted
to bury myself on the spot. But Dr. Erlik tolerated the accident with patience
and humor. WasnÕt this accident a sign from heaven, an omen forecasting the
upcoming developments in Rambam?
* * *
I completed my internship
in Hadassah on 31 January 1958 and
on 1 February started the residency in Surgery. The Rambam Hospital had two
Departments of Surgery: A and B. Department A took care of general surgery
only. Department B (that of Dr. Erlik) handled, in addition to general surgery,
also urology and vascular surgery. The background of this state of affairs
should be explained, because it sheds light on Dr. ErlikÕs distinctive personality.
In 1948, after the creation
of the State of Israel, the British Hospital in Haifa became the Israeli Rambam
Government Hospital. At that time the hospital did not yet have a separate
urology service. Patients with urologic problems were treated, as in many other
hospitals, in the Department of Surgery. To aid in the development of the
hospital, a decision was made in the Ministry of Health, to open a separate
urology service. Dr. Erlik from Hadassah became the chief of this new service.
Due to his past experience in Hadassah, Erlik was equally proficient both in
surgery and in urology, liked both, and had not the slightest intention of
cutting himself off from either one of these branches. From the beginning, as
the new chief, he admitted to his unit patients with both kinds of problems
– general surgical, and urologic. The new unit became not just a urology
service, but a full-fledged Department of Surgery, with urology as part of it.
In retrospect, the Ministry of Health recognized the fact that two Departments
of Surgery are better for the Rambam Hospital than one, and acceded to the new
reality. But Dr. Erlik did not stop there. At that time a new branch of surgery
started developing - vascular surgery - a novelty that appealed to Dr. Erlik
very much. Within a short time this branch also became part of Dr. ErlikÕs
department, which by now had changed its name from Urology to Department of
Surgery B. In later years, Erlik performed the first successful kidney
transplantation in Israel. Accordingly, his residents had an opportunity to
learn and gain experience not only in general surgery, but much beyond. And not
just an opportunity; there was simply no other way. The program required
more effort, but provided greater experience.
Surgery flowed in Dr. ErlikÕs
veins and his grasp of it was all-inclusive. He never hesitated to perform
important, life-saving operations in any anatomic region outside of his domain.
Chest surgery was not out of bounds, although he never studied it. I remember a
soldier brought in as an emergency. He was wounded in the chest. Blood was
flowing freely through the tube drain placed in his chest. The young man, with
blood pressure near zero, was close to death. Without a momentÕs hesitation Dr.
Erlik opened his chest. The lung and pulmonary vessels were torn, and there was
no way to stop the bleeding, short of resection of the entire lung. Erlik
caught the pulmonary hilum (root of the lung) with his hand, pressed on it
firmly and placed several heavy sutures on the entire mass of tissue, without
trying to separate between the pulmonary artery, veins and bronchus. The
bleeding stopped. He placed some more sutures to make sure that the bleeding
would not restart. When the patientÕs blood pressure began to rise, Erlik cut
off the lung beyond the sutures and removed it from the chest. Then, in a voice
expressing great satisfaction, he said: ÒThis is the way to do a
pneumonectomy.Ó To all present it was obvious that he had never before
performed this kind of operation. He probably never even saw one being done.
Indeed, this was not the way to do a pneumonectomy. But the bleeding did
stop, and the soldier recovered and was discharged from the hospital. Many
surgeons, among them chiefs of departments who had never learned how to do a
pneumonectomy, would have stood there helpless, while the patient
exsanguinated. But not Dr. Erlik. Erlik judged surgeons according to their
performance in the operating room. He classified them either as Òsurgical
stuffÓ or Ònon-surgical stuff.Ó If there ever was a physician made of Òsurgical
stuffÓ, it was Erlik.
Dr. Erlik demanded absolute
discipline and promptness. I remember the appendectomy of Dr. Fliegelman, Chief
of the Department of Psychiatry in our hospital. Dr. Erlik made the diagnosis
while examining him at home. The operation had to be done immediately. It was
afternoon. Dr. Erlik was busy with some other business, which influenced his
mood unfavorably. I was in the hospital on first call for emergencies. Dr.
Erlik called me and demanded that the patient be on the operating table at 5
oÕclock. Exactly at 5. I did all I could to complete the examination and
bring the patient to the operating room on time, but an unexpected obstacle
prevented me from achieving it: Dr. David Barzilai, a senior physician (later,
chief of the Department of Medicine), decided to obtain an electrocardiogram
before the operation. Due to some technical problem, it was impossible to make
the EKG machine work, and Barzilai stubbornly refused to transfer Dr.
Fliegelman from the Emergency Room to the operating suite without an EKG
record. I told him that Dr. Erlik wishes to have the patient on the table at 5
oÕclock, wants to start the operation exactly on time and is in bad mood. ÒDo
you want the Chief of Department to undergo an operation without an EKG
record?Ó asked Barzilai with derision. To my answer, ÒYes, this is what Dr.
Erlik ordered,Ó Barzilai did not even bother to answer. At 5 p.m. exactly Dr.
Erlik entered the operating room, but the patient was not there: he was still
waiting for the EKG in the Emergency Room. With shouts of rage Dr. Erlik ran to
the Emergency Room and Dr. Fliegelman was immediately sent to the operating
theater. Without an EKG. The operation started after 6 p.m. and
throughout its entire course I felt Dr. ErlikÕs anger.
* * *
When I came to the Rambam
Hospital, all the work on the service, including emergencies on our days on
call was done by three physicians: Dr. Singer - deputy chief of the department,
Dr. Schramek - senior surgeon and Dr. Levin - second year resident, one year
ahead of me. I was the fourth to join the team. Occasionally we had an intern
for a month, but unlike Hadassah, most of the time there was no such luxury in
Rambam. Just then Dr. Singer left for a sabbatical year in the United States,
and all the work in the 45 bed department, plus emergency calls, was carried on
by the reduced team. To make the picture complete, it should be clarified that
in those years, the Emergency Room of the Rothschild Hospital in Haifa was open
for emergencies only one day a week, and the Carmel Hospital did not have an
emergency department and did not accept emergencies at all. In 1958, the
Emergency Room of Rambam Hospital was the busiest and carried the greatest
burden of all the hospitals in Israel. There were, as I mentioned, two
Departments of Surgery in the hospital, each with two residents. The nights on
call were divided equally between the two departments. As senior surgeon, Dr.
Schramek did not take emergency calls in the hospital (he was on second call at
home). Each one of the four residents was, therefore, on emergency call every
fourth night. When one of the residents was called to the Armed Forces for
reserve duty (which accumulated to several months per year), we were on call
every third night. No one thought that the Emergency Room should have a team of
its own, or, at least one surgical resident just for itself. Nights on call
were hard. The single surgical resident set into a perpetual motion was
cruising between the Emergency Room, the operating room (emergency operations)
and both surgical services, taking care of IVs and other urgent matters there.
Today it is difficult to imagine the war-like situation that prevailed in the
Rambam Hospital in those days. Many times, the work in the operating room went
on uninterruptedly until morning hours, and through the windows one could see
the rising sun, while no one attended to the Emergency Room, where patients
were waiting...
I remember one early
morning following a 24-hour period of uninterrupted work, I was assisting Dr.
Schramek on a lengthy operation. In the midst of it, I fell asleep. I woke up
from a roaring shout of Schramek in Yiddish: ÒWeissberg, shluf nisht (donÕt
sleep)!Ó It was a rare occasion that a surgical resident actually slept while
on a night duty; usually my bed remained untouched. On the day following the
night duty, came the usual routine of morning rounds, drawing blood samples,
operations, admitting new patients, and so on, until late afternoon or evening
hours. In view of this intolerable situation, we went to Dr. Erlik to complain.
We asked for a solution, which would make our work a little easier. His
response was short and typical: ÒYou donÕt know how lucky you are, that you
have something to do.Ó That was it. At the time we found it difficult to
understand the great wisdom in Dr. ErlikÕs words. Yes, I really mean it.
Please, try to imagine for a moment people who have nothing to do. There are
many. I know them and pity them much more than those young surgeons (including
myself) who have no time to be bored. On our free evenings we found time for
recreation, company, studies and hobbies. Indeed, I did have girlfriends, saw
plays, read books and scientific journals, and more. Anyone who cannot bear
this load, perhaps should not be a surgeon... Is this the way it should be? No,
certainly not. But this is the way surgery was taught in the past; the way
generations of surgeons have grown. And one can live with it. However, if good
results are to be expected from such exertion and stress, two prerequisites
must be fulfilled: friendly atmosphere and feeling of progress.
The senior surgeon in our
department, Dr. Alfred Schramek worked hard and demanded a lot, not only from
others, but from himself as well. He was broadly educated, had a fine sense of
humor, spoke several languages fluently, loved music and understood literature
and art. One could converse with him on any subject. In short, an intelligent
person. But he was hard to work with, did not excel in politeness and in
gentleness, and I, the most junior member of the team, felt it well. Dr. Dan
Levin, although only one year ahead of me, let me feel his seniority at every
opportunity. The atmosphere in our department and in the entire hospital was
unpleasant and gave me the feeling of deprivation. Dr. Yaakov Singer, deputy
chief of the department, was patient and friendly, but this did not help me
when he was studying in America while I was trying to adapt to the uninviting
environment. I recall many incidents that exemplify the Rambam atmosphere at
that time. A patient with multiple injuries was hospitalized on our service.
His broken leg was in a cast. Dr. Steiner, chief of the Department of
Orthopedics was supposed to decide when to take the cast off. When the time
came, Dr. Erlik ordered me to remind Dr. Steiner, which I did. Dr. Steiner gave
me a scorning look and quietly said ÒgoodÓ. Then he waited patiently. On the
day when Dr. Erlik made bedside rounds (ÒGrand RoundsÓ – twice a week),
and when the entire retinue was in the 20-bed ward, a deafening noise of an
electric saw burst suddenly in the room. It was Dr. Steiner, removing the cast.
This was his way to demonstrate displeasure. Dr. Erlik stopped the rounds,
approached Dr. Steiner and asked him what happened. To this Dr. Steiner
answered: ÒYour junior resident gave me an order to take the cast off. ThatÕs
all.Ó Apparently the way I addressed him was not sufficiently polite, or,
perhaps he preferred to be invited for a consultation, so that he
would decide what to do, rather than being reminded what had to be done. But
instead of pointing this out to me, he preferred to make this theatrical
demonstration. Dr. Steiner had his own peculiar sense of humor, not always
pleasant to his victims.
The Department of Orthopedics
did not always have a resident on night call. Minor orthopedic emergencies were
taken care of by the surgical resident, who called a senior orthopedist when
needed. One evening I was called to see a patient whose leg was in a cast; his
toes had become blue and swollen. The cast was apparently too tight and the
foot was in danger. I opened the lower part of the cast with an electric saw,
to relieve the pressure. I had seen this many times done by experienced
orthopedists. The patientÕs foot improved immediately. The next day, Dr.
Steiner, short of staff, needed assistance on an operation, and I was sent to
help him. After the operation he turned to me and said: ÒI would like to thank
you for your help...Ó Certain that Dr. Steiner was talking about my help in the
operation that we had just completed, I answered: ÒNot at all, I will gladly
help, whenever you needÓ. But Dr. Steiner kept talking: Ò... for your
ÔwonderfulÕ help in opening the cast last night,Ó and continued criticizing my
way of releasing the pressure, which apparently was not done in the best
possible way.
With regard to the feeling
of progress, the situation in Rambam surprised me greatly and gave me much
to think about. Basic teaching methods, such as clinical sessions, bedside
rounds with instruction, and preparation of subjects for seminars and lectures,
in Hadassah were taken for granted. In Rambam of 1958 they simply did not
exist. The active method of teaching introduced in Hadassah by Dr. Nathan
Saltz, based on the North American residency training program, had been
initiated by William Halsted at the end of the nineteenth century. It put
emphasis on active teaching and gradually increasing the responsibility of the
surgeon-in-training (resident). There was an explanation for the lack of
similar training program in Rambam: ÒYou see how busy we are; there is simply
no time for lectures and discussions. Treating patients comes before anything
else.Ó This was certainly true: hospitals do exist first of all for the purpose
of treating patients. However, even simple clinical or technical questions
asked during an operation or at bedside rounds, were left unanswered, with a
curt ÒI donÕt have time now, letÕs move on.Ó In short, I came to the Rambam
Hospital to learn surgery, and after a short while, I had the feeling of
marching in one spot. One typical incident clearly illustrates the prevailing
situation and the reasons for my frustration.
I had worked already for
several months in the department and assisted in many inguinal hernia operations.
On the day of the incident the operating schedule included, among others, two
boys, 6-year-old twins, both with an inguinal hernia. Dr. Erlik was supposed to
operate on both of them, and he chose me to assist him. While we were scrubbing
for the first operation, I asked him whether I might operate on one of the
boys. Dr. Erlik was visibly shocked by my question. His wet hands, one holding
a scrubbing brush, stopped in midair. His eyes, greatly surprised, fixed on me
while he asked: ÒWeissberg, are you crazy?! You want to operate on a
hernia? A hernia is a serious operation! You have to learn first how to do it.Ó
If Dr. Erlik was shocked by my question, I was not less shocked by his answer.
During my internship in Hadassah I had already operated on a hernia. It was
customary that a hard-working, good intern who was interested in surgery, was
rewarded toward the end of his rotation either with an appendectomy or a
herniorrhaphy. Of course, this operation was done under the supervision of a
senior surgeon, but it was the intern who performed the operation with his own
hands, and thus learned. Due to the close supervision, the patient was not
endangered in any way. The supervising surgeon (in my case Theodor Wiznitzer)
was at the head. Had there been any difficulty, he would have taken over and
completed the operation by himself. There were no such fancy games in Rambam.
* * *
Dr. Erlik had a number of
principles with regard to surgical technique. One was the need for a
sufficiently long incision at every operation. He insisted that a surgeon
should have plenty of space available with a comfortable approach to all
structures and a possibility to accomplish the purpose of the operation without
compromising the patientÕs safety. He pointed out jokingly that an incision
heals from side to side, not from end to end. This principle is worth
remembering now, in the days of minimally invasive surgery, when the tiniest
possible incision is pursued above all other considerations. Without denying
the advantages of minimally invasive surgery that did not exist in the 1950s, I
often see surgeons, some with considerable experience and knowledge, who
struggle helplessly with abdominal or thoracic organs because of their
difficulty to reach some remote corner of the belly, sometimes causing great
damage to tissues. All this, in order to avoid an incision of adequate length.
The size of the scar seems more important.
Another of Dr. ErlikÕs
principles was related to the resection of the thyroid gland. A common complication
of this operation is damage to the recurrent laryngeal nerve, the nerve
that controls the muscles of the larynx. Injury to this nerve causes speech
impairment and must be avoided. While operating on the thyroid gland, some
surgeons separate this nerve to protect it against damage. Dr. Erlik claimed
that looking for the nerve and dissecting it may be harmful; it is preferable
to avoid injury by staying away from it. His results with thyroid operations
were excellent, and I do not recall a single case of injury to the laryngeal
nerve in our department. One day a well known surgeon from Boston visited
Israel. Dr. Berlin was world-famous in the field of thyroid surgery. He
insisted that it is essential to dissect the entire length of the recurrent
laryngeal nerve, to see it clearly and thus protect it. Dr. Erlik invited
Berlin to operate on one of our patients. Dr. Berlin demonstrated his technique
clearly, and skillfully separated the nerve from the surrounding tissues.
Everything seemed in best order. However, after the operation, the patientÕs
voice was hoarse, and a laryngoscopy[1] demonstrated paralysis of
one of his vocal cords... This was
the first time that I have seen both, how to separate and protect the
recurrent laryngeal nerve, and this kind of complication. For many months
we joked at the expense of the famous visitor. Apparently Dr. ErlikÕs principle
was worth more than the elegant demonstration of the nerve.
* * *
There was a general
frustration among the residents. Our progress was far too slow, and we all felt
immense starvation for operating. Itzhak Horowitz, a resident in the Department
of Surgery A and later chief of surgery in the Rothschild Hospital, was two
years ahead of me in training. Toward the end of his third year in surgery, he
was still not permitted to do a cholecystectomy, and Itzik was ÒhotÓ to perform
it. During one of his nights on call, a patient entered the Emergency Room. She
complained of abdominal pain, vomited, and her abdomen was tender in the proximity
of the gallbladder. The diagnosis of acute cholecystitis due to gallstones was
clear. Horowitz had waited a long time for such a case, and his course of
action was planned well ahead of time. He declared that the patient had acute
appendicitis, wrote this diagnosis on the admission chart and, according to
routine, took the patient to the operating room. Dr. Schramek was on second
call at home, but Horowitz decided not to inform him about the case, at least
for a while. He asked me to help him on an ÓappendectomyÓ. At that time all abdominal
operations in Dr. ErlikÕs department were done through vertical incisions.
Contrary to many surgeons, Dr. Erlik preferred this incision to all others.
This fit exactly HorowitzÕs plan. While realizing that the correct diagnosis
was acute cholecystitis, he made the incision in the lower abdomen on the right
side, as for an appendectomy. As soon as the belly was open, the appendix was
found to be normal, as expected. Horowitz resected it, then said ÒletÕs see
whatÕs in the gallbladderÓ, and extended the incision upward. He found the
gallbladder inflamed and full of stones, and started the resection. When this
was nearly completed, he asked one of the nurses to call Dr. Schramek and to
inform him that during a routine appendectomy an inflamed gallbladder was found
and had to be resected. ÒPerhaps he wants to come, although it is not
necessary. I can manage it by myself.Ó By the time Schramek arrived, the
gallbladder was already out and the abdomen almost closed. Horowitz said:
ÒSchramek, there is no need for you to scrub in, the gallbladder is already
out.Ó Schramek was flabbergasted. He barely managed to utter the words: ÒHorowitz,
what have you done?!Ó ÒA cholecystectomyÓ, answered Horowitz, calm and
relaxed. He did not show any signs of emotion. Eventually, this entire incident
passed without further turbulence. I was too timid and too new in the trade for
such tricks, but even much later, I have never reached this level of abusing
the regulations.
During the first year of my
surgical residency (not an internship anymore!) I was permitted to do
appendectomies, but never a case of an inguinal hernia, hemorrhoids, varicose
veins etc. Obviously, a cholecystectomy was beyond discussion. I worked in the
Rambam Hospital, with an interruption, for a total of nearly two years. During
the second year, likewise, I have not done any of these operations, that in the
spectrum of general surgery are not considered Òmajor,Ó except for three
operations of inguinal hernia. These were awarded to me through the kindness of
Dr. Singer who consented to help and instruct me. Appendectomies and three
inguinal herniorrhaphies – this was the total surgical experience that I
managed to accumulate during two years of such hard labor in the department of
surgery. I felt I was walking in one place and wasting time.
I had enough of the Rambam
Hospital and did not want to stay. But what could I do? I went to meet some of
my former teachers, chiefs of various surgical services in Hadassah (general,
thoracic and others). Conversations with them clarified to me ultimately that
my way to Hadassah was blocked. If I was unhappy in Rambam, whose fault was it?
Perhaps I was not good enough. And if I failed in Rambam, why should they risk
it and take me on? But I believe that there was one other, major reason for
their reluctance to specifically accept me as resident in
Hadassah: it was their concern not to offend Dr. Erlik. There were plenty of
other candidates whose acceptance would not offend anybody. Eventually I realized
that my efforts in Hadassah were wasted; there was no point trying there.
Should I start looking for a residency position in other hospitals in Israel?
As a matter of fact I worried that a position in some other hospital might not
necessarily be better than my present position in Rambam, but still, I tried.
Several department chiefs in Tel Hashomer and in Beilinson answered my
inquiries: ÒYou have an excellent residency position in Rambam. Why are you
looking for a job?Ó Again, the same suspicions and the same reasons for not
accepting me, as in Hadassah. There remained two options: to resign myself to
the state of affairs in Rambam, or, to give up surgery and specialize in a
different branch of medicine.
Or..., there were before me
physicians who went to specialize in the land of unlimited possibilities - the
United States of America. The most striking example was Dr. Saltz from
Hadassah. He did not really ÒgoÓ to the United States, as he was born in New
York, but he took his surgical residency there. I personally saw the truly
impressive results of his training. I started inquiring among my friends who
have spent various periods of study in North America, and I obtained a lot of
valuable information and some good advice.
In order to work in the
United States as a physician, a foreign medical graduate must first pass
examinations both in medicine and in English, to satisfy the requirements of
the American authorities – the ECFMG.
To expedite matters, I
decided not to take the full advantage of my one-year postponement, but
to leave the Rambam Hospital as soon as possible and get over with my military
service. I contacted the military authorities and informed the SurgeonÕs
General Office that my disability is over. I feel well, I function well, and am
ready to serve. Within days I was notified that the next Medical OfficersÕ
Course is expected to open in October (a couple of months ahead), and received
an order to return to service. I parted from my colleagues at Rambam with good
feelings, we maintained contact and remained friends.
The OfficersÕ Course
started on 8 October 1958. It was enjoyable and, unexpectedly, quite
interesting. Part of it was military training, but a considerable portion was
spent in the various departments of Tel Hashomer Hospital (later renamed Sheba
Medical Center). From time to time I participated in operations and learned.
For the first time I saw that clinical and surgical problems can be approached
in different ways in various departments, and that these differences are discussed
freely, rather than dogmatically dismissed. I learned to set broken bones and
to immobilize fractures in a cast. I particularly enjoyed seeing lung
operations elegantly executed by Dr. Yehuda Pauzner (Fig. 4).
After graduating from the
course, I spent a short holiday in Eilat – my first visit there.
Following that, I served in various units of the Air Force and took a course in
Aviation Medicine. In parallel, I took emergency calls on weekends and nights
in the Rambam Hospital, for a fee. In addition to the income, these calls
helped me stay in touch with surgery and with the hospital.
In the beginning of 1960,
due to some obligation on the part of the Israel Defense Force (IDF), the
Medical Corps was supposed to provide a military physician who would work for
one year in the Rambam Hospital as part of his
military service.
Fig. 4. At the OfficersÕ Course: in the center Prof. Spira
and the author holding a bottle of brandy.
Dr. Erlik
realized that after having spent eight months in his department, I had
experience in taking emergency calls, could assist in operations, and could no
doubt work more efficiently than some newcomer who had never worked in surgery
before. Therefore, he requested from Col. Dr. Baruch Pade, the IDF Surgeon General,
to send to Rambam not just any military physician, but me. Dr. Pade objected.
According to the administrative routine in the Medical Corps, I was supposed to
serve in a field unit and was not entitled to the ÒtreatÓ of spending one year
in a hospital, without committing myself to an additional period of service.
But, when Erlik wanted something, he knew how to insist. No one could refuse
him. To fulfill his wishes, I was sent to serve in Rambam for one whole year.
The first six months were
to be spent on the neurosurgical service. This was new to me. During the years
in the Medical School and in my internship I never spent any time on
neurosurgery, and this was my first opportunity to learn something in this
field. The sole resident that worked there, had just left in rage after a fight
with the chief, and Dr. Eli Peyser remained alone. I came to fill the vacuum.
Besides the chief, I was the only doctor on this 14-bed service, always full,
all its patients seriously ill.
Dr. Peyser was a difficult
person, short on patience, exploding easily. However, he was a very good
surgeon and an excellent teacher. He taught me how to perform a thorough
neurologic examination, management of trauma to the central nervous system, and
more. He instructed me in reading articles relevant to our patientsÕ problems
and invested great effort in my education. As his only resident, I participated
in every single neurosurgical operation done in Rambam during the 6 months I
spent on his service. However, as the only junior member of the team, I was on
call every day and night, seven days a week. On days without operations, I
could leave the hospital, but had to be within reach by phone, and not too far
from the hospital. I found out to what ridiculous situations this can lead, when
I was called from a movie theater in the middle of a movie. In the hospital
they knew my seat number and called the theater. My girlfriend went home (she
did not want to stay and watch the movie alone), while I went to the hospital
for an emergency operation. A rather unpleasant experience.
For the remaining 6 months
I returned to the Department of Surgery B. During my absence, Dr. Singer
returned from the United States, and the general atmosphere became more
tolerable. Also, the surgical team had expanded by a couple of new residents
and I, as an old-timer among them, felt certain superiority.
There were rumors that Dr.
Singer may accept a position of a department chief in the Rothschild Hospital.
During a coffee break, this possibility was a subject of conversation. When I
uttered a few words, Dr. Yaakov Assa, a new resident, asked me with some
derision: ÒAre you also interested in applying for the position?Ó I felt
embarrassed, and did not know what to say. Instead of me, Dr. Erlik answered in
Russian: ÒNie tot soldat, kotoriy nie khochet bytÕ generalomÓ (One is no
soldier, if he does not desire to become a general). Suddenly, I felt like a
victor, because even at that early time, there was a glimmer of hope in the
depth of my heart to become one day chief of my own department. Erlik
understood this.
While working in Rambam, I
learned to keep Dr. Erlik in the highest esteem. Today I understand that he was
one of the greatest surgeons I ever met. In my memory he remains engraved as a
man of great wisdom and integrity, made of the most distinguished Òsurgical
stuff.Ó He was a man of impeccable character, utterly devoted to his patients
and always ready to support his pupils. All those who managed to endure his
residency program, have reached important positions in surgery; several became
professors and department chiefs. Also, one should remember that Dr. Erlik was
the decisive factor in founding the Medical School in Haifa, and its first
dean. Without him, establishment of this important institution would have been
delayed for many years. A great man (Fig. 5).
Fig. 5. Dr. David Erlik,
1960.
2
From Rambam to America
Upon my return to the Rambam Hospital in 1960, I met Jack Abouav. Jack
completed his medical studies in Hadassah in 1952, four classes ahead of me.
After the internship, he went to the United States to learn surgery. He stayed
there for six years: four, as a resident in surgery at the Mount Zion Hospital
in San Francisco, and two, as a resident in thoracic surgery at the Albert
Einstein College of Medicine - Bronx Municipal Hospital Center in New York.
Close to the end of his residency he met Dr. Erlik.
Dr. Erlik was a man of wide
horizons, concerned not only with the future of his own department, but also
with the expansion and progress of the entire Rambam Hospital. He wanted to
establish a first rate medical center in Haifa, with its own medical school,
based on Rambam and serving the entire north of Israel. Within several years
this dream became a reality due to his initiative and persistent efforts. The
nearing return of Abouav to Israel presented Dr. Erlik with an opportunity to
bring to Rambam a young, capable, and well-trained thoracic surgeon. For Abouav
it was an opportunity to return to Israel and obtain a senior position in a large
and growing medical center, with prospects to become the future chief of a new
department. At their meeting in New York, they agreed that Jack will start
working in Rambam, in Dr. ErlikÕs department, and will be in charge of all
thoracic patients. With time, the number of patients and the volume of work
will grow, creating appropriate conditions for opening a separate thoracic
surgical unit or department. Obviously, when the time comes to open such a
unit, Abouav will be appointed as chief.
In 1959 Jack graduated from
the residency program, passed the American Board examinations, and returned to
Israel, to the Rambam Hospital. He entered his new job with eagerness and zeal,
was involved in general, vascular, as well as thoracic surgery, and in parallel
was active outside of the hospital, not sparing efforts to attract to Rambam
patients in need of thoracic operations. The number of those patients grew
steadily. Jack also enjoyed teaching. At the bedside, in the operating room and
in clinical discussions, he explained everything with enthusiasm (strangely, he
managed to find time for those activities). When asked, Abouav either gave the
correct answer, or responded with questions that stimulated thought. When the
answer did not satisfy him, he recommended appropriate reading material (Fig.
6). A spirit of learning was felt in the department. Also, the way he spoke to
everybody was noted. Whether it was the most junior member of the staff or a
nurse, he spoke politely, quietly, without rage; an unusual way of
communicating in Rambam prior to his arrival. Jack was an asset, which
everybody recognized and respected. Obviously, those features were acquired
while he went through residency training in the United States. I reflected on
it and asked myself: ÒIf this is how they learn surgery in America, then what
the hell am I doing here?!Ó
At that time I had already
been studying for the ECFMG examinations, and started correspondence with
several institutions, the best and most prestigious ones in the United States
and Canada. I thought it pointless to take a position in a mediocre hospital,
just because it was in America. I chose the hospitals on advice of several
physicians who had spent time in America and had some idea, where and how to
look for a residency. My list included Johns Hopkins, Mayo Clinic, Peter Bent
Brigham, McGill, and several other medical centers of the highest caliber. I
showed my list to Abouav. He looked at it, listened patiently to what I had to
say, and finally suggested that I write to Dr. David State, Chairman of the
Department of Surgery at the Albert Einstein College of Medicine, the
institution at which he himself took residency training in thoracic surgery. He
recommended State warmly as a teacher and as a person, and said: ÒMayo Clinic,
Johns Hopkins and the others on your list, will remain a dream. With State you
have a chance to be accepted. Write to him. I was trained by him and I do not
regret it.Ó So I wrote.
Fig. 6.
Dr. Jack Abouav, Rambam Hospital, 1960.
On 21 September 1960 I
passed the ECFMG examinations and the following December received a letter from
Dr. State, informing me that I had been accepted for residency at the Albert
Einstein (Fig. 7). Toward the move, I turned to some of my Medical School
teachers for letters of recommendation. They wrote good letters. I never used
them, but the wonderful collection remains in my possession until this day.
Fig. 7. The letter from Dr.
State.
Only two of my teachers
refused my request: Dr. Moshe Prywes and Prof. Moshe Rachmilevitz. Dr. Prywes,
at that time Deputy Dean of the Faculty of Medicine and in later days President
of the Ben Gurion University and Dean of the Faculty of Medicine at that
University, claimed that it is not good for me to go to the United States at
this early stage of training. Physicians who go to specialize there, reach such
high levels of professional expertise, that there is no place in Israel to
which they can return. Every job offer in Israel seems too small to them, and
eventually they stay in America. Thus most Israelis who go to the United States
prematurely, at their own initiative, do not return. My explanations about my
great disappointment in Rambam did not convince him. Dr. Prywes suggested that
I look for another place in Israel. It will be better for me to go to America
later, for a more advanced specialization. The hospital that will send me
there, will be obliged to keep a position reserved for me until I return.
Professor Rachmilevitz saw
my plans for residency training in the United States as a preparation for
settling there permanently. The idea of abandoning Israel was preposterous to
him. He told me that bluntly. He did not want to listen to my explanations
about Rambam and assurances that I do intend to return to Israel.
The intentions of both
teachers were good and motivated by genuine concern. Both tried to prevent
emigration of their pupils, graduates of IsraelÕs only Medical School. Much
effort and expense was invested in our education, and we were expected to stay
and serve our people.
While the arguments of Dr.
Prywes did not impress me, the words of Professor Rachmilevitz Òso you decided
to emigrateÓ touched my very soul. I have no other land and the thought of
emigration never occurred to me, but I felt that I caused pain and did great
injustice to the dearest, most important and most respected of all my teachers.
He invested so much in my medical education, and I had offended him. The memory
of our conversation did not leave me during all the years I spent in America
and did not let my conscience rest. Eventually, when I returned with my family
to Israel, I went to see Professor Rachmilevitz and reminded him of our sad and
unfortunate conversation. I told him where I had been, what I had done, and
what I am now doing in Israel. He smiled. It made him feel well. So it did to
me. And I am sorry that he cannot read this book and accept it as my apology
(Fig. 8).
Fig. 8.
My venerable teacher, Professor Moshe Rachmilevitz.
I was discharged from the
military service at the end of February 1961. During the month of March I made
preparations for the trip, and on 3 April was on my way. After paying for the
trip to America (flight from Tel Aviv to Rome and travel by ship from
Marseilles to New York), I had $200 left, which I decided to spend on a 2-month
excursion in Europe. A 2-month excursion in Europe on $200? Yes, if one sleeps
in youth hostels, travels by hitchhiking, enters museums with a student
discount or on days when the entrance is free, and eats only bread with
margarine; in 1961 this was possible. Indeed, I managed to survive. I was not
really hungry, and hitchhiking was more interesting than travel by train or by
bus, and much cheaper. I managed to visit every museum I wanted, climb any
tower and see any opera I desired, including the Opera of Rome and La Scala in
Milano. The performance of Madame Butterfly with Antonietta Stella and Fernando
Corena in La Scala was unforgettable. I saw Italy, Austria, Switzerland,
Holland and France, and on 22 May boarded in Marseilles the S. S. Zion. We
reached New York on 2 June, and in my pocket I still had $10 for Òsmall
expensesÓ. During the month of June I stayed with my motherÕs cousin, Edith
Abner, and ÒstudiedÓ New York.
On 1 July I started my new
job at the Bronx Municipal Hospital Center, the main teaching hospital of the
Albert Einstein College of Medicine. I was given a room in the Staff House, and
the hospital took care of the residentsÕ laundry and supplied us with three
free meals a day. And no wonder - the salary of first year resident was $2580
per year ($215 per month), well below the poverty line by the U.S. standards of
1961 (Fig. 9).
After I received my first
salary, I entered a branch of the Chase-Manhattan Bank located in the vicinity
of the hospital, opened an account and deposited my check. Then, in the
hospital, I asked one of the doctors whether Chase-Manhattan is a good bank.
ÒFor your $200 it is good enough,Ó answered Dr. Henry Friedman.
Fig. 9.
Certificate of Eligibility for Exchange Visitor Status, specifying the
conditions of work and fee.
For this salary the
physician worked full time and was on emergency calls every other day. Thus we
worked a whole day, night and another day, before having a free night. This was
the system during all the years of my residency. Fifteen or 16 nights on call
every month. In my first letter to Dr. Erlik I described the situation, adding
that it is not customary here to complain. My colleagues in Rambam wrote to me
that Dr. Erlik underlined those words, and on bedside rounds attached the
letter with a safety pin to his coat. All could read and appreciate how good
they have it in Rambam.
* * *
My residency started with a
rotation on the Urology Service. During my second week there, they already let
me operate. There was a patient with carcinoma of the prostate and metastatic
spread. In addition to chemotherapy and hormones, the treatment included
orchiectomy (amputation of the testicles). This operation is quite simple and
it was decided that I will do it. In order to be prepared, I studied all stages
of this procedure in an Atlas of Urology. A resident in a more advanced stage
of training assisted me. Several minutes after I started, Dr. Leo Charendoff,
the almighty Chief Resident entered the operating room. ÒDoctor Weissberg,Ó
I heard his voice. ÒI am here.Ó ÒYou are here? And what are you doing?Ó ÒThis
is Mr. PosnerÓ, I responded. I told him the name of the patient, so he would
know who I am operating on. ÒI know that this is Mr. Posner, but what are
you doing?Ó The intonation of Dr. CharendoffÕs voice sounded rather severe.
ÒI am doing a bilateral orchiectomy.Ó ÒAnd why are you doing it?Ó asked
Charendoff. ÒBecause Mr. Posner has cancer of the prostate.Ó ÒSo why do you do
an orchiectomy, not a prostatectomy?!Ó Only then did it occur to me, that
Charendoff did not ask because he did not know what I am doing. He knew this
very well, since he himself decided and wrote the operating schedule. He wanted
to know whether I understand why an orchiectomy is necessary in a patient with
prostate cancer. I prepared myself by studying the technical stages of the
operation, but it did not cross my mind to review the physiology and pathology
of the prostate and to learn about the changes that occur in the prostate as a
result of orchiectomy. Charendoff did not relax, and continued his
investigation mercilessly. At the end of the operation I was covered with
sweat. This was the first time that I was taught during the operation as it
always should have been, and the last time that I came to operate unprepared. A
lesson of exceptional value. It sufficed for the rest of my life.
I had one more undesirable
incident with Dr. Charendoff. He knew that I had worked in the
surgical-urologic department of Dr. Erlik, before coming to the United States.
I also told him that I have done a cystoscopy in the past, which was true. When
I asked Dr. Erlik to let me do cystoscopies, he said: ÒYou will be allowed to
do, when you know how to take care of the complications.Ó But Dr. Singer was
more liberal, and let me do one, while he supervised. The procedure passed
uneventfully and seemed easy. However, the cystoscopy that I did under Dr.
CharendoffÕs supervision, was not so uneventful. I perforated the urethra.
However, by this time, I knew how to treat this complication. I removed the
cystoscope and Charendoff inserted a catheter into the bladder. The perforation
healed within a few days.
Would it have been more appropriate not
to let me do the procedure and so prevent the complication? He who does not
operate has no operative complications, but how does one learn surgery? How did
Doctor Erlik learn? Was it by not operating? As my training progressed,
I caused many more complications. What surgeon did not? But with the passage of
time and growing experience, my work improved, and I learned not only how to
treat complications, but also how to avoid them.
* * *
Jack Abouav did not stay
long at Rambam. In 1960 a thoracic surgeon from South Africa immigrated and
settled in Israel. After a job could not be found for him in Hadassah and in
Tel Hashomer, someone in the Ministry of Health thought up the idea that a
position could be created in Rambam - a separate Department of Thoracic
Surgery. Therefore, arrangements were made, and the new Department was opened,
upon the foundations laid during the previous year by Abouav. It was widely
known that Abouav was a capable and successful thoracic surgeon. Everybody
valued and highly appreciated his clinical and organizing work, but the new
thoracic surgeon was older, and therefore, supposedly, more experienced. He
became chief of the department. Abouav found himself in the position of the new
directorÕs deputy (his assistant, as a matter of fact). He became deeply
offended. Assurances had been given to him that he would be the chief, once the
department is established. His bossÕs manners did not make things easier. He
treated Abouav with ostentatious criticism and disrespect.
According to the American
immigration laws, a foreign physician who comes for postgraduate education, is
granted a visa (Exchange Visitor, Visa J) that enables him to stay in the
United States until the completion of training. Following this, the physician
has to leave the United States, and must not return for at least 24 months.
This regulation was enacted in order to encourage physicians to return to their
countries of origin and improve the standard of medical care there, while using
the knowledge and experience gained in America. Because of this regulation,
Jack had no choice, and remained under the new chiefÕs heavy hand until the end
of the two-year period. He did not stay in Israel a day longer, and left
greatly disappointed and embittered. His old teacher in San Francisco, Dr.
Rosenman accepted him with open arms to the Mt. Zion Hospital, where he settled
permanently and spent the remainder of his professional life. He did not try to
return to Israel. The Mt. Zion Hospital gained a capable surgeon, full of
energy and enthusiasm. The main loser of the affair was the Rambam Hospital in
Haifa. And I learned from this story an important lesson, to which I will
return later in the book.
3
Training program with a curriculum
In the United States, the training program in surgery
is determined by the American Board of Surgery. Chiefs of surgery in accredited
hospitals are responsible for carrying out the requirements of the Board, while
strict control is maintained over the quality of the training and the volume of
operative experience of every resident. The minimum period of training is four
years. However, every department chairman can extend it by a year or more,
according to his own judgment and the needs of the hospitalÕs particular
residency program. Toward the end of his training, the resident submits a
detailed list of operations that he had performed by himself, and those in
which he participated as the first assistant. A minimum number of each kind of
operation is required and strictly adhered to. After approval by the Board, the
resident is permitted to take the examinations that will qualify him as a
specialist in his particular field.[2]
Dr. David State, Chairman of the Department of Surgery
at the Albert Einstein College of Medicine, had been trained by Owen
Wangensteen at the University of Minnesota, was involved in scientific research
and desired to transfer this tradition to his pupils. According to this
concept, he added one year to the four required by the Board. During this extra
year, every resident worked in surgical research (laboratory or clinical). The
first two years of the residency were spent on rotation between the various
surgical services and the resident gained clinical and operative experience.
The third year was devoted to research, but the resident still spent nights on
duty in the Emergency Room. This was to assure that he would not lose contact
with clinical medicine. During the fourth year, as senior resident, he was
again on the clinical services, and now his work included more advanced
operations and greater clinical responsibility. During the fifth and last year,
as chief resident, he had the ultimate responsibility for patients in his
charge. He decided which operations to perform by himself, and which to let
others do. The operating room schedule was checked and usually confirmed by the
department chairman. In the most extensive operations, particularly those that
he had not done before, one of the senior surgeons, qualified as a specialist,
supervised and assisted him. The rule of chief resident was almost absolute. He
divided the work between the other residents on the service, and devoted to
their training as much or as little time as he desired, all according to his
own judgment and sometimes caprice. He also evaluated the work and progress of
the trainees under his control and reported this to the department chairman.
These reports became part of the residentÕs permanent record and influenced the
chiefÕs decision – whose training to extend and whom to fire. In this
connection I must mention Dr. Ronald Dee, the best chief resident I met during
all the years of my training. He spent many hours introducing me to ÒpracticalÓ
surgery and taught me many Òsecrets of the tradeÓ, both in clinical approaches
and in surgical techniques – this particular aspect of teaching that I
had longed for at Rambam Hospital. We remain friends until this very day. There
were also chief residents of a different kind, who took advantage of their
position and coerced all kinds of personal services from their subordinates.
* * *
Three or four times a week, one hour was devoted to
teaching and to the discussion of problems on the service; this included the
mortality and morbidity conference, analysis of recently published journal
articles (ÒJournal ClubÓ), practical instruction in anatomy with dissection of
cadavers, etc. We worked hard and did not have time to waste. As in the Rambam
Hospital, this caused much fatigue. I remember a young Japanese intern, Dr.
Takaro Suzuki, who was so tired that he fell asleep while examining a patient.
I remember the strange view of an unconscious female patient stretched out on
the examining table and lying on her, across the table, Dr. Suzuki, stethoscope
clutched in hand, deeply asleep and snoring loudly. I tried to wake him up,
pulled him firmly by the shoulder and yelled directly to his ear ÒSuzuki, wake
up!Ó but to no avail. The chief resident, Dr. Chinda Suwanraks, who heard me
yelling, entered the room, evaluated the situation, and decided that whatever
we do, Suzuki would not wake up. We picked him off the patient and gently put
him on the floor. Then I, instead of my sleeping intern, examined the patient.
This incident reminded me of that night in Rambam, when I fell asleep during an
operation, but with one difference: Dr. Schramek had no difficulty waking me
up. Suzuki, known for his drinking habits, was probably drunk at the time.
* * *
Whether a patient should be told the entire truth
about his condition, is a matter of controversy. There are differences between
the Israeli-European, and American approaches. What to tell a patient with an
incurable disease? This is a humane-psychological matter, with deep roots in
medical ethics. Considerable progress has been made in recent years, but the
ideal solution has not yet been found. During the years spent in medical school
and at the Rambam Hospital, I had been repeatedly told, how important it is to
soothe patients and keep them calm. The truth should never be mercilessly
thrown into the patientÕs face. Hiding it was customary with a variety of
diseases. If high blood pressure did not drop in response to treatment, the
patient was not told so, for fear that this would cause the blood pressure to
rise even more. This ÒsoothingÓ approach reached various degrees. Among the
physicians I met, there were great liars, small liars, and some, who tried to
avoid lying as much as possible, but in general, the tendency was to make the
patient calm at almost any cost. This was as important as the treatment itself,
if not more so. The intention was always good. For what can be more important than
protecting patients from the harsh reality of an incurable malignant disease?
The thought behind this was that if the cruel truth becomes disclosed, the
patient might commit suicide.
I remember a 50-year-old patient, admitted to the
Rambam Hospital because of rectal bleeding. She had cancer of the rectum and
was supposed to undergo abdomino-perineal resection of the rectum with creation
of an artificial opening in the abdominal wall (colostomy) for bowel movements.
This is unquestionably a major and traumatic operation. How does one obtain the
patientÕs consent for it, without disclosing to her the unpleasant diagnosis?
The solution seemed relatively simple. The patient was told that she had
hemorrhoids and needed an operation. Not a word that this would be an abdominal
operation, nothing about its magnitude and about the artificial opening in the
abdominal wall that would replace her anus forever. In those times there was no
need for an informed consent; as a matter of fact, any signed consent
was not considered essential and quite often was omitted. To the innocent
suggestion of hemorrhoidectomy the patient consented without hesitation. How
great was her surprise after the operation, upon discovering the long abdominal
incision, the big open wound between the buttocks packed with gauze, multiple
drains in the abdomen, nasogastric tube in her stomach, catheter in her
bladder, two intravenous installations, and severe, unbearable pain. Desperate,
she asked what happened. ÒNothing. You had an operation,Ó answered one of the
doctors. For whatever reason, this ÓsoothingÒ response did not satisfy our
patient. ÒSo much suffering because of hemorrhoidectomy?Ó she asked. ÒYes.Ó
ÒHad I known what to expect, I would not have agreed to undergo this
operation,Ó answered the patient. Such ÒimpertinenceÓ from a thickheaded woman
who understands nothing in medicine! The doctor raised his voice: ÒAre you
trying to teach us, how to operate on hemorrhoids?!Ó This response
shocked not only the patient, but me as well.[3] While
I did not know what answers to give to a patient who asked those reasonable
and fully justified questions, it was obvious to me that the system of white
lies and extreme arrogance exhibited by my colleague was a tragic error. It
seemed clear that we should not tell the patient that she has cancer. But what
should we tell her? How to prepare her for accepting the unbearable trauma,
both psychological and physical? How to convince her to agree to undergo a
necessary operation, if she does not understand its importance? I devoted much
thought to these questions, but at that time did not find suitable answers.
A short time after starting my residency in New York,
I came across a patient with cancer of the cecum. He was supposed to undergo
resection of part of his large intestine (right hemicolectomy). When the time
of operation came close, I approached him in order to obtain his consent - a written,
informed consent, properly signed (this was the United States, not the
Middle East!). I told the patient that we plan to resect the right half of his
colon, gave him the properly filled consent sheet, and asked for his signature.
ÒOperation? For me?Ó the patient laughed. ÒI do not agree.Ó ÒBut you have
intestinal bleeding and it might increase. We must resect the bleeding part of
your bowel.Ó ÒDonÕt worry,Ó answered the patient, Òthe bleeding has stopped.Ó
ÒThere is almost no doubt that it will recur. It will be more severe and
endanger your life.Ó ÒOut of question! I will not have an operation.Ó The
conversation lasted several minutes, during which I tried to explain how
dangerous it is not to have treatment, while he, with growing impatience,
responded that if I donÕt stop bothering him, he would leave the hospital
immediately, against medical advice. I went to a senior surgeon, Dr.
Meyerowitz, and told him that Mr. V. refuses to sign consent for the operation.
ÒImpossible,Ó answered Dr. Meyerowitz, as if he had never heard this before
from a patient. We both went to Mr. V. ÒDr. Weissberg tells me that you refuse
to sign the consent for the operation,Ó said Dr. Meyerowitz. ÒYes, indeed, I do
not need one, my bleeding has ceased.Ó ÒBut you have cancer of the large bowel
and the bleeding will recur. Besides, the tumor will metastasise.Ó ÒCancer?!Ó,
answered the surprised patient and pointed his accusing finger toward me, ÒHe
did not tell me that I have cancer!Ó Following this, Mr. V. signed the consent
form without further delay, and I felt like an idiot. Mr. V. did not become
depressed. He did not commit suicide. His operation went smoothly and he lived
for many more years, free of cancer. And I still enjoy this didactic lesson in
surgical psychology.
Nowadays it is much more acceptable, even in Israel,
to tell patients the truth about their condition, although not always the whole
truth. There are still differences of opinion on this matter, but finally, the
patientsÕ rights to participate in major decisions regarding their own health
and life were recognized. It is their right to know the diagnosis and plans for
treatment and to decide whether they wish to accept the treatment.
Psychology of the patient should be considered not
only when dealing with consent for operation. I remember a patient with chronic
illness who stayed in the hospital for a long time. One day, while she slept, a
man came to visit her. The visitor preferred not to wake her up and left the
ward. When the patient awoke, I told her that her son had visited her while she
slept. ÒMy son? I do not have a son.Ó ÒWell, the young fellow who comes to
visit you every day, I thought he was your son,Ó was my innocent response. ÒDo
I look so old?Ó asked the lady in a scared voice. ÒThat is my husband.Ó I felt
awful, and since then became more careful.
The hospital was always full of medical students, and
the residents participated in their instruction (Fig. 10). I enjoyed this work
and also learned from it myself. With time, my feeling that I learn best while
teaching became stronger. It is relevant at all levels: teaching students and
physicians, lecturing to nurses and instructing various other groups and
individuals. When I assist a less experienced surgeon on an operation and teach
him, I learn together with him. I always allowed my residents to operate from
the beginning of their training. They never gave me reason to regret it.
Fig. 10. Lesson in tying a surgical knot; the author first from
left.
* * *
Being in America gave me an opportunity to see
world-famous surgeons operating. I took advantage of it from the earliest
stages of my residency. From time to time I excused myself from work and went
to see the ÒgreatÓ ones, usually recommended to me by friends who knew them. I
spent one whole day in the Mount Sinai Hospital and saw the legendary Òroaring
lionÓ John Garlock perform several operations on the gastrointestinal tract. On
another occasion I spent a day in the Beth Israel Hospital and saw Leon
Ginzburg at work. In 1932, he, together with Crohn and Oppenheimer, described a
new type of granulomatous inflammation of the intestine, known today as CrohnÕs
disease. Ginzburg expressed interest in the unexpected young visitor who came
to see him operating. He asked several questions, invited me to assist him on
one of his operations, and we drank coffee together. I may not have learned
much from visiting these famous people, but the meetings enriched my memories.
* * *
Each year of my residency I was entitled to a two-week
vacation. During the first year I decided to spend the holiday in Washington,
D.C. and visit some of the historic sites, museums and other interesting places
there. Three weeks prior to my planned trip, I bought a used car,
Renault-Dauphin, in good condition. I was a new driver. I received my license
about six months earlier, but had almost no opportunity to drive, and my driving
experience was close to nothing. After several uneventful trips to Manhattan, I
came to a hasty conclusion that I have mastered driving and can drive safely.
My friends were surprised at my self-confidence and advised me not to get on
the New Jersey Turnpike. But I had no doubts in my driving abilities. ÒAfter
all, it is only a four-hour trip. What could possibly happen?Ó On the way to
Washington, near Baltimore, I was stuck behind a truck, driving way too slow
for my liking. I made a quick move to bypass it...
I woke up in the Emergency Room of the Hartford
Memorial Hospital in Havre de Grace, a little town in Maryland. Because of a
brain concussion, I did not remember the accident itself. I was lying on the
treatment table and felt pain in my chin. The skin was lacerated and a doctor
was stitching it up. We started talking. After a couple of sentences it became
clear that we were both Israelis, and the conversation continued in Hebrew. The
physician, Dr. Gunther (Gideon) Hirsch treated me as if I were his old friend.
Instead of leaving me in the hospital for observation, as is customary after
brain concussion, he took me to his home for ÒprivateÓ observation, where I
stayed with his family for several days. On one of those days I went to visit
the Johns Hopkins Hospital in nearby Baltimore. There, I had the opportunity to
see Dr. Henry Bahnson operate on an aortic aneurysm. Bahnson was one of the
first surgeons who performed operations on the aorta with success. I had heard
about him earlier from a friend, an operating room nurse, who had worked with
him a couple of years before and admired both his fine work and him as a
person.
After recovery at Dr. HirschÕs home, I still had a few
days of vacation left. I went to Washington by train, because the remnants of
my car could not be rescued. Dr. Hirsch remained in the United States and still
lives in Havre de Grace where he served several terms as its mayor. We remain
friends, and exchange holiday cards every year.
* * *
In
January 1963 I spent my annual two-week vacation in Mexico. I visited
archeological sites, places of religious importance, villages, markets,
museums, the university campus and the new University Hospital in Mexico City.
I saw examples of art and architecture like nothing I had seen before, and
conversed a lot with people with whom I had no common language. The holiday was
great, perhaps the most interesting and enjoyable in my whole life.
Touring the pyramids of San Juan Teotihuacan was
particularly impressive. At noon I became hungry and entered the restaurant ÒLa
GrutaÓ located in a mountain cave. I looked at the menu. ÒRabbit a la GrutaÓ
attracted my eyes immediately. I recalled an event that occurred in 1950, when
I worked in the zoology laboratory of the Hebrew University, together with Paul
Yarden, a classmate and my roommate in the studentsÕ dormitory. We studied
anatomy of the mammals, and we were doing an anatomic dissection of a rabbit. I
worked with diligence and followed the instructions scrupulously. My meticulous
dissection arose PaulÕs anger. ÒYou are destroying the meat!Ó he said. ÒExcuse
me, I am following the instructions exactly, not destroying anything.Ó ÒYes, of
course, you are following the instructions and destroying the meat,Ó insisted
Paul. It took some time before I understood that Paul intended to take the
rabbit home to eat. One could understand this. In 1950 Israel was on a strict
austerity regime. The immigration wave was at its peak, and in order to feed
everybody, the government imposed rigid austerity measures with rationing of
all food. The rationing of meat was particularly rigorous, with 100 grams (3.5
ounces) of meat per week, per person. Everybody was hungry for meat. Assuming
that our rabbit was not poisoned, but had been killed by a blow on the head,
and that prior to death it was a healthy creature (this we could not verify,
but it was a convenient assumption), dissection completed, we took the dead
animal home and cooked it. Neither of us knew how to cook a rabbit, and we did
not add any spices. We just put the rabbit in a pot full of water and let it
boil for several hours. We certainly managed to kill all the germs, but the
food... A terrible stench filled our room and the entire dormitory floor, but
this is the smell of rabbit, and nothing could be done about it. We tried to
eat the ÒbrothÓ, but its taste was so awful, that we poured it down the drain.
But we could not afford to waste the meat. We managed to eat it, despite the
bad taste.
And now... the menu! I wanted to taste a rabbit, a properly
cooked rabbit, and nothing would stop my spirit of exploration. So this was
my lunch for the day. The taste and the smell reminded me very much of that
awful dinner in the studentsÕ dormitory. I could not finish the dish. But the
lunch added something to the spirit of my wonderful holiday.
* * *
My third year of residency (research laboratory)
started in the summer of 1963. I desperately wanted to work in the vascular
laboratory of Dr. Robert Goetz. In order to assure that I would be assigned to
his laboratory (for there were several other, less attractive possibilities), I
activated all my diplomatic abilities one year ahead of time.
First, I
met Dr. Goetz, told him that I would like to work in his laboratory and asked
him about subjects for research that might fit the 12 months allotted to me.
Presented with several possibilities, I studied one of the subjects and
prepared the project in general outlines. Dr. Goetz read my research plan,
expressed reservations and criticized the weak points. This enabled me to
introduce changes and to add some points. This went on several times, until the
project was ready. At this point I went to Dr. State (Chairman of the
Department) and told him that I was interested in spending my research year with
Dr. Goetz, and that we were already well advanced in planning a research
project on a subject related to blood vessels. My plot worked well. When the
time came to allocate third year residents to the various laboratories, I was
assigned to work with Dr. Goetz.
Robert Hans Goetz was born in Germany and studied
medicine in Frankfurt. He completed his studies in 1933, the year the Nazis
came into power. He was not Jewish, but because of his democratic-liberal ideas
and his opposition to the Nazi regime, he left Germany in 1934 and worked for
several years in research in Switzerland and in England. In 1938 he moved to
South Africa, where for the next 20 years he directed the cardiovascular
research laboratory at the University of Cape Town. The results of his work
became famous among scientists and he won international renown. In 1958 Dr.
Goetz moved to the United States and assumed a position at the Albert Einstein
College of Medicine in New York, where he became chief of the surgical research
laboratory and of the vascular surgical unit. A brilliant man abounding in
original ideas and a charming person (Fig. 11).
Fig. 11. Dr. Robert Goetz in his research laboratory.
In surgery, those were the times of excitement with
the use of glue in place of sutures for joining tissues. Dr. GoetzÕs dream was
to create a safe vascular anastomosis[4] in
coronary bypass operations.[5] The
bypass operation was considered difficult, and Goetz believed that if a
sutureless technique could become feasible, it would make the operation easier.
Our purpose was, therefore, to create a coronary anastomosis, using surgical
glue instead of sutures. The experiments were carried out on dogs, under
general anesthesia. Besides me, two other residents worked in the laboratory:
Ruben Hoppenstein, a resident in neurosurgery and Mo (Mohammed) Amirana, a
Pakistani, resident in thoracic surgery. Each one helped the two others in
their experiments, and we published some of our articles together. My project
on vascular anastomoses begun with a failure: the dogs survived the operation,
but were dead within several days. At autopsies we found that the anastomoses
disrupted because of necrosis of the tissue that came in contact with the glue.
The adhesive, methyl-2-cyanoacrylate, in short Òpreparation E-910Ó was no good.
The project was, therefore, changed: from then on, I studied the adhesive
itself, and its effect on tissues. I found that application of E-910 to blood
vessels and other tissues caused abscesses and necrosis. There was no point in
using it. Because the ÒrevolutionaryÓ glue was in widespread use in many
laboratories in the United States, we described the various aspects of our
findings, presented them at three international conventions and published six
articles in surgical journals (Fig. 12).
Fig. 12. One of the research papers published with Dr.
Goetz.
In spite of the heavy work load in the laboratory, the
emergency night calls and the usual teaching sessions in the hospital, I felt
considerable relaxation throughout the entire year. The working hours (morning
till afternoon) were convenient, and the work was not nearly as strenuous as
that on the wards. There was enough time for socializing, seeing plays and
excursions - particularly on weekends. I tried my abilities at skiing, with
fracture of my leg as a result (Fig. 13).
Fig. 13. My broken leg – result of skiing.
Fig. 14. Dr. Goetz on the fishing boat.
The work in Dr. GoetzÕs laboratory was an ongoing
pleasure. He was a great teacher, and I had a very rewarding year. Toward the
end of the year he took the entire laboratory team for a day of fishing (Fig.
14).
My friendship
with Dr. Goetz lasted a lifetime. I visited him shortly before his death and
found him active, of clear mind and, as always, young in spirit. He died in
December 2000, at the age of 90.
* * *
During the fourth year, as senior resident, I no
longer had to do the boring, routine work. Instead, I operated more, my
operations were more extensive, and I also taught more. This greater
responsibility had serious implications regarding matters of my judgment.
I was on a rotation in the Lincoln Hospital in
southern Bronx – a neighborhood of poverty, crime and violence. This was
an important and useful rotation because of the wide exposure to trauma, that
were rarely encountered in the more civilized and quieter neighborhood of the
Albert Einstein. I remember a black boy, 16-years-old, shot in the abdomen. I
operated on him late at night. Abdominal exploration disclosed extensive laceration
of the blood vessels supplying the left kidney, with profuse bleeding. The
kidney itself was not damaged, but repairing and connecting the blood vessels
was out of the question. The patient was close to death. I had to resect his
kidney, which was a life-saving procedure. The bleeding stopped, and the boy
recovered. At the weekly mortality and morbidity conference, one of the senior
surgeons, Dr. Donald Perlman pointed out that I had resected a ÒhealthyÓ kidney
of a 16-year-old boy. To my explanation that otherwise the bleeding could not
have been controlled and the boy would have died, Dr. Perlman shouted in anger:
ÒBut you did stop the bleeding! How did you accomplish it?Ó ÒI put a clamp on
the blood vessels proximal to the laceration site.Ó ÒAnd why did you not use
the DeBakey clamp?Ó This is a special clamp for blood vessels that enables a
gentle grasp to stop bleeding, without crushing the vessel. Then one can repair
the torn vessel by sutures. In our case this solution was not possible, because
the vessels were totally destroyed. There were no sufficient stumps to put
sutures in. Had I tried to repair the vessels, the bleeding would have
restarted, and the boy would have died. But Dr. PerlmanÕs outburst gave me
something to think about. I learned something. Two years later, while serving a
thoracic residency at the University of Mississippi, I operated on a patient
shot in the left lung. Upon opening his chest, I saw that the bullet had passed
through the pulmonary artery[6], which
was bleeding profusely. Rather than resecting the lung, I put the DeBakey clamp
on the bleeding vessel, as suggested by Dr. Perlman at the Lincoln Hospital.
The bleeding stopped. I sutured the torn vessel gently and removed the clamp.
The lung was saved and the patient recovered. While a similar approach was not
feasible in the boy who lost his kidney, Donald PerlmanÕs screaming planted a
seed of an idea in my head.
Anticipation of a major operation that I had not
performed before, may end in a great disappointment, if the operation is
cancelled. I remember a patient with cancer of the rectum, on whom I was
supposed to perform my first abdomino-perineal resection. I prepared myself
well by reading the relevant articles and book chapters. The morning of the
operation, I approached the patient for a little chat. He complained of chest
pain and shortness of breath. Appropriate tests were performed immediately and
disclosed myocardial infarction. The operation was cancelled, and the patient
received treatment for his heart attack. Despite all efforts, he died on that
same day. I was disappointed to lose this major operation, supposed to be my
first of this kind. The senior surgeon in charge of the patient told me ÒDo you
know how lucky you are that the patient died before you operated on him,
rather than during, or immediately following your procedure? Imagine what
everybody would have thought about you and how it would have effected your
further progressÓ. Small consolation...
Good working relations and cooperation are of utmost
importance and influence the conduct of an operation and its results. Among the
many surgeons at the Albert Einstein there was one, with whom I did not manage
to establish good relations. Dr. R. did not miss an opportunity to make my life
difficult. He always managed to find flaws in my work and criticized every
aspect of it, both in the course of operations and on the wards. I never found
out his reasons for this strange conduct, so different from all the other
senior staff members. Naturally, I did not like to work with him and tried to
limit as much as possible my contact with him, but this was never easy, and not
always possible. My efforts to avoid Dr. R. became particularly important in
the case of Mrs. Angelina Occuizzo, a 72-years-old Italian woman who had cancer
of the lower end of the esophagus, where it connects to the stomach. An
adequate operation for this tumor involves resection of the lower half of the
esophagus and two-thirds of the stomach, with translocation of the remnant of
the stomach into the chest and its connection by anastomosis to the remaining
part of the esophagus. This is a major operation and a challenge for every
surgeon, particularly a young one who had not completed his residency yet. Dr.
R. was in charge of this patient, and he was supposed to help me with her
operation. I had no earlier experience with this kind of operation, and I
particularly worried that if Dr. R. will start his ÒgamesÓ with me, the
operation might end in a failure, perhaps even result in the patientÕs death. For
the patientÕs benefit it was important to get Dr. R. out of the way and prevent
his participation in the operation. For this particular operation I desired the
help of Dr. Louis DelGuercio, whom I respected very much as a knowledgeable and
experienced surgeon, and as an excellent instructor. My relations with
DelGuercio were good, and at operations we always got along very well. But how
to neutralize Dr. R.? How does one prevent a senior surgeon who is in charge of
a patient, from participating in this attractive and challenging operation?
There was no doubt in my mind that Dr. R. would not renounce his right
voluntarily. In order to avoid him, I had to use a stratagem.
I decided to act as a naive ÒboyÓ and pretend that I
was not aware of Dr. R.Õs role in the case. While ignoring him, I went to Dr.
DelGuercio, told him about the patient and asked when can we operate on her.
DelGuercio was not stupid. He knew very well, who was in charge of the case,
but decided to cooperate. He chose a day convenient for the operation and gave
me detailed instructions on how to prepare the patient. Our cooperation brought
good results. The operation was uneventful, without difficulties or surprises.
I enjoyed and learned. The postoperative course, likewise, was smooth.
Dr. R. boiled with anger. Dr. State, Chairman of the
Department, was on a sabbatical year in Los Angeles, and Dr. R. complained to
the acting chairman, Dr. William Metcalf. I had committed a serious
transgression, a sophisticated trick, connived in collusion with DelGuercio. Dr
Metcalf was an austere man, rarely seen with a smile, and all residents were
afraid of him. But he was unbiased. He usually appreciated my work, and always
treated me with fairness. Still, I was quite scared when he called me to his office,
less than 24 hours after the operation. Luckily, I was not the only offender.
Dr. DelGuercio, the senior surgeon on the case, cooperated with me. Dr. Metcalf
did not investigate my transgression in depth; he just wanted to know why I
asked Dr. DelGuercio, not Dr. R., to assist me. I took advantage of the
situation and told him about Dr. R.Õs unfairness toward me and about our
unhappy working relations – the plain truth. I did not have any remorse
about ÒtellingÓ on Dr. R. After all, I wasnÕt the one to initiate the
conversation with Dr. Metcalf. He had invited me and I only answered his
questions. We conversed in good spirits and I wasnÕt even reprimanded. However,
Dr. Metcalf made it clear that only the surgeon in charge of patient, and no
other, should be called upon to assist the resident with the operation. He also
stressed that in the future I must behave in accordance with the department
rules and not initiate changes on my own. When I told DelGuercio about the
judgement, he laughed. And Dr. R. learned that he should not give me
unjustified trouble. Our working relations improved instantly. From then on,
when we operated together, he behaved decently. Dr. Metcalf probably pointed
out to him his past unfairness toward me.
Angelina Occuizzo was discharged from the hospital
after an uneventful recovery and remained a grateful patient. This woman who
had never learned to read and write, sent me every year a Christmas-New YearÕs
card written by her daughter. The daughter added relevant information about her
motherÕs progress and so enabled me to maintain a follow up. Angelina lived for
another 20 years. She died at the age of 92, free of cancer. Her daughter and I
continue to exchange Christmas and New Year cards now for more than 35 years.
So perhaps it is justified to use a Ònon-kosherÓ trick from time to time...?
* * *
An essential part of a surgical residency is
cooperation between a senior surgeon and a resident, in which the resident is
obliged to obey. This is part of learning. But on occasion it can lead to
mishaps with serious consequences. I operated on a patient with a mass in the
cecum (part of the large bowel). The mass was demonstrated on the barium enema
study, and the patient was scheduled for a right hemicolectomy. The senior surgeon
who assisted me on this operation had worked earlier in a most prestigious
oncologic hospital in the New York City and had extensive experience in
oncologic surgery. He was aggressive in all that concerned cancer and usually
favored radical, extensive resections. During the operation, I wanted to be
sure that the mass is, indeed, cancerous, and suggested that we send a small
section for an immediate microscopic examination, while we continue to operate.
My instructor looked at me with surprise, smiled and asked: ÒAre you in doubt?
What else can it be?Ó ÒIt could be a periappendicular abscess, a complication
of appendicitis in the past.Ó ÒReally?Ó He took the mass in hand, moved it from
side to side and asked: ÒHow many times have you seen an abscess that can be
grasped by hand and moved from side to side?Ó ÒNeverÓ, I answered. ÒSo, what is
this mass?Ó ÒThis is cancer of the cecum.Ó ÒAnd what is the treatment of cancer
of the cecum?Ó ÒRight hemicolectomy.Ó ÒVery well then, do it.Ó So I did. The
postoperative course was uneventful. After several days we received the report
of histologic examination: the resected mass was not cancer, but an abscess,
the result of perforated appendicitis...
The same bold and aggressive senior surgeon was
embroiled with another case, similar, but with more grave implications. This
time, fortunately, I was not involved. The ÒhonorÓ was bestowed upon another
resident. The patient was admitted because of rectal bleeding. Examination
disclosed an ulcerated nodule in the rectum. The finding was strongly
suggestive of cancer. The appropriate treatment for cancer was
abdomino-perineal resection of the rectum with creation of colostomy for bowel
movements. The resident who examined the patient suggested biopsy of the nodule
in order to confirm the diagnosis, but the senior surgeon was amused: ÒWhat
else can it be? It is a clear-cut case of cancer.Ó The operation was technically
a ÒsuccessÓ, but histologic examination disclosed an inflammatory lesion in
the rectum, with no evidence of cancer. The patient recovered uneventfully, but
remained without the anus and with a permanent colostomy...
* * *
The ultimate responsibility for all the patients on
the service rests with the chief resident. This brings certain rigidity and
inconvenience to the routine of his work: he has no nights off. The chief
resident is on call at all times, day and night.
There were three surgical services in the Department
of Surgery at the Albert Einstein College of Medicine, with a chief resident on
each service. Every night one of the three remained on active duty in the
hospital. The other two left hospital at the end of the day, but remained in
contact by telephone with their respective services. While during the earlier
years I had enough time to see plays and occasionally a movie, this became
impossible during my final year as chief resident. However, I did not grasp
this new reality from the beginning. I learned it from experience.
On Broadway they were showing the musical ÒOklahoma!Ó
I invited a nice medical student who was on a rotation on my service and bought
two tickets. I had great hopes for an interesting and pleasant evening. Toward
the end of the day I made bedside rounds and discovered a complication in one
of my patients: bleeding after a stomach operation. I had to operate on him
again, immediately, to stop the bleeding. My hopes for the pleasant evening
evaporated in a moment. I apologized to the student (this was the end of our
friendship), gave the theater tickets to a junior resident who was free that
evening, and stayed in the hospital to operate. The next morning the young
physician told me that he and his wife had enjoyed the show immensely...
The bleeding that prevented me from seeing the show
had three consequences. First, I never saw the musical ÒOklahoma!Ó Too bad.
Second, for the rest of the year as chief resident I never bought tickets for
another play. For the whole year I did not see a theater performance. Never
mind, one can live without it. But the most important result of that bleeding
was the third one: three years later, when I met Milka, I was still a bachelor.
Pure gain. Since then I believe in luck.
* * *
Lung operations caught my interest long before the
beginning of my surgical residency. As early as my internship in Hadassah,
chest surgery appealed to me. The thought remained hidden in some corner of my
brain and started developing while I made my first steps in surgery. The idea
matured during my annual rotations on the thoracic surgery service at the Albert
Einstein. During the year in the research laboratory it was already clearly
established in my mind. I decided to specialize in thoracic surgery. I
immediately started searching for an attractive residency position. At this
time I met my old friend from Hadassah, Yona Fruman. She used to be an
operating room nurse, but at that time worked as a flight attendant in El Al
and visited New York frequently. In the spring of 1964 she told me that Dr.
Morris Levy from Tel Hashomer has been appointed as chief of the Department of
Thoracic Surgery in the Beilinson Hospital in Petah Tikvah. He was expected to
return shortly to Israel from the University of Minnesota. I remembered Dr.
Morris Levy well from the time I spent in the department of Dr. Pauzner in Tel
Hashomer, and had seen him operating on a number of occasions. In 1960 he left
Tel Hashomer to work at the University of Minnesota Medical Center in
Minneapolis. The news about his imminent return to Israel electrified me. The
moment I heard it, I decided to go to Minneapolis to meet Levy and discuss with
him the possibility of working with him in the future. Yona suggested that I
hurry, because Levy was planning to return to Israel within the next couple of
weeks.
Several days later I was on the plane to Minneapolis.
Levy remembered me from Tel Hashomer and met me in a good, agreeable mood.
Toward his return as department chief, he would need a new team of surgeons. He
suggested that I stop my surgical residency, return with him to Israel and join
his staff. ÒWhy waste your time here? Come to my department and you will learn
something.Ó His offer was kind and friendly, but I had different plans. Ahead
of me were the best two years of my residency: senior and chief. To discontinue
at this point, after I invested so much time and effort and became well settled
at Albert Einstein – did not make sense. Also, I was planning to continue
my surgical education – residency in thoracic surgery – in the
United States. My purpose of meeting Dr. Levy was to establish contact toward a
more remote future, rather than an immediate, drastic change that would involve
interruption of my residency. Thus our meeting did not end in a matrimonial
union. But we decided to maintain contact, with eyes on the future.
After the meeting, Dr. Levy showed me the research
laboratories of the University of Minnesota. From there I took a short trip to
Rochester, to see the Mayo Clinic. I spent a whole day there and became
immensely impressed by this legendary institution. I believe that every physician
in the world should strive to visit it at least once in a lifetime, to see and
learn from its rich history and wonderful organization. Medicine at its
best.
4
In applying for residency in thoracic surgery I took into account several considerations. I felt certain that I could get an appointment at the Albert Einstein. But this was not what I wanted. During each year of my residency I spent a month or two on rotation on the thoracic surgery service and I had already learned well the routine of the department. Now I was looking for a change: I wanted to meet different surgeons and learn different methods and approaches from them. I wanted to work in a department with a predominance of pulmonary rather than cardiac surgery. Furthermore, I thought that after five years in New York, it might be better to move elsewhere and spend time in a different part of the United States. Above all, I was interested in a department with a good training program, and a leader in surgical progress. With Dr. StateÕs recommendation I could apply to the best and most prestigious institutions, with a good chance of being accepted in one. Friends advised me to visit the hospitals where I applied and to get a personal impression of the places of my choice, before committing myself anywhere. I took that advice seriously and traveled to several medical centers for exploratory conversations with surgical residents. To my surprise, I discovered that the most prestigious hospitals were not necessarily the best ones for learning. After much hesitation, I applied to eight medical centers and was accepted in four. The hospital that suited my needs best was the University of Mississippi Medical Center in Jackson. It was not the most prestigious hospital on my list, but the Chairman of the Department, Dr. James Hardy was a known pioneer in surgery. Among his many accomplishments were the worldÕs first human lung transplantation (1963) and the first ape-to-man heart transplantation (1964). Dr. HardyÕs response to my letter was
Fig. 15. The response letter from Dr.
Hardy.
encouraging (Fig. 15). In March 1965 I met him during his visit in New York, in September 1965 my acceptance was formalized (Fig. 16) and in the last week of June 1966 I crammed all my possessions into my old battered Volkswagen beetle, and went on a one-way trip to Mississippi. On the way I took time to visit places of interest, among them the Shenandoah Valley, the Luray and the Skyline stalactite caverns in Virginia, the battlefields of Gettysburg and other historic sites from the Civil War. On the evening of 29 June I arrived in Jackson and stayed in a hotel. The next morning I went to the Medical Center and in one day of fervent activity, managed to meet all the secretaries of Dr. Hardy, register in the hospital offices and obtain a bachelor apartment in the Medical Center. Already on my first day in Jackson I encountered difficulties in understanding the English spoken in the South. It took me some time to get used to it, but today I hear and understand the southern drawl without difficulty.
* * *
Each year Dr. Hardy accepted one resident for two
years of training in thoracic surgery. During the first year the resident
occupied a junior position in relation to the second year thoracic resident,
but he was senior in relation to the general surgical residents. This
particular state of affairs existed because there was no administrative
division between the thoracic and the general surgical services. All surgical
patients in the University Hospital – general, thoracic and vascular
– were hospitalized together, and were taken care of by one Òhouse staffÓ
– the team of surgical residents. This arrangement, which also existed in
the Veterans Administration Hospital in Jackson, enabled the general surgical
residents to become involved and gain experience in thoracic and in vascular
surgery throughout their training. However, this arrangement also created
tension between the general surgical and the thoracic residents, because we,
the thoracic residents, were ÒtakingÓ all the thoracic and some of the vascular
cases, considered ÒbestÓ, from the generalists.
Fig. 16. Confirmation of acceptance for residency at the University of Mississippi Medical Center.
The entire
Medical Center included both these hospitals, as well as the School of Medicine
and, in addition, the Mississippi State Sanatorium – a hospital for
tuberculosis located in Magee, 75 km (45 miles) from Jackson. The head of this
whole surgical empire was Dr. James Daniel Hardy.
In addition to routine clinical work, each resident
participated in some kind of laboratory research project, and the further one
advanced in clinical surgery, the stronger was the research obligation. I was
involved in lung and heart transplantations in dogs. This work was done in the
laboratory for experimental surgery, three to four hours a week, usually in the
afternoon (Fig. 17).
Fig. 17. With Dr. Hardy
and our exhibit at the Convention of the American College of Surgeons, 1967.
The entire period of my stay in Mississippi was
characterized by loneliness, especially if one considers the plentiful social
life (within the possibilities of a surgeon-in-training) that I had in New
York. The thoracic resident one year ahead of me was Dr. Suheil Saleh, an Arab
born in Palestine. In 1948 his family moved to Jordan, and he studied medicine
in Beirut. We never worked together: when I was at the University Hospital, he
worked at the Sanatorium; due to rotation between the three hospitals we were separated
most of the time. This way political frictions were avoided, except for a
short-lasting increase in tension during the Six-Day-War.
There were about 150 Jewish families in Jackson and
around 100 families in the remainder of the State of Mississippi. But the main
problem was not just the small number of Jews in the area. In the past, in my
youth in Poland and later in New York, I had quite a few non-Jewish friends,
and I felt well in their company. But I did not find a common language with the
Mississippi gentiles. Their way of life was utterly different from mine. They
never understood my background and my past, and I never showed any interest in
hunting, fishing or football (American or European). I like photography, opera,
history books... There is no doubt in my mind that there were people like me in
the southern states, but I did not have an opportunity to meet them. Many of my
gentile acquaintances in Mississippi tried hard to be friendly with me, but
usually the conversation centered on their attempts to educate me about Jesus
and to point out (for my benefit, of course) my erroneous ways without him.
Still, for whatever reasons, I was not in want of Jesus. In spite of many
invitations, I had no desire to attend religious ceremonies in churches and
listen to sermons, interesting and eye-opening as they may have been. So I
remained lonely.
Nevertheless, I found a way to the Jewish community.
Before I left New York, my old friend, Dr. Ronald Dee (the chief resident in
the beginning of my training), provided me with the telephone number of his
relatives in Jackson. They invited me to their home, and later to the temple on
Friday night. All the Jews, even those from distant towns where only one Jewish
family lived (there were several such towns) used to attend services on the
Sabbath. They, like me, missed the company of other Jews, and every Friday
night, the only temple in Jackson (reform) was full to capacity. This way I
became acquainted with the entire Jewish community in the State of Mississippi.
It was the first time in my life that I have been to a reform temple. The rabbi
and the majority of congregation prayed with their heads uncovered, although
there was no penalty for wearing a skullcap. Some people covered their heads.
Men and women sat together. In general, this institution called the Jewish
Temple reminded me more of a Christian (Protestant) church than a synagogue. Is
this important? I do not know. But the entire show, when seen for the first
time, seemed strange. Still, I believe that it was better to attend this
ÒunusualÓ synagogue, than to remain completely separated from the Jewish
community. They welcomed me with friendliness and hospitality. A lonely
Israeli, the only one in their town and in the entire state, stimulated the
interest and curiosity of many. There was a local chapter of Hadassah
Organization, and here, at their court, was a young physician, a graduate of
Hadassah, Òmade in Israel.Ó Several families invited me to their homes, usually
for dinner, but also for a lecture: they wanted me to tell them about Hadassah.
I had plenty of relevant slides, and used them in Jackson as best I could.
The approach to work was most serious. Dr. Hardy
insisted on it and gave a good example. He made bedside rounds every day,
including Sundays. All physicians, from the most senior ones to the most junior
interns, and all medical students had to participate. On Sundays the rounds had
to be over by 11 a.m., so that people could go to church, therefore it started
early in the morning. Dr. Hardy burst with energy and was short on patience. He
never waited for an elevator. After completing the rounds on the first floor
(adult service), the entire retinue leaped upstairs to the pediatric surgical
service on the seventh floor. No one would wait for the elevator, while the
boss practically ran up the stairs.
Heart operations were scheduled two days a week. After
a heart operation, the resident who participated in the procedure (in essence,
always myself), stayed with the patient without a break until the next morning.
I used to sit next to the patientÕs bed in the Intensive Care Unit all through
the night, and if there was anything to do for him, I did it. In the free time
I memorized all available current information on the patient, including the results
of the most recent laboratory tests (tension of blood gases etc), in order to
have instant answers ready for the chiefÕs visit. He usually came late at night
or just before dawn, asked questions and gave example of devotion to the
patient and profound knowledge of his problems. However, despite the efforts,
the results of our heart operations were not satisfactory, and I did not find
much interest in them. I studied cardiac surgery, because this was part of the
material I needed to know toward the board examinations, but at this time I was
already determined not to continue with it after the completion of my
residency. In contrast, the pulmonary and vascular surgery results were
exemplary. The team of surgeons included several who accumulated extensive
experience in this field and were excellent teachers.
I learned, made progress, and the day was approaching
when I would perform my first pulmonary lobectomy. The operation was planned
for September 24th that coincided with Yom Kippur. I asked Dr. Gus
Neely, the senior thoracic surgeon on the case, to postpone the operation for a
day or two. I tried to explain to him what Yom Kippur was and why it was
important for me not to operate on that day. But Dr. Neely was not agreeable,
and my reasoning did not impress him. He thought that because of my laziness I
simply did not want to work on a holiday. He issued a verdict that the
operation will be performed as scheduled, with or without my participation. He
knew that not performing the lobectomy would be a punishment for me, and was
fully satisfied with it. Other residents did not understand my problem. Some
asked: ÒWhy canÕt you just operate and then go on to celebrate?Ó For non-Jews
in Mississippi it was totally impossible to grasp the meaning of Yom Kippur. Holidays
are for celebrating, not for mourning and fasting. I stopped explaining, and on
Yom Kippur did not come to work at all. Instead, I went to temple and stayed
there – for the first time in my life – the whole day. The
operation was performed by another surgeon. Dr. Hardy knew about the incident,
but did not interfere. And I was left with the feeling that I did the right
thing. It gave me more satisfaction than the lobectomy would have.
The best part of my work was the rotation at the
Sanatorium in Magee. This 250-bed hospital was for patients with advanced
tuberculosis, coming from the entire State of Mississippi. The work was done by
a team of pulmonary physicians. The only surgeon in the house was the thoracic
resident from the University Hospital – myself during the six months of
my rotation. Three times a week one of the senior thoracic surgeons from the
Medical Center in Jackson used to come to the Sanatorium to teach and help me
with the operations. The majority of operations were in patients with pulmonary
tuberculosis, but there were also many with lung cancer, infectious diseases of
the lung and chest cavity, lung cysts, emphysematous bullae and other problems.
I also did all the surgical work outside of the chest. For operations on
gallbladder, uterus or prostate I contacted the appropriate expert at the
University Hospital and made an appointment for the operation date. I performed
all the operations, with the expertsÕ help.
Three senior surgeons instructed me on lung
operations. The most prominent character was Dr. Gus Neely – the one who
refused to yield on that famous ÒYom Kippur lobectomyÓ. In the much smaller
community of the Sanatorium, without disturbances from the ÒaudienceÓ, Dr.
Neely learned to appreciate my work, and the relations between us improved
greatly. We remained friends until my last day in Mississippi. I know that his
reports to Dr. Hardy on my performance as resident were excellent. The second
surgeon, Dr. Jesse Wofford, could be best characterized by his extreme
religiousness. He served as a part-time Methodist preacher. On every occasion
(suitable and unsuitable) he used to bring up the subject of Christian faith
and ask me what I think about Jesus. My usual response that I do not think
about Jesus did not satisfy him. Apparently he saw the opportunity to convert
me to Christianity as his most important human obligation. It seemed obvious to
me that his efforts would not stop as long I remain in Mississippi. In fact, he
did not stop even for years after I left. I happened to meet Dr. Wofford
several times at various surgical conventions in the United States. He never
forgot to ask me whether I had learned meanwhile about Jesus and what I think
about him now. Both Dr. Neely and Dr. Wofford had been Dr. HardyÕs residents
some years earlier. Both were excellent surgeons and teachers and I learned a
lot from them. The third surgeon, Dr. Hans Karl Stauss, a German, was born in
Dresden in eastern Germany and spent a major part of his life in Romania. He
arrived in the United States after World War II and settled in Mississippi. He
was friendly toward me and showed great interest in my past in Europe. Dr.
Stauss was a good teacher, but as a surgeon, did not equal his two friends.
During my six-month rotation at the Sanatorium, I performed under the guidance
of these three surgeons 77 thoracic operations. This included pneumonectomies,
lobectomies, thoracoplasties of every possible kind and others. As far as
operative and clinical experience is concerned, my work at this hospital for tuberculosis
was for me the richest and most rewarding period ever.
Wednesdays at the Sanatorium were devoted to
bronchoscopies[7] and bronchographies.[8] These
procedures were performed on the conveyor belt principle: nurses placed the
first patient on the table and started applying local anesthetic to the larynx.
I continued with the anesthesia (always local), performed bronchoscopy, and
concluded the procedure by injecting contrast medium through a fine catheter
into the bronchi. While I was recording the bronchoscopy findings, the nurses
took the patient to the Radiology Department for a series of roentgenograms
taken at various angles. Meanwhile, I started working on the next patient. At
the end of the dayÕs work, I saw and interpreted all the roentgenograms and
compared them with the bronchoscopy findings, as recorded earlier. On an
average day there were between 10 and 20 bronchoscopies and bronchographies.
All this was done without the help of an anesthesiologist or a radiologist, as
such specialists were not on the Sanatorium staff. The work was completed by
midday. Then I collected all the roentgenograms and drove to the University
Hospital in Jackson – a trip of over one hour – for a conference
with my three instructors. They praised my work and decided on further
treatment of the patients. The majority were operated on during the following
week. In the middle of the conference there was a coffee break (actually, this
was my Wednesday lunch). We discussed the white patients before the break and
the black ones after (Fig. 18). An
important detail should be pointed out: this
Fig. 18. Roentgenogram
of a black patient. ÒColored InfirmaryÓ is clearly indicated on the film.
separation
by race was exercised only with regard to patients from the Sanatorium. At the
University Hospital and the Veterans Administration Hospital the conferences
were integrated with no regard to skin color. Racial separation was abolished
in the mid-1960s in all hospitals and other institutions that received
financial support from the federal government. This change occurred in all
Veterans Administration hospitals in the United States, and also in ÒourÓ
University Hospital, but not in the Mississippi State Sanatorium, which was
financed entirely by the government of the State of Mississippi. Accordingly,
the segregation at the Sanatorium remained in power, and was not limited to
conferences. The institution was based in two buildings: the ÒSanatoriumÓ,
where white patients were hospitalized (Fig. 19), and the ÒColored InfirmaryÓ for
blacks (Fig. 18). Each of the buildings had separate teams of nurses and other
employees (it was inconceivable that a white nurse would serve black patients),
although there was only one team of physicians – all white.
Fig. 19. The Mississippi State Sanatorium.
A typical characteristic of Southerners is
considerable politeness and notable formality. Except for relatives and close
friends, one never addresses people by the first name, only as Mr. or Ms. with
the surname following. In my ÒignoranceÓ, I used this formal approach with
regard to everybody, including my black patients. This resulted occasionally in
a misunderstanding, because the blacks did not understand that I was talking to
them, and did not respond. However, a corrective remark by one of the nurses
was not late to come: ÒDoctor, we do not call them Mr. or Ms. Her name
is Jessie.Ó
The struggle of blacks for equality in the Southern
States reached its peak while I was there. In the summer of 1966 I happened to
witness a demonstration in Jackson. Two competing groups of demonstrators
arrived in town. One was headed by Martin Luther King, Jr., the other by one of
the more violent activists; if my memory does not fail me, it was Stokely
Carmichael. Both groups met in one of the townÕs main squares. The two groups
stood opposite each other. The Carmichael group shouted in unison Òpower!Ó, and
the group led by King, responded Òfreedom!Ó, and so alternating: Òpower -
freedom - power – freedom.Ó Blood was not spilled. I may have felt lonely
in Mississippi, but there was no boredom.
While working at the Sanatorium, I lived in a
comfortable house, sufficient for a whole family. Many of the employees lived
on the hospital grounds, in similar houses. During a tornado that struck
Mississippi (the only one that I have experienced in reality, not on
television), I locked myself in the house and worried that the wind might blow
it away along with me, as happened to quite a few uprooted trees and some cars.
But my house was strong enough and remained firmly on the ground. My
Volkswagen, likewise, did not suffer any damage (Fig. 20).
Fig. 20. My house on the Sanatorium grounds.
I had good and friendly neighbors who made every
attempt to help me, according to their best understanding. For example, my
secretary, Mrs. Mary Polk – like Dr. Wofford, religious to the extreme
– overwhelmed me with invitations to visit her church and meet her
pastor. Later she implored that I tell them about Òthe land where Jesus
walked.Ó After several such requests, I accepted the invitation and took my
slides and projector to their church. My slide show must have disappointed
them, at least to some extent, because presumably they expected to hear about
the primitive life in the Holy Land: shepherds and sheep – as in the days
of Jesus; also, they probably expected me to tell them more about the Christian
holy places and about Jesus himself. Views of contemporary Jerusalem and Tel
Aviv, the Hadassah Medical Center (less impressive than the buildings of the
University Hospital in Jackson), and sunbathing beauties at the seashore in
Haifa were not of particular interest to them. Despite that, Mrs. Polk
continued with invitations to visit her church, but I became more resistant and
did not come again. Mrs. Polk remained a good and faithful secretary, and her
husband, the best barber in Magee, cut my hair every month with great
expertise.
* * *
The news about the Six-Day-War reached me in the most
peculiar way. For a long time before the war started, television and radio
programs abounded in threats by Arab leaders who predicted prompt destruction
and elimination of the State of Israel. They were arrogant and brazenly
self-confident. The economic stagnation in Israel reached new depths. It
seemed, that in a well coordinated war effort against Israel, the Arab armies
might overcome Israel and materialize their threat. The situation was very
grave and there was a general feeling of an approaching war.
On June 5th 1967, while I was on the
rotation at the Sanatorium, I woke up later than usual and, contrary to my
routine, did not have time to listen to the radio newscast. Without knowledge
of the last 24-hour developments in Israel, I went to the operating room. I had
just completed a bronchoscopy, when one of the nurses called me to the
telephone. It was from the Israeli consulate in New York. They told me that the
war had just begun, there is an urgent need for Doctors, and asked me to fly to
Israel as soon as I can.
I left the operating room, drove to Jackson, entered
Dr. HardyÕs office and told him that I must leave for Israel immediately (Fig.
21). At the Kennedy Airport in New York, an immense crowd of Israelis was
waiting for flights to Israel. But the number of planes and flights was
limited, and the chances to fly ÒimmediatelyÓ were slim. Everybody had good
reasons to get to Israel, and my argument that I am a surgeon, did not impress
the El Al clerks very much. I waited in the airport on a stand-by basis for a
couple of days, with minimal hope and no result. In the meantime, the political
and military situation in Israel changed completely. Israel prevailed on all
fronts and won the war. I returned to Mississippi to continue my work.
Fig. 21. The Six-Day-War letter from Dr. Hardy, June 5th
1967.
* * *
I heard about mediastinoscopy for the first time at
the congress of the American Association for Thoracic Surgery in Montreal, in
the spring of 1964. Dr. State, always utterly concerned about the education of
his residents, used to send us to scientific conventions. He knew about my
interest in thoracic surgery and decided that I should go to Montreal. One
presentation at the convention arose my particular interest: it was a report on
mediastinoscopy with experience in 74 patients. The material was presented by a
young surgeon from Toronto, Dr. Frederick Griffith Pearson.
Mediastinoscopy, a method of exploration of the
mediastinum,[9] is indicated in patients with
enlarged lymph nodes or other masses in this anatomic area. The procedure
consists of a direct inspection of the mediastinal contents and obtaining
tissue sections for microscopic examination. It is particularly important in
patients with lung cancer. The spread of cancerous cells from the primary lung
tumor to the mediastinum is a contraindication to major lung surgery, and a
documentation of such metastatic spread has important therapeutic implications.
I was greatly impressed by the usefulness of this procedure and easiness of its
performance. The clarity of the presentation enhanced my interest in the
subject. I became obsessed with the idea of mediastinoscopy, and upon my return
to New York, suggested to the chief of the thoracic surgery service, Dr. Robert
Frater, that we introduce it to our clinical practice. However, Dr. Frater
thought that the procedure was hazardous and expressed objections. He also
thought that any new method, such as mediastinoscopy, should be concentrated
initially in the hands of only one person, who would first learn it well and
then teach others. At that time I was the only one in the hospital with an
interest in mediastinoscopy and spent only short rotations on the thoracic
service. It was not possible for me to take charge of this new operation. Thus
my pleas to Dr. Frater did not lead to any results. But the idea remained in my
head.
After several months in Mississippi I suggested to Dr.
Hardy, as to Frater before him, that we start doing mediastinoscopies. Dr.
Hardy, likewise, did not become excited with the idea. He pointed out the
dangers. Mediastinum contains large blood vessels, heart and other organs. The
method of inspecting mediastinum is performed through a 25 mm incision in the
neck. Through this incision the operator inserts the scope – a metal tube
illuminated at the end. The area of inspection is limited by the 15-mm internal
diameter of the scope. During the procedure blood vessels might be injured,
with possible life-threatening bleeding. Still, I was not ready to give up, and
waited for a suitable case. A short time later, a patient with lung cancer was
admitted to our service. Roentgenograms showed enlarged lymph nodes in the
mediastinum, and metastatic spread was suspected. When Dr. Hardy repeated his
warnings about the possibility of complications, I said: ÒDr. Hardy, you were
the first surgeon to perform human lung and heart transplantations; you are
doing kidney transplantations and open heart operations; are these not
dangerous procedures? What about medical progress?Ó Hardy thought for a moment
and said: ÒWell, try, but be careful!Ó The next day I performed the first
mediastinoscopy in Mississippi. I had no previous experience with it, and felt
a burden of great responsibility and fear of complications. I knew that I must
not fail, and worked with extreme caution. Thus my first exploration of the
mediastinum was very limited; as a matter of fact, it was incomplete. Yet, I
was very lucky, and this limited procedure sufficed: next to the windpipe I
felt a firm nodule – an abnormal finding in any mediastinum. I took a
small section of the nodule for biopsy and did not look for more. Histologic
examination of the tissue disclosed a metastasis of lung cancer. The importance
of this finding could not be overrated. It prevented a major operation: an
unnecessary thoracotomy. Dr. Hardy felt that progress has been made. He smiled
and summarized the subject in one sentence: ÒDov, you have my permission to do
mediastinoscopies.Ó So I did. The results were not always as clear-cut as on
the first case, but I always managed to avoid complications. The feeling of
great satisfaction that I was the first surgeon to perform mediastinoscopy in
Mississippi (and later in Israel as well) has not left me until this very day.
For historical honesty, I must admit that I learned the proper technique of
mediastinoscopy later, while working on the service of Dr. Pearson in Toronto,
the same surgeon who summarized his experience with mediastinoscopy at the
convention in Montreal.
* * *
To complete the process of obtaining a specialist
certificate, one must pass the examination of the American Board of Surgery.
The examination is composed of two parts. Part I is a written examination and
includes, in addition to surgery, also basic sciences. Only the candidates who
pass this part, can apply for Part II – the oral examination. After having
completed my residency in surgery in June, the earliest date of the written
examination was 7 December 1966. On this day the examination was held in
several cities; the nearest to Mississippi was Galveston, Texas (Fig. 22). I
used part of my annual vacation, and after the examination stayed in Galveston
a day longer, to see this historically interesting city. From there I went to
the National Aeronautics and Space Administration (NASA) and to the Baylor
University Medical Center in Houston. I managed to have a look at the
superstars of cardiovascular surgery in America – Drs. DeBakey, Cooley
and others of worldwide fame.
The oral examination took place in Houston on 31
January 1967 (Fig. 23). The atmosphere was relaxed. Dr. DeBakey, usually feared
by those he examined, was among my examiners, but was simply charming (Fig.
24). After the examination I stayed in Houston for ten days, again to see the
ÒsuperstarsÓ operating. The volume of their work, their organization and
efficiency were exemplary and exceeded all that I had expected or could have
imagined. Between operations, Dr. Denton Cooley invited me for a short
conversation over a cup of coffee.
I received my specialist certificate after several
weeks (Fig. 25).
Fig. 22. Letter of admission for the written part of the examination.
Fig. 23. Letter of admission for Part II (oral) examination.
Fig. 24. Schedule for Part II examination.
Fig. 25. Specialist certificate in surgery.
As in general surgery, the examination in thoracic
surgery could also be taken only after completing the residency. However, my
visit in the United States as a trainee in surgery was initially limited to
five years. For the purpose of residency in thoracic surgery my stay was
extended for an additional two-year period, but this extension was final, with
no possibility of appeal. I could not stay in the United States beyond June 30th
1968.
In order to enable me to take the examination and
obtain specialist certificate, Dr. Hardy used his influence with the American
Board of Surgery, and I was given permission to be examined while still in
training. The examination dates given to me were 20 and 21 April 1968. The
examination took place in Pittsburgh, during the days preceding a convention of
thoracic surgeons in that city (Figs. 26 and 27). This examination, likewise,
was successful (Figs. 28-30).
Fig. 26. Admission letter for examination in thoracic surgery.
Fig. 27. Examination card of candidate No. 75.
Fig. 28. Letter informing me of examination results.
Fig. 29. Specialist certificate in thoracic surgery.
Fig. 30. Congratulatory letter from Dr. David State.
* * *
Equipped with specialist certificates in general and
in thoracic surgery, I was ready to return to Israel, and I hoped that this would
become possible as soon as my residency was completed. But that was not a
simple matter. Before I left Israel, Dr. Prywes from the medical school told me
that every physician who succeeds in training in America, returns to Israel
with demands that the Israeli hospitals, as a rule, cannot accept. The return
to Israel is thus delayed, and, eventually, the successful graduate stays in
America permanently. Professor Rachmilevitz, likewise, was let down by my
decision to seek training abroad, and accused me of abandoning Israel. At that
time I did not believe that this could happen to me, but now his prophesy
threatened me.
As early as during my work in the Rambam Hospital, I
felt the heavy hand of my seniors. I dreamed that some time in the future, I
would become chief of my own service. During the two years spent in Dr. HardyÕs
department, this feeling consolidated. Hardy was a great teacher and
represented the best in medical education and in surgical progress, but during
all the time spent under him, I felt like a slave. More than anything, I wanted
to obtain a position of department chief. No more serving another master.
Assuming that I would start working in Israel in someone elseÕs department, it
was very unlikely that the chief would be to my taste. Much more likely he
would be similar to Jack AbouavÕs boss at the Rambam Hospital. This possibility
was unacceptable to me. I felt that my knowledge and experience were sufficient
for heading a department of my own. During my visit in Israel in 1965 I met several
high-ranking personalities in the Ministry of Health, the central offices of
Kupath Holim (health services of the Labor Federation) and other institutions.
I told them about my plans to return to Israel, and about my expectations. They
were ready to offer me a job in almost every hospital, but no one offered me a
service of my own. As a matter of fact, I was not surprised. They did not know
me and had not seen me working. The risk of accepting a ÒstrangerÓ for a
position of chief was too great.
Following
my visit in Israel, I continued to correspond with people who could offer me a
job, but I received only hints and implications as to the future. These did not
satisfy me.
Because I had to leave the United States by 30 June,
it seemed that the best solution for me would be accepting a temporary job in
Canada. I had no desire to stay in Canada permanently, but while working in
Canada, I would continue maintaining contacts with medical institutions in
Israel.
I initiated contacts with several medical centers in
Canada. The most attractive response came from Dr. William Drucker, Chairman of
the Department of Surgery at the University of Toronto. Dr. Drucker informed me
about his plans to establish a general thoracic surgical division, separate
from heart surgery. In view of my qualifications, he was willing to consider
accepting me to the staff of the new division. He invited me for an interview.
In Toronto, in addition to Dr. Drucker, I met the
appointed chief of the soon-to-be-opened new division – Dr. F.G. Pearson,
who interviewed me, showed me the hospital and invited me to the operating
suite to see some of the operations scheduled for that day. The first procedure
on the schedule was mediastinoscopy. At this point I suddenly realized that Dr.
Pearson is the same one who lectured on mediastinoscopy in Montreal in 1964. At
the end of the interview I was accepted to the new division as a senior fellow
in thoracic surgery for one year, with a possibility of an extension for
another year.
5
At the end of June 1968 I parted from my friends in
Mississippi and on 1 July started my new work in the Toronto General Hospital,
the University of Toronto main teaching center. The activity of the new
Division of Thoracic Surgery involved surgery of the lungs, trachea, esophagus,
thymus, diaphragm –all
the chest contents, excluding heart and major blood vessels. These confines of
work were very much to my liking. The service was temporarily situated in the
hospitalÕs oldest building. It was erected in 1913 and situated at the corner
of College Street and University Avenue. Four certified surgeons formed the
team. Chief of the division was Dr. F.G. Pearson.[10] Another
member of the team was Dr. Norman C. Delarue, an older generation thoracic
surgeon, with extensive experience in pulmonary surgery. The third surgeon was
Robert (Rob) Henderson, who concentrated his activity mostly around the
esophagus – study of esophageal physiology and disease, and surgery of
the esophagus. I was accepted as a senior fellow (the highest rank of
postgraduate training), although at that time I had been already certified in
thoracic surgery. In addition, there were residents and interns on rotation.
Dr. Pearson was among the worldÕs first surgeons to
operate on the trachea[11]
(resections, plastic repairs) and by the time I worked on his service, had
already been widely recognized as one of the leaders in this new and exciting
field. My involvement in the clinical workup of his patients and participation
as an assistant in his operations, provided me with much valued experience and
enabled me to learn a lot about the problems associated with surgery of the
trachea. In parallel, I studied records of all the patients with tumors of the
trachea treated in the hospital in the past and prepared an article on this
subject for publication (Fig. 31).
Similarly, I prepared and wrote up neoplasms of the thymus[12] and
another group of interesting tumors – the bronchial carcinoid. This
material was presented at several congresses of the most prestigious surgical
societies and was published in leading medical journals. Through Pearson I
became acquainted with other pioneers of tracheal surgery, among them Hermes Grillo
from Boston and Mikhail Perelman from Moscow. Griff Pearson was an excellent
teacher and a charming person. He treated members of his team as equals, and
never gave anyone the feeling of being his subordinate (Fig. 32).
Fig. 31. The article on
tumors of the trachea, with Pearson and others, Annals of Thoracic Surgery,
1974.
Every
one of us, the senior staff members, as well as interns and nurses, visited his
home in Toronto and his farm in the country, a 2-hour drive from the city. He
had a house there with a creek behind it, widening to a fish pond, all
surrounded by woods – part of his farmstead, with cows and other animals.
Canada is a big countryÉ (Figs. 33 and 34). I spent many weekends on that farm,
befriended the Pearson family – GriffÕs wife and their three little
children, swam in the pond, skied and even tried to hunt –
unsuccessfully. I spent Christmas Eve of 1968 there, and in 1969 watched on the
television the first man landing on the moon. Griff Pearson and I remain
lifelong friends.
Fig. 32. F.G. Pearson at the end of a hard dayÕs work.
Fig. 33. F.G. Pearson with his family.
Fig. 34. At the Pearson farmstead.
Pearson knew that I wanted to return to Israel and
that I was looking for a job. However, for the time being, my connections with
the institutions in Israel were limited to the exchange of meaningless letters.
There was no progress. In order to revive the subject, I had to go to Israel,
meet people personally and remind them that I existed and was looking for an
opportunity to return to Israel. It was embarrassing to ask for a vacation only
three months after I started working, but there was no choice. Pearson did not
object that I take my annual holiday in the beginning of the year rather than
at the end. So, in October, three months after starting my new job, I went to
Israel.
I had meetings with senior officials in the Ministry
of Health, city hospitals, central offices of Kupat Holim (health services of
the Labor Federation) and the deans of both medical schools – Tel Aviv
University and Hadassah. The possibility to find a position in Kupat Holim
seemed reasonable for a while. A meeting was arranged for me with Dr. Eger,
chief of the Department of Surgery in the Kupat Holim Hospital in BeÕer-Sheva
(today the Soroka Medical Center). Dr. Eger described to me the situation on
his service and stressed that he needed a good deputy. Also, he told me that
the hospital was in desperate need of a thoracic surgeon, and that there were
plans to open a thoracic surgery service. If I start working there as his
deputy, I would be able, besides my work as a senior surgeon, to take care of
all the thoracic patients. When the time comes to open the thoracic surgery
service, it would be only natural that I would be its chief.
I was very much impressed with Dr. Eger. ÒThis is an
example of a department chief, not to be afraid ofÓ I thought. ÒWith a man like
him, it would be possible for me to cooperate and, in parallel, built
foundations for a unit of my own.Ó The dayÕs activity was over and I was in
good mood. I went to visit an old friend who served as a senior physician in
one of the hospital departments. I told him about my conversation with Dr. Eger
and about my plans and dreams for the future. My friend was skeptical. He
agreed that Dr. Eger was a nice person and an excellent surgeon, but was
surprised at my naivetŽ. ÒOf course, you could work and get along well with Dr.
Eger, but your hopes for a thoracic surgical service of your own will remain a
dream.Ó He told me that during the Six-Day-War, a thoracic surgeon, Dr. Joseph
Borman from Hadassah, was brought to the hospital in BeÕer-Sheva to fill the
void. He was my age, a senior surgeon on the thoracic surgery service headed by
Professor Milwidsky. He worked well and had a good reputation. He was
the candidate of Kupat Holim to become chief of the thoracic surgery service,
once it will be established. My friend was greatly surprised that I did not
know about this, as apparently everybody else did. Meanwhile Dr. Borman worked
under the greenhouse conditions of Hadassah, and was not in a particular hurry
to come to BeÕer-Sheva and start organizing the new service from scratch. He
preferred to wait for the department to open, and then come as its chief. He
had been assured of this position by the hospital administration and by the
Kupat Holim executives.
I had witnessed a similar scenario before. An exact
reconstruction of the Jack Abouav affair in Rambam was now unfolding in
BeÕer-Sheva. By accepting the Kupat HolimÕs offer, I would actually be building
the foundations of thoracic surgery service for Joe Borman. Should I prefer to
stay in thoracic surgery, I could possibly work on Dr. BormanÕs service,
perhaps as his deputy. In the Kupat Holim offices no one told me this, nor did
Dr. Eger mentioned it to me, although it stands to reason that he must have
known about it.
I returned to Kupat Holim with a counter-offer: I
would start working in Dr. EgerÕs department as his deputy, if the
tender for the position of chief of thoracic surgery takes place now, and I win
it. Once the thoracic surgery service opens, no matter when, there will be no
need for another tender. ÒThis is not logicalÓ was the officialsÕ response.
ÒThe tender will be announced when the service is ready to open; at the moment it
is not of immediate interest.Ó They added that if I start working now and
organize the service from the foundations, there would be almost no doubt that
I would succeed in the tender. However, they were not ready to commit
themselves. During those conversations no one mentioned Joe Borman. The people
who conversed with me did not suspect that I knew anything about him, and I
preferred not to disclose all the information I had, bringing about an open
confrontation. In the final outcome I did not accept the job offer in
BeÕer-Sheva, but the correspondence with the Kupat Holim and other institutions
in Israel was rejuvenated and strengthened.
Although at this stage I did not obtain a desired job
in Israel as I had hoped, my visit in Israel had one other important result.
Until that visit, I have never seen the Western Wall in Jerusalem. Now, that
Jerusalem was liberated and united, I went to see it. In the Old City I met an
old medical school friend, and right there she introduced me to her relative
Milka. I will not elaborate on the details of courting that lasted two weeks,
but at the end I proposed to Milka and brought her to Canada, where we married.
Now we have four children and nine grandchildren. One could say that my trip
was not wastedÉ
Dr. Joseph Borman did not come to BeÕer-Seva to run
the thoracic surgery service. On 21 February 1970, a Swissair aircraft exploded
in the air, fifteen minutes after its takeoff from Zurich, on the way to Tel
Aviv. ÒThe Popular Front for the Liberation of PalestineÓ took proud
responsibility for the explosion. Among the 47 victims of this heinous act
of ÒliberationÓ was Professor
Hanoch Milwidsky, Chief of the Department of Thoracic Surgery in Hadassah.
Joseph Borman was appointed as the new chief and was no longer interested to
move to BeÕer-Sheva.
In order to work in the Province of Ontario (Toronto
is the capital of Ontario) I needed an Ontario medical license. I passed the
necessary examinations in 1969 (Fig. 35). I also sought recognition of my title
of Specialist (Board Diplomate) that I had obtained in the United States.
However, during the late 1960s, the institution in charge of qualifying
specialists in Canada (The Royal College of Physicians and Surgeons of Canada)
was not yet ready to approve titles that were obtained Òsouth of the borderÓ.
My Specialist Certificate, valid in the United States, was meaningless in
Canada. I had to study for examinations once again. At that time, the Royal
College examinations were conducted on two levels. The lower level was to obtain
the title of a specialist (Fig. 36). The higher level was to become Fellow of
that prestigious and highly respected College. All examinations were written
and oral.
Fig. 35. Certificate of the Medical Council of Canada.
Fig. 36. Specialist Certificate of the Royal College
of Surgeons of Canada.
For physicians who read this book, I copied some of
the questions from the written part of the fellowship examinations (Figs. 37
and 38). Those were the most difficult examinations in my entire life. But I
passed them too, and in 1970, at three different ceremonies, I was accepted to
three prestigious societies: the Royal College of Physicians and Surgeons of
Canada (Fig. 39), the American College of Surgeons (Fig. 40) and the American
College of Chest Physicians (Fig. 41). All paths of professional progress in
North America were now open for me, on both sides of the border.
Fig. 37. Questions in
pathology and bacteriology at the examination in surgery.
Fig. 38. Questions in basic sciences at the examination in surgery.
Fig. 39. Fellowship Certificate in the Royal College of Physicians and Surgeons of Canada.
Fig. 40. Fellowship Certificate in the American
College of Surgeons.
Fig. 41. Fellowship Certificate in the American College of Chest Physicians.
My daughter Dorit (named in the memory of my late mother) was born in March 1970 (Fig. 42), and in the summer I completed my second year of fellowship at the University of Toronto. I wanted to obtain a permanent position in Israel and to return home. The search for a job by correspondence reached a new peak, but there was no real progress. I reached a dead end, exactly as predicted by Dr. Prywes, when I had asked him for a recommendation letter before setting on my American adventure. Therefore, in parallel to the search in Israel, I started looking for work in the United States. The most attractive job offer came from the Montefiore Medical Center in New York. This hospital had been requested to upgrade the professional level of an old city hospital – the Morrisania City Hospital in the Bronx, a few city blocks from Montefiore. The administration of the
Fig. 42. Dorit, six days old, with Milka and Yifat.
Montefiore Hospital was supposed to fill the vacancies in Morrisania with physicians who were on the Montefiore staff and served on the faculty of the Albert Einstein College of Medicine. The position offered to me was a full time appointment in the Department of Surgery at the Morrisania. I would instruct residents in general surgery and, as the only thoracic surgeon in the hospital, would be in charge of thoracic surgery. In parallel, I was offered the academic appointment as Assistant Professor of Surgery at the Albert Einstein College of Medicine. The salary, to be paid by Montefiore, was quite good. I accepted this offer, and in July 1970 my family and I moved to New York. During the four years of my absence, some changes had occurred at the Albert Einstein: Dr. State moved to Los Angeles and the new Chairman of the Department of Surgery was Dr. Marvin (Marv the Marvelous) Gliedman from the Montefiore.
The Morrisania Hospital was located in an area of
poverty, riddled by crime. Most of the work in surgery was related to trauma.
Until I came, no chest operations were performed there; all thoracic patients
were transferred to the Montefiore Hospital. My initial work concentrated on
organizing the groundwork for thoracic surgery. The necessary instruments were
purchased and operations on lungs and esophagus were performed for the first
time in Morrisania. The thoracic surgeons in Montefiore were relieved when the
volume of chest trauma in their hospital dropped significantly. Groups of
students from Albert Einstein – Montefiore came to the Morrisania for
short periods of study. My relations with the surgical staff and with the
department chairman – Dr. Gliedman, were excellent. I enjoyed my work and
was happy.
* * *
I had been at the Morrisania for about two months, when a letter came
from the Ministry of Health in Jerusalem: a position of chief of surgery became
vacant at the Shmuel Harofe Hospital in BeÕer-Yaakov, and a tender was
announced. Forms were enclosed, to be filled, in case I was interested in
applying for the position. Before receiving that letter I had never heard of
the Shmuel Harofe
Hospital and had not been aware of its existence. Its obscurity
notwithstanding, Milka and I, both viewed this tender with great hope: an
opportunity to return home. In case I won the tender, I would have an assured
job and could return to Israel immediately. There was no room for hesitation.
Without knowing a thing about the Shmuel Harofe Hospital, I filled the forms
and mailed them to the Civil Service Commission in Jerusalem. The authorities
in charge of the tender agreed to my unusual request to conduct the tender
without my personal appearance and were satisfied with my documents, submitted
by mail. From the day of application until the results of the contest became
available, we lived under indescribable stress. I could barely function. The
tender took place in November. At the end of that month I received a telegram
(why not a phone call?) stating that I had won the contest (Fig. 43). Here I
must point out an extremely important detail: the tender was for the position
of Chief of the Department of Surgery (Thoracic and General). At the
time I did not realize the importance of this particular phrasing. Its
significance became clear only ten years later, when Shmuel Harofe was
converted to a geriatric hospital and my department was transferred to the
Wolfson Medical Center. I will return to this subject in a later chapter.
From that
moment on, our lives had changed greatly. After ten years in America we became
used to certain way of life. We had to liquidate our home, make purchases
toward our return to Israel and organize the trip. But most
important, I had to see the hospital
in which I
expected to spend the following years,
perhaps the
remainder of my professional life. With this in mind, in December 1970 I went on
a trip of acquaintanceship.
Fig. 43. The telegram (in Hebrew): ÒWe are happy to
inform you that you were appointed for the position of Chief of the Department
of Surgery at the Shmuel Harofe Hospital. Please let us know the time of your
arrival.Ó
The hospital in BeÕer Yaakov was
built in the days of the British Mandate in Palestine as part of a big military
camp. It consisted of barracks built of Ómud and ragsÓ, according to the
description of the hospital director, Dr. Walter Davidson. During World War II
they started using this particular part of the camp as a British military
hospital, and the barracks served as hospital wards. After the establishment of
the State of Israel, the hospital was converted into a rehabilitation center
for new immigrants with chronic disabilities (ÒMALBENÓ). Most patients were
hospitalized for long periods of time, sometimes for several years. Many had
lung diseases, usually tuberculosis. After several years, the center was
transferred to the government ownership and served as a hospital for
tuberculosis. During the Six-Day-War it was temporarily converted to a hospital
for wounded prisoners of war. Later it became a general hospital, with a heavy
predominance of chest medicine: there were four pulmonary services, but only
one general medical service. The Department of Surgery consisted of one 50-bed
surgical ward. It filled the function of a general surgical service, but again,
there was great predominance of pulmonary surgery. The chief of the Department,
Dr. SŸsskind Herman, was a thoracic surgeon with extensive experience in
surgery of the lungs. In 1970 he died after a prolonged illness and the
position of department chief became vacant. Dr. HermanÕs staff consisted of two
surgeons, both in their fifties. The hospital was not affiliated with any
medical school and had no teaching tradition. Patients were admitted to the
surgical service for operations only. Dr. Herman performed all lung operations
by himself. The two members of his team performed operations of hernia,
hemorrhoids and the like. ÒMajorÓ operations in the realm of general surgery
were rare. The physicians in the department of medicine preferred to refer
patients who needed surgery, to other hospitals. However, the four pulmonary
services supplied Dr. Herman with sufficient volume of work.
When I came for my acquaintance visit in BeÕer Yaakov,
I met the hospital director, Dr. Davidson, who also served as chief of one of
the pulmonary services. I was not given the opportunity to meet the staff of the
Department of Surgery. In retrospect, I believe that this omission was
intentional, planned ahead of time by Dr. Davidson, who had good reasons to
hide my future team from me.
The hospital barracks were spread over a wide area
(Fig. 44). Among the hospitals in Israel it was a peripheral institution, not
widely known. Of course, there were no medical students. Only the Department of
Medicine was approved for residency training and in 1970 it had only one
medical resident. All the other services, including surgery, were not approved
for training and had no residents. Thus I was condemned to work with two
surgeons whom I had never met. I only knew that both were much older than I.
That was it, at least for the immediate future.
Fig. 44. Department of Surgery (barrack no. 7) in Shmuel Harofe Hospital.
I could not have been encouraged by this visit. But
what was the alternative? To stay in the United States and wait for another
opportunity? Others before me have done that. Their ÒtemporaryÓ stay in America
lasted their lifetime. It was obvious that the chances for another Òlucky
strikeÓ with a possibility of returning to Israel were close to nothing. This
was my first and probably the only opportunity to become chief of a department
of surgery in an Israeli hospital, miserable as it may be. I expected years of
tough struggle, but also a challenge. In spite of the disheartening impact of
my visit, I did not hesitate. My final conversation with Dr. Amos Arnan, the
executive officer in the Ministry of Health in charge of Hospitalization
Services, concentrated only on the date of my arrival. Dr. Arnan tried to
convince me to return to Israel and start working immediately. Without a chief,
the surgical services in Shmuel Harofe were close to collapsing. However, my
contract with the Montefiore Hospital obliged me to work for a whole year at
the Morrisania, and I was not ready to violate it. In addition, after ten years
in America, I needed time to get organized. I promised Dr. Arnan to try to
shorten the ÒarrangementsÓ as much as possible, but could not commit myself to
return before July – six months ahead.
In New York I had a concluding conversation with Dr.
Gliedman, Chairman of the Department of Surgery at the Albert
Einstein-Montefiore – the surgical empire of the Bronx. Dr. Gliedman
considered me an asset, important to the further progress and development of
the Morrisania Hospital and did not want me to leave. He offered me a
considerable raise in salary, tried to tempt me with promises of additional
modern equipment, such as a flexible bronchoscope (a novelty in 1970), and
more. But all this did not attract me. My decision was unshakable. I had spent
ten years in America. It was now time to part from this wonderful country.
Further postponement would turn into a permanent abandonment of Israel.
Milka supported my decision without hesitation. During
the following six months we concentrated all our efforts on preparations for
the return home and in July we set on a trip. We were happy.
On 1 August 1971 I entered my new position as chief of
my own surgical department.
6
Shmuel Harofe
Hospital
Upon our return to Israel we needed, first of all, a place to live. The hospital administration took care of this problem ahead of time and, on the day we arrived, we received keys to one of the houses kept by the administration for hospital employees. It was a modest two-bedroom wooden house (ÒSwedish barrackÓ), adequate as temporary living quarters for an unassuming family trying to take root in a new place. We could catch our breaths and start looking for permanent housing. We soon found and purchased one Òon paperÓ: at the time of signing the contract, an old house stood on that site, ready for demolition. However, the contractor assured us that the construction of the new building would take no longer than two years. Indeed, in September 1973, just prior to the outbreak of the Yom Kippur War, we entered our own new apartment in Rehovot.
The immediate proximity of our temporary house to the hospital was very convenient, particularly during the first two years of my work, when I used to spend whole days in the hospital, from the early morning hours (before 7 oÕclock) until after the evening bedside rounds, weekends included, and quite frequently nights as well. This exhausting schedule was the result of my early relationship with the two surgeons on my team. They viewed the appointment of an outsider as chief of the department, as an encroachment upon their ÓrightsÓ, sanctified by their longer presence on the service and their age. For them, I was an intruder without seniority, who had seized the position on the top of the pyramid and pushed them down.
As chief, I wanted to be in full control of the department. This was not only my right, but indeed, my obligation. In order to achieve this, I had to be present on the ward at all times. I had to write and personally sign every order; without it, none would be carried out. My work would be sabotaged – I knew this for sure. [13]
The only person on the surgical service I could rely upon, was the head nurse, Nurit Firt. Nurit was a charming and hard-working woman, full of enthusiasm and initiative. She did not spare time and effort to save the service from collapsing. During the following years, my relations with my deputy, Dr. Shmuel Winter, improved markedly. We learned to work together, with respect for each other. Dr. Winter told me, repeatedly, that only since I came to Shmuel Harofe Hospital, did he start performing lung operations by himself. Under Dr. Herman, his participation in the operations was limited to opening and closing the chest. Dr. Winter remained my deputy until his retirement in 1980.
The second surgeon was quite a different matter. I despised him, and for obvious reasons, do not wish to reveal his name. Of course, my opinion might not be considered objective, but save for my own impression, I have no other sources to draw upon. In my appraisal, he was extremely lazy, incredibly stubborn and dishonest. On many occasions I discovered complications – the result of his negligent work that he had tried to hide from me.
The following incident may serve as an example of his dishonesty. A patient who had undergone resection of the pilonidal sinus (abscess over the tail bone) came to me and complained that his operative wound failed to heal. Upon investigation, I found that this surgeon had operated on him, and at the end of the operation, had left a drain in the wound. At the time of closing the wound, the drain had been unintentionally caught in one of the sutures. When the time came to remove it, the surgeon pulled it forcefully, tearing the drain, so that part of it remained in the wound. The surgeon knew well that the wound would never heal as long as the foreign body remains inside, but he told the patient that the treatment has been successfully completed, and discharged him. The wound continued to discharge pus for many weeks, and the patient returned to the hospital. Upon opening the wound, I found the torn drain inside. I showed this to the surgeon. He smiled and said ÒI thought that it would heal.Ó I barely restrained myself from slapping his face.
His stubbornness and laziness are well exemplified by his refusal to take emergency night calls because ofÉ his age. He was 51 at the time, and many physicians, his age and older, took night calls according to the needs of their respective services. Following his refusal, he simply ignored the rules and did not stay in the hospital while on a night duty. What could I do? I had no means to impose the law upon him, because of his tenure – a sacred and untouchable right in the Israeli labor relations. I could not fire him. In order not to leave the service overnight without a surgeon on duty, I had to stay in the hospital myself, or to look for surgeons from other departments (urology, orthopedics), or even from outside the hospital. Those surgeons would be strangers, who did not know the patients on the service at all. But nothing else could be done about it. I could only hope, pray, and wait for a miracle to happen. I do not usually believe in miracles, but perhaps this case should provide an opportunity to reassess my beliefs, because a miracle did, indeed, happen.
One day this surgeon told me that he needed two or three months leave of absence. A relative of his had died and he must go to France to receive a great inheritance. In view of the extreme shortage of doctors on my team, it was very inconvenient for me to let him go. But together with the hospital director, we came to a conclusion that we had no choice. The surgeon had accumulated a sufficient number of unused vacation days, and had a good reason to take them now. I had to consent to his request.
The leave of absence declared to last two months, started in February 1974. In May 1974 I received a letter from the surgeon. The return address was that of an attorneyÕs office in France. The Doctor asked for an extension of his leave for an additional three months, in order to Òcomplete his business.Ó After another consultation with the hospital director, I granted him this extension too, but added that this one was final. If he does not return by the end of the additional three months, we would replace him. Following this, I did not hear from him for over a year. I wrote him several letters, mailed them all to the attorneyÕs office in France, but they remained unanswered. During that time, people who knew him well told me that the story about the inheritance in France was a pure fiction; the surgeon was in Germany, where he tried to obtain a medical license and find a job. The chances of his return to Israel were nil.
In November 1974, a doctor with a Russian accent asked for an appointment with me. Dr. Moritz Kaufman, a new immigrant from the Soviet Union, one year in Israel, was a general surgeon with 20 years of professional experience. During the past year he had worked in the Ichilov Hospital in Tel Aviv on a temporary job, but at the end of the year, no position could be found for him, and he was looking for work. I accepted him for a trial period. He came full of energy. It was the first time since I came to Shmuel Harofe, that I had in my department a surgeon with a positive approach, willing to work. He had experience, common sense and good clinical judgement, and always worked hard. He was a general surgeon, but while working with me, learned thoracic surgery as well. We became good friends. When Dr. Winter retired, he became my deputy. On several occasions he told me: ÒIn 1974, when you set our appointment for 6 a.m., I thought that it was an isolated incident.Ó But he became used to the unusual working hours on my service. Until this day I do not understand why they had not kept him on at the Ichilov Hospital. It was, undoubtedly, their mistake, from which I benefited for the next 21 years. At the end of this period we both retired.[14]
Fig 45. Twenty-one years of cooperation and friendship.
The surgeon who tried to settle in Germany, returned to Israel in 1975 and appeared before me without any announcement. He entered my room and, with the usual smile on his face said ÒI am backÓ. To this I answered ÒI am very happy to see you, but I wrote you several times that if you do not return by the specified date, we will be forced to look for a replacement. We found one. The position, previously yours, is now occupied by Dr. Kaufman.Ó ÒThis position belongs to me. I have tenure. Kaufman can look for a job elsewhere,Ó answered the surgeon, this time without a smile, and left the room. Since then I have not seen him. Not seen, but I heard a lot. The struggle for the position in question lasted a whole year. It involved the Israel Medical Association and the Organization of Government Physicians, both of which supported the surgeonÕs claim of his ÒrightsÓ, but it also involved the executive director of the Ministry of Health, whose primary concern was the benefit of the very problematic Shmuel Harofe Hospital. The hospital had to be upgraded. It was a war in which I invested great efforts, letters, and innumerable hours of emotional argumentation at discussions devoted to this problem. Tenure is holy and untouchableÉ but at the end I won. Does anyone still doubt that miracles do happen?
When I started my job in Shmuel Harofe, I found there one more surgeon, who was not there during my ÒacquaintanceÓ visit in December. Because of the severe shortage of staff, the hospital director looked desperately for a surgeon, and found an unemployed one. He appointed him to the surgical staff, in spite of the fact that during the preceding two years the new surgeon had been appointed on a trial basis in 12 different departments of surgery in virtually every hospital in Israel and was fired from each one promptly. It did not take me much time to discover that he was a difficult psychopath and an incurable liar. Fortunately, he did not have the ÒholyÓ tenure, so I promptly initiated the proceedings for dismissing him. He reacted to the letter of dismissal by beating up the hospital director and wrote to the Ministry of Health malicious letters of accusation against me, the hospital director and the hospital.
Getting rid of these two surgeons was a very important and decisive
step in improving the status of my department. In parallel, I applied to the
Scientific Council of the Israel Medical Association (the equivalent of the
American Board of Medical Specialties) for accreditation to provide residency
training to surgeons. A commission was appointed and the term for its
investigation was set for April 1972. The moment I saw the three surgeons,
members of the commission, entering my office, I knew that my chances of
passing the test were nil. The Commission Chairman was that thoracic surgeon
from the Rambam Hospital, involved in the old ÒAbouav affairÓ. He knew me, knew
that I was Jack AbouavÕs friend, and there was strong feeling of aversion
between us. The second member of the commission was Dr. Joseph Borman from
Hadassah – a former student and friend of the chairman. That was enough.
The third member was Dr. Dintsman from the Beilinson Hospital. He did not know
me and had no incentive to struggle in my favor.
The ÒinvestigationÓ by the Chairman of the Commission was particularly
traumatic. In striking contrast to the custom of such investigations (in later
years I participated in them many times), he did not concentrate on the number of
operations done on my service, nor on their variety; not on the function of the
supporting services in the hospital, such as the Institute of Pathology, the
Emergency Department and others, nor on the availability of other services
(e.g. urology, orthopedics) on which the residents would spend part of their
training (ÒrotationÓ). Instead, he chose to concentrate on the number of
patients who died on my service after prolonged illnesses, digging from under
the earth ÒcomplicationsÓ that supposedly could have been prevented, had we
tried hard enough, and other similar allegations. The investigation was
intentionally antagonistic and ended with the unavoidable and expected result:
the accreditation was not granted.
In the beginning of 1973, less than a year since my failure with the
first commission, I was granted a second chance. This time the composition of
the committee was different and the investigation was conducted in an
objective, unbiased spirit. In spite of the fact that no great changes could have
occurred in the hospital and in the function of my department in such a short
time, the members of the committee did not have any reservations and my
department was granted full accreditation for training of surgeons. Many came;
some were from other hospitals, interested to spend rotation on my service. The
work became more interesting and academically oriented.
The residents were happy with their training and some asked for
extension of their rotation period, which was usually granted. A rather
striking example of such turn of events was Dr. David (Dudu) Schneider, a
resident in gynecology and obstetrics at the Assaf Harofe Hospital. The
curriculum of his residency included a six-months rotation period on a surgical
service, and he chose to do it in my department. Close to the end of his
rotation he asked Prof. E. Caspi, his chief in Assaf Harofe, to let him stay on
my service for an additional period of six months. Professor Caspi consented.
After that came another request for a six-months extension, and another one.
Altogether, Dudu Schneider spent a full two years on my service. He was
satisfied with the experience gained and won the highest appraisal of the
entire staff. He was a charming fellow and an intelligent and industrious
physician. During his rotation, besides the routine work, he managed to write
two clinical papers, which we published together. Eventually, he became chief
of the Department of Obstetrics and Gynecology at the Assaf Harofe Medical
Center, and a leading gynecologic-oncologic surgeon in Israel.
Medical students also came to my department, initially for their
elective period of study – one or two months at a time. The first student
who came was Richard Reznick from Canada. My friends, surgeons in Toronto told
him about me, and he decided to spend his elective month on my service. We were
Òon the mapÓ. Today Dick Reznick serves as Professor and Chairman of the
Department of Surgery at the University of Toronto Faculty of Medicine.
Training residents and teaching students demanded great efforts, in which the
help of Dr. Kaufman was of inestimable value.
In the early 1970s only four hospitals in Israel had departments of
thoracic surgery: Hadassah in Jerusalem, Rambam in Haifa, and two hospitals in
the Tel Aviv area – Beilinson and Tel Hashomer. In addition, there was my
department – thoracic mixed with general surgery. Because other hospitals
did not have services of a thoracic surgeon, I was frequently called for
consultations, and the patients were transferred to my department for operations.
Particularly good relations evolved with three hospitals: Hadassah-Rokach in
Tel Aviv (today part of the Sourasky Medical Center), Assaf Harofe and Kaplan.
However, I was also frequently called to other hospitals. On several occasions
I operated in the Meir Hospital in Kfar Saba.
Soon after entering my job in Shmuel Harofe, I started performing
operations that were not done in Israel before. The first one was, quite
naturally, mediastinoscopy – that exploration of the mediastinum, which I
did in Mississippi in 1967. I was the first surgeon to perform it in
Mississippi, and now, the first one in Israel. Since 1971, this procedure
became routine in my department, before every resection of lung cancer, as part
of the preoperative workup. Many patients were referred to me from other
hospitals for this operation, before it became common.
Another operation, that according to my knowledge, no one performed in
Israel before me, was the resection of the trachea, because of a tumor, or a
scar with an obstruction. During the 1970s I performed more than 20 such
operations in Shmuel Harofe, and several others on visits in Meir and Assaf
Harofe Hospitals. It should be pointed out that all tracheal resections at
Shmuel Harofe, were performed on patients referred from other hospitals.
Pleuroscopy[15]
had been in clinical use in the first half of the twentieth century, mainly in
the evaluation and treatment of tuberculosis. With the discovery of drugs
against tuberculosis and the development of techniques of pulmonary resection,
the importance of pleuroscopy declined markedly, and gradually its use was
discontinued. The early 1970s brought renewal of this method, not in the
management of tuberculosis, but for diagnostic purposes, mainly in patients
with pathological changes in the chest cavity, such as masses or collections of
liquid. In 1974, my department was the first one in Israel to reintroduce it
into clinical use, and in 1980, at the convention devoted to pleuroscopy in
Marseilles, France, I presented our early experience with this method in three
lectures.
In general surgery, likewise, an invigoration occurred in my
department. Patients with major problems in need of surgery, who until recently
were referred from the Department of Medicine to other hospitals, started
coming to our service. In 1971 and 1972 we did our first porta-caval shunts[16]
─ the operation that Dr.
Erlik was doing in the 1950s as a pioneer, and which I observed him perform
when I came for my interview; radical neck dissections for cancer of the neck;
resections for cancer of the esophagus with transposition of the stomach into
the chest; fundoplication[17]
─ at that time a new operation in Israel; and others.
Most of these operations were done in Israel before, but never in Shmuel Harofe
Hospital.
At that time I was still interested in surgery of blood vessels, and I
performed such operations from time to time. However, for good practice of this
branch of surgery, one needs special instruments and a unique installation for
angiography.[18]
We did not have all these, not even the special needle needed to inject the
contrast medium. I received one such needle, a used one, from Prof. Pajewski,
chief of the Radiology Institute at Assaf Harofe Hospital. I used it several
times successfully, but this was not enough. I talked about it with my former
chief, Prof. Erlik, and with Prof. Mark Mozes from Tel Hashomer, both pioneers
and leading vascular surgeons in Israel. They managed to convince me that one
cannot practice vascular surgery in the 1970s, using methods and equipment of
the 1950s. Complications are likely to occur. Furthermore, Prof. Erlik told me:
ÒYou cannot be a successful specialist in all three branches: thoracic surgery,
general surgery and vascular surgery. Each one demands time for itself. Leave
something to othersÉÓ Rather than waiting for complications, I decided to follow
his good advice and gave up on vascular surgery.
I continued doing only one kind of operation classified as ÒvascularÓ,
but in which no procedure is performed directly on the blood vessels. There is
a condition of excessive palm sweating (hyperhidrosis), caused by a
disproportionate function of the autonomous (sympathetic) nervous system.
Excision of a short segment of the sympathetic nerve (the segment that affects
the palm sweating) brings sweating back to its normal level. This operation is
not new. It was conceived and carried out for the first time in 1949 by my old
teacher in New York, Dr. Robert Goetz, while he was working in South Africa,
before moving to the United States.[19]
This operation is not difficult, trauma to the patient is minimal (a 5 cm.
incision in the armpit) and the results are excellent. There is no need for any
special instruments or radiograms, and every surgeon acquainted with anatomy of
the chest and with the physiologic basis of the operation, can perform it. I
learned it from Dr. Goetz, while working in his laboratory in New York. In
Shmuel Harofe, I introduced this procedure into routine use, and patients
started arriving in impressive numbers. Nowadays, this operation is performed
in many hospitals in Israel, and the technique for its execution has changed
somewhat.
* * *
The building of our apartment house lasted two years, and in
mid-September 1973 we moved to Rehovot. Of course, we had no telephone. In the
1970s, waiting for a telephone line in Israel (for someone without connections)
could last up to 10 years and more (yes, ten years, no mistake), and
cellular phones were not yet invented. I hoped, that due to my function as
chief of surgery in a government hospital, my waiting period would be
shortened, but at the moment we did not have a phone connection.
On Yom Kippur day, 6 October, we were all at home. As usual on that
day, there were no radio broadcasts; in fact, we were effectively isolated from
the world. Should I suddenly be needed in the hospital for any reason, they
would send an ambulance to bring me. There was quiet and tranquility and I was
reading a book. A knock on the door interrupted my rest. Our neighbor, a
military reserve paramedic was suddenly called to service. Military maneuvers
on Yom Kippur? We turned the radio on and the broadcast was on. This was the
way we found out that the war had started.
I went to the hospital. The hospital director and his deputy were
already there, as well as a group of military officers from the Medical Corps.
Within a short time, most of the physicians and the other senior employees were
in the hospital. Dr. Davidson explained the situation. All wounded prisoners of
war would be concentrated in one hospital, and Shmuel Harofe was selected to be
the one. We had to quickly organize to be ready for an influx of wounded
prisoners. The plan included:
1.
Maximizing the
number of available beds. This would be achieved by discharging nearly all of
our current patients. Those who could not be discharged, would be transferred
to other hospitals.
2.
Converting as
many barracks as possible into ÒsurgicalÓ units.
3.
Organizing the
work of all physicians in the hospital, and adjusting it to the conditions of
war.
4.
Preparing a daily
working schedule with detailed hours, and a list of emergency calls.
5.
Organizing the
Emergency Department.
6.
Organizing the
Operating Rooms.
7.
Preparing a
helicopter landing pad.
With regard to Point 1, discharging patients and freeing beds –
most of our patients could be discharged either immediately or within a couple
of days. Transferring patients to other hospitals was impractical, as all the
other hospitals were also preparing for the war and needed free beds. None
would accept civilians from Shmuel Harofe. Thus the patients who could not be
discharged, were concentrated in one barrack, and were taken care of by their
respective physicians.
Point 2 did not present any special problems – the necessary
equipment for wound care and change of dressings was brought from the
storerooms.
Point 3, organizing work of the physicians, meant concentrating the
greatest efforts on treatment of the wounded. Teams were formed, composed of
doctors with different expertise (internists, pulmonologists, etc), with one
surgeon (from any surgical subspecialty) for every team.
The new daily working schedule was identical for all the medical and
surgical staff: 36 hours of work, followed by 12 hours of rest. The 36-hour
working period started in the morning and ended in the evening of the following
day, when the physician would leave the hospital for the night. This way, we
were all in the hospital during the day, every day, while half of us stayed in
the hospital for the night. This was not entirely my own original idea. I
followed the example of my residency at the Albert Einstein – Bronx
Municipal Hospital Center.
The Emergency Department and the Operating Rooms were staffed by
surgeons, urologists and orthopedists, who used maximum flexibility and
adaptation according to the volume of work.
Point 7 was, of course, not my concern. The helipad was prepared by an
Army team.
The wounded were brought by ambulances or by helicopters, usually in
groups (Fig. 46). There were hours of relative quiet, but when a wave of 20 or
30 casualties hit the emergency room, all changed in a moment, and the team
worked under pressure. In every group of wounded there were some severely
injured and some who needed operations. The shortage of working hands was
overcome by an excellent cooperation between the Emergency and the Operating
Room teams. In addition, when needed, groups of ÒinternistsÓ were temporarily
transferred from the ÒwardsÓ (barracks) to the Emergency Department.
Classifying the wounded and making early decisions demanded particularly great
responsibility, often more than that required by the operations, therefore, the
senior surgeons, those with the greatest experience, spent most of their time
in the Emergency Department.
Fig. 46. The helicopter
landing pad in Shmuel Harofe Hospital.
The small staff of Shmuel Harofe Hospital could not handle all these
demands by itself. We needed enforcements. Many Jewish physicians, among them
experienced surgeons from various countries, felt a need to contribute to the
war effort. They interrupted their usual occupations and volunteered to work in
Israel. Upon their arrival, they were distributed to various hospitals; some
were sent to Shmuel Harofe. Their work was of inestimable value, and I will
never forget them. Dr. Ashkenazy, an Israeli, interrupted his surgical
residency in Buffalo, U.S.A., and worked in Shmuel Harofe. Professor Gurevitch
arrived from Britain and contributed from his extensive experience. Dr. Alan
Gross arrived from Canada. I had met him several years earlier, during my
fellowship at the University of Toronto, while he was a resident in
orthopedics. He came to Israel full of enthusiasm and worked hard until the end
of the war. Later, he was promoted to the rank of Professor and Chief of the
Department of Orthopedics at the University of Toronto. Dr. Alan Padwell, a
young physician, just beginning his training in surgery, arrived from Britain.
After the war ended, he stayed in Israel and continued his surgical residency
in my department. Eventually he married a charming English young lady and
returned to Britain.
I developed a particularly warm relationship with a volunteer from
Boston, Dr. Theodore (Ted) Waltuch. This young surgeon was certified both in
general and in thoracic surgery. He worked with amazing industriousness beyond
the ÒofficialÓ hours, under hard and primitive conditions, so utterly different
from those he was used to in Boston. His enthusiastic approach to work and to
helping the wounded was exemplary. After the war we remained friends and kept
close contact. He returned to Israel for a visit, and during several of my
trips to the United States, I visited his home, met his family and lectured at
the staff meeting in his hospital. Last year Ted died from heart disease.
Blessed be his memory.
To complete the picture, I cannot avoid mentioning another, less exemplary
case. About a week into the war, a vascular surgeon from the United States came
to Israel. Because of his expertise in vascular surgery, he was referred to
Shmuel Harofe, as we did not have a good vascular surgeon. He did not hide his unhappiness with
being referred to treat prisoners of war, and said: ÒI came to help Jews, not
ArabsÓ. I replied that helping in our war effort certainly helps Jews, and a
conscientious physician cannot abstain from treating wounded enemy soldiers. He
seemingly agreed with me. Then I showed him our working schedule, pointed to
his working hours and nights on call, and we agreed that he would enter his
schedule the next morning. However, he did not come. Neither the next morning,
nor evening. And not the following day. He did arrive at my office ten years
later, with his new wife, before whom he praised himself and his heroic
deeds as a war ÒvolunteerÓ. I did not want to embarrass him in front of his
wife, therefore I did not correct his chivalrous stories, but also I did not
praise him for what he had not done ten years earlier.
During the war we admitted to the hospital 779 wounded soldiers. Of
these, 284 (a little over one-third) were operated on. Ten prisoners died from
their injuries. Seventy-seven wounded had penetrating chest injuries (10% of
all). There were no deaths in this group. One particular point is worth
stressing: although all chest wounds were contaminated and 70 of the 77 were
grossly dirty, full of sand, clods of earth and torn clothes, only in one
patient (1.3%) did an empyema (purulent infection in the chest) occur. Review
of data from the Vietnam War disclosed a 6% empyema rate among the American
soldiers with chest injuries. This big difference can probably be explained by
the different background of the casualties. The majority of the Egyptian and
Syrian combatants were from rural areas. In contrast to the urban Israeli
population or to the U.S. combatants in Vietnam, they had rarely received
antibiotic treatment in the past. Thus their microorganisms were not resistant
to antibiotics, and the first antibiotic treatment gave immediate good results.
This phenomenon was particularly striking among soldiers with chest injuries
and those with burns.[20]
The wounded remained in the hospital for a long time beyond that
justified by their medical condition, because it was impossible to discharge
them ÒhomeÓ or to a convalescent home. They had to stay, until they could be
sent to a camp for prisoners of war, which usually meant some time after their
complete recovery. Thus they continued to occupy valuable beds, keeping the
hospital full to capacity, until the end of the war. A surplus of casualties,
for whom no place was available (to the best of my memory, over 30 combatants)
were hospitalized in the Assaf Harofe Hospital. Those in need of neurosurgical
treatment, were hospitalized at the Sheba Medical Center in Tel Hashomer.
We developed good personal relations with some of the Egyptians, and
from time to time we heard a few words of thanks. I remember a young military
physician injured in the chest and with fractures in three of his limbs, all in
a cast. We conversed almost every day and, as an expression of our special
relations, gave him a separate room. In contrast to the Egyptians, we never
heard a word of thanks from the Syrians; their eyes and conduct expressed only
deep-rooted hatred, and they did not engage in any private conversations with
us.
The cease-fire agreement with Egypt was signed in December 1973. Soon
thereafter, most of the Egyptian prisoners were freed, and we returned to
ÒcivilianÓ surgery. The progress with Syria was slower and their prisoners
remained with us until January 1974 (Fig. 47).
Fig. 47. The
deliberations preceding discharge of prisoners; the hospital director, Dr.
Davidson, first from right, in white coat.
On 17 November 1973, Nurit, the head nurse, left the service for
maternity leave and the same day gave birth to a daughter. Another nurse took
her place on the surgical service. At that time I thought that the replacement
was temporary, but it was an illusion. As I later found out, the substitute
nurse agreed to replace Nurit under the condition of permanency on the service.
When Nurit returned from her leave, it was to a different service, not to
surgery.
During the 1970s the Shmuel Harofe Hospital made great progress. Much
had been achieved. However, at the same time there were serious considerations
in the Ministry of Health, to convert the hospital into a geriatric
institution. Finally, in 1979, it was announced that at the end of the fiscal
year, Shmuel Harofe would be converted from a general to a geriatric hospital.
No one knew what would happen to the acute services, such as surgery, that do
not belong in a geriatric institution. Various ideas were discussed. One
possibility was to merge Shmuel Harofe with the Assaf Harofe Hospital, located
in close proximity, and transfer our acute services to Assaf Harofe. At the
same time, the construction of another hospital had just been completed. This
was the Wolfson Hospital in Holon, supposed to replace the old and obsolete
Donolo Hospital in Jaffa. Toward the end of the year, stormy deliberations were
repeatedly conducted in the Ministry of Health with regard to the future of the
various departments at Shmuel Harofe and their personnel. I did not participate
in these meetings and do not know many of the details. Some may have been left
intentionally undisclosed. The entire affair was characterized by immense
tension between the teams of the various departments. A strong feeling of
deprivation developed among those supposed to remain at Shmuel Harofe. The
final decision was that the departments of orthopedics, urology and medicine
(Second Department), would be transferred to Assaf Harofe, while the first
medical department, surgery and one of the pulmonary services with its
respiratory intensive care unit – to Wolfson.
I remained in Shmuel Harofe until the end of the fiscal year – 31
March 1980, when the operating rooms and the Emergency Department were closed,
and the acute departments were transferred, each one to its respective new
place.
The 9-year period at Shmuel Harofe was very important for me. During
that time two of my children were born: Limor Tal, in January 1974, while we
were still under the shadow of the Yom Kippur War; and Avishai Moshe, in
September 1975. Avishai was named in memory of our fathers: MilkaÕs and mine.[21]
I learned to be independent and to direct a hospital department. I did commit
some errors, but also had successes. And I played a significant part in putting
Shmuel Harofe Òon the map.Ó. In my judgment, the conversion of Shmuel Harofe
into a geriatric institution was a success. Today it is a magnificent geriatric
hospital, in my opinion the best in Israel. We did have part in making it such
by building the foundations. In spite of all the difficulties, it was a
beautiful era.
7
Struggle at the Wolfson Hospital
The construction of a new medical center in the area of Jaffa –
Holon – Bat-Yam was planned because of the deterioration of the Donolo
Hospital in Jaffa. The old Donolo Hospital, dispersed in several barracks, was
rapidly becoming obsolete. As there was no other general hospital nearby, a
replacement was urgently needed. In 1963, construction of the new hospital was
started in the Tel Giborim section of Holon. However, the ÒdisappearanceÓ of
huge sums of money designated for continuation of work, halted the
construction. According to the official version, the funds were diverted from
the Ministry of Health to the coffers of one of the political parties, an event
known as the ÒItzhak Rafael affairÓ. Due to shortage of capital, the
construction was delayed for many years and, quite likely, would never have
been renewed, were it not for the generous help of the British-Jewish
philanthropist, Sir Isaac Wolfson, whose magnanimous contributions enabled the
work to continue. The building was completed in the beginning of 1980, and the
Edith Wolfson Hospital named in honor of Lady Wolfson opened in Holon at a
solemn ceremony on 4 March 1980 (Fig. 48). On 1 April my department was
transferred to the new establishment. Because the operating rooms were not
quite ready, I used to spend most of the time in my office, reading or writing.
On several occasions I operated at the Assaf Harofe Hospital, and in May, I
managed to arrange a trip to Marseilles, France, to participate in a convention
on pleuroscopy. The orderly work started only in July, with opening of the
operating rooms.
Fig. 48. The Edith
Wolfson Medical Center in Holon.
Initially, the Wolfson Hospital was planned to replace Donolo and was
intended to have two surgical services – the two that functioned in
Donolo. Because of the last momentÕs decision to convert Shmuel Harofe into a
geriatric hospital and the long-lasting deliberations regarding the future of
the ÒacuteÓ services at Shmuel Harofe, my department was not taken into account
and, in a way, became superfluous: a third surgical service in the hospital
where only two were planned. The hospital administration came to Wolfson from
Donolo and did not want us. For them, we were not a transfusion of fresh blood
that would rejuvenate and invigorate their aging institution, but invaders who
came to rob them of all that by the force of habit became ÒtheirsÓ. They approached
the team of Shmuel Harofe with undisguised hostility. From the first moment we
were treated as unwanted ÒstepchildrenÓ, and we felt it acutely. The 73 beds
appropriated to surgery were divided according to the scheme that only the
hospital administration could understand. The first surgical service was
assigned 30 beds, the second service, 25, and the third (my service), 18. This,
despite the fact that in the Donolo Hospital each of the two surgical services
commanded only between 25 and 30 beds and performed only general surgery, while
my department in Shmuel Harofe had 45 beds, and served both general and
thoracic surgery. Also, the first service, since the death of its chief, Dr.
Haim Izak, did not have a permanent chief, only an acting chief. This was with
complete disregard of the requirements of the Scientific Council concerning
accreditation for training residents in surgery. In Israel, for full
accreditation, a surgical service must have a minimum of 30 beds, and for
partial accreditation (in collaboration with other services) a minimum of 25
beds. The first surgical service that did not have a permanent chief until
March 1982 and therefore could not become accredited, was assigned 30 beds, as
required for full accreditation. The second service, with its 25 beds, could
barely become partially accredited. My service would not qualify even for
partial accreditation. My appeals and petitions to the administration fell on
deaf ears. I conducted a number of conversations with senior officials in the
Ministry of Health, individuals who were personally involved in the transfer of
my department and its integration within the Wolfson Hospital, but they ignored
my arguments. In case I desired further conversations in the Ministry of
Health, they advised me to apply for an audience through my hospital
administration, according to the rules. A ÒusefulÓ suggestion, indeed. I was
completely helpless. Throughout all my professional life, I do not remember a
period of greater anguish than the first four years at Wolfson. Only in 1985
did the hospital director make the fortunate decision to retire at the age of
62, and in his place came Dr. Amnon Shahar from the Sheba Medical Center. He
had not been involved in the Donolo Hospital politics and was not prejudiced
against the Shmuel Harofe ÒinvadersÓ.
Among the surprises that the administration had in store for me, was
its unshakable desire to get general surgery out of my department and to limit its activity to thoracic and vascular
(!) surgery, this branch that I had stopped practicing several years
earlier. I was not sufficiently skilled in it, and I had good reasons to
believe that the administration intended to make me fail by imposing it on me,
and by forcing on me a ÒdeputyÓ who would Òhelp meÓ with vascular surgery and
in parallel sabotage my work. An appropriate candidate did, indeed, work in the
hospital at that time, and the administration tried to force him into my
department against my manifest opposition. The struggle over the character of
my department reached the Ministry of Health, but I had a strong legal base to
lean on: that famous letter of appointment from 1970, when I won the tender for
the position of Chief of the Department of Surgery (Thoracic and General).[22]
The law of tenders was on my side and the hospital administration had to
retreat.
In parallel, several changes occurred in the hospital. Dr. Alex Dinbar,
chief of the second surgical service, also became disenchanted with the Wolfson
Hospital atmosphere. He applied for a position of chief of surgery in the Meir
Hospital in Kfar Saba, and won. In his place came Dr. Arie Merhav from the
Ichilov Hospital. After a year of trial, he returned to Ichilov. Following him,
there was one year of interregnum, when Dr. Dona served as acting chief,
and in September 1983 Dr. Yehuda Adam arrived from the United States. After
three months, in December of the same year, he too decided to leave, and
returned to the United States.
This rapid rotation of chiefs paralyzed the work of the second surgical
service completely. In 1984 it was decided to ÒfreezeÓ it, and its beds were
divided between the first and the third services. Now I could apply to the
Scientific Council. Accreditation of my department for training of residents
followed promptly.
Likewise, the hospital directors changed from time to time. Dr. Shahar
remained in Wolfson until 1989 and then returned to the Sheba Medical Center.
Dr. Waysbort served as acting director from 1989 to 1993, and in 1993 Dr. Moshe
Mashiah came, bringing with him stability and progress.
* * *
The affiliation of my department with a medical school was delayed for
a number of years. My petitions to the successive deans of the Faculty of
Medicine of the Tel Aviv University remained without response for a long time. In
1986 I was invited to Prof. Theodor WiznitzerÕs home. At that time he was not
the dean anymore – Prof. Haim Boichis had replaced him. While we drank
coffee, Wiznitzer told me some details connected with that tender in 1957, when
my candidacy for residency in Hadassah had been rejected. Also, in contrast to
his earlier indifference, he promised to take an interest and to find out the
reasons the medical school was not responding to my repeated petitions for
affiliation. His ÒinterestÓ appeared to be quite effective, because in the
beginning of the new academic year, in October 1986, I was appointed to the
Faculty of the Tel Aviv University Sackler School of Medicine. I did not have
to pass through all the ranks of academic promotion, such as instructor, lecturer
and senior lecturer, but was appointed directly as Associate Clinical Professor
of Surgery (Fig. 49). Together with the appointment, came a variety of
functions, such as lecturing in the Medical School, instructing groups of
students in the hospital, and others. During the years that preceded my
appointment, I missed students greatly, and now I received them with
enthusiasm.
Fig. 49. Letter of
appointment as Associate Clinical Professor.
* * *
The job of instructing physicians and turning them into expert surgeons
brings both joy and obligations, and sometimes disappointments. During the
years, many physicians started their training in my department. Some were good,
others very good or excellent. But there were also individuals who did not
complete their tour of education. I remember a resident who, while admitting a
patient, wrote that normal breath sounds were heard over both lungs. In the
past that patient had undergone a left pneumonectomy (total resection of the
left lung). Was the resident unable to recognize the absence of breath sounds
over the left lung? Did he not see the large operative scar? No. It was a
simple case of laziness and cheating. The doctor admitted that he did not
examine the patient: ÒEverybodyÕs breath sounds are the same anyway, so why
bother with examination?Ó This resident did not stay long in my department.
There were also cases of gross meanness. I remember two residents who started
working on my service, and without telling me, tried to get residency positions
in another hospital. When those positions became available, they left my
service without a momentÕs notice. I could have tried to hold their paychecks,
but what good would that do? They foiled me and failed me, but I learned
something from this experience.
It is, therefore, gratifying to recollect those residents who excelled
in intelligence and in performance. Their achievements are the true measure of
my work as an educator.
I mentioned Dudu Schneider in the preceding chapter. Another striking
example was Manoucher Robenpour, a young physician, just out of medical school.
He managed to escape from Iran, arrived in Israel and came to me looking for a
job. As a newcomer to Israel, he did not know Hebrew. My first impression of
this graduate of the Teheran University was not particularly favorable (what
can one learn in Teheran?). But he came to me in 1985, several years before the
onset of the great immigration wave from the Soviet Union, when we were very
short on staff. Discussing his application with Dr. Kaufman, we arrived at a
conclusion that the newcomer could not be any good. However, he could assist on
operations and participate in emergency night calls. At that time, even
construction of the Òon callÓ list was difficult. I had no choice, but to accept
him.
Dr. Robenpour had some surprises in store for me. He worked with
exceptional diligence. He came to see patients with difficult clinical problems
every night, even when not on call, 4read scientific journals and books
pertaining to those problems and stimulated discussions. In addition, he found
time to write a number of articles for publication. I learned from Manoucher
that it is not important what university one graduates from, but the
personality of the graduate. In 1987 I recommended him for citation as an
outstanding resident. He stayed in my department for three years, but
eventually went into plastic surgery, of which he had always dreamed. At
present he is in private practice – a well-known plastic surgeon in
Israel.
There was another bright
star among my residents. One day in 1993, a young female doctor entered my
office, told me of her desire to become a surgeon and asked whether I would
accept her for residency training. ÒLittle girlÓ, I though skeptically, Òhow
will she fit into surgery?Ó Eventually, I accepted her for a trial period. This
graduate of the Ben Gurion University School of Medicine, Dr. Yael Refaely,
worked hard, had a brilliant mind, excellent clinical judgment and manners, and
the skillful hands of a born surgeon. During her work on my service we wrote
and published together seven clinical papers. Her most important features were
honesty, integrity and courage to carry a responsibility. I remember well an
operative complication in which Yael was involved – a bleeding that could
have been easily avoided. In other, similar cases, I saw how the physician who
caused the complication, tried to shift the responsibility onto others who
participated in the operation (Òhe told me to do soÉÓ). Instead of trying to
evade responsibility, Yael entered my office, told me about the case, accepted
full responsibility for the complication and asked me whether this was not the
time for her to leave surgery and find a different branch of medicine that
would fit her better. I took that idea out of her head. From complications such
as hers, one should learn, not run away. Only someone who does not operate, has
no operative complications.
Among the doctors who worked on my service (both, residents and
certified specialists), Dr. Refaely was the only one, the head nurse never
yelled at. She was like a flower on the service. Years later I found out that
before visiting me, Yael conducted a search among residents on surgical
services in several hospitals, including my own, before she decided to ask for
a position in my department. Following two years of fellowship at leading
medical centers in Baltimore and in Boston, she became chief of Thoracic
Surgery Unit at Soroka Medical Center – Ben Gurion University in BeÕer
Sheva (Fig. 50).
Fig. 50. ÒThe girl who
wanted to be a surgeonÓ –
Dr. Yael Refaely at the
time of her work on my service.
* * *
In April 1976 a 53-year-old patient was referred to me because of
coughing and raising sputum mixed with blood. He smoked two packs of cigarettes
a day for most of his life. His chest roentgenogram disclosed a tumor in the
left lung. At the operation I found cancer (squamous cell carcinoma) at the
base of the lung. The tumor invaded the diaphragm and the spleen. I resected
the lower lobe of the lung along with part of the diaphragm and the spleen, and
closed the rent in the diaphragm with a patch of plastic mesh (marlex). The
postoperative course was uneventful. The remaining upper lobe of the lung
expanded well and filled the chest cavity, and the patient recovered promptly.
In spite of my repetitive advice and his wifeÕs assertive demands, he did not
stop smoking and refused to accept any further treatment – either by
radiotherapy or by chemotherapy. But the operation apparently had been adequate,
the cancer did not recur, and the patient enjoyed another 17 years of good
life. He died at the age of 70, from a different kind of cancer (sarcoma) in
his other lung. We remained friends until the day of his death, and during
those 17 years that he won, I shared many of his joys, such as the weddings of
his daughters and the births of his grandchildren. The course of cancer is
sometimes a matter of luck, more than anything else.
* * *
Another victory, with a romantic background, occurred when a
24-year-old woman was attacked by her former boyfriend. He grasped her hair
with his one hand, and with a knife held in the other, stabbed her eight times
in the belly and on both sides of the chest. This event occurred very close to
our hospital. There was no time for the usual routine evaluation. Without
roentgenograms or any other tests she was brought into the operating room. She
had no palpable pulse and her blood pressure was zero, but her heart sounds and
breath sounds were still audible. Her bleeding had to be stopped before
anything else. I was ready to begin the incision, when the anesthesiologist
said: ÒDov, you are wasting your time, she is deadÓ. I started the operation.
Inside the abdomen I found two liters of clotted blood. There were several
bleeding stab-wounds in the liver that I sutured, a torn spleen which I
resected, and several cuts in the intestines and in the stomach – all
treated according to needs. By the time of closing the abdomen, her blood
pressure rose to 60. The injuries to the chest were taken care of by inserting
tube drains on both sides. Over one liter of blood was drained from the chest,
but the bleeding diminished gradually, and there was no need to open the chest.
The patient recovered. One year later I attended her wedding. When I danced
with her, she seemed alive and very much so. I would point this out to the
anesthesiologist, but he was not present at the wedding.
* * *
Unfortunately, surgery is not composed only of victories and joys. A
short time after the operation just described, I treated a 26-year old man,
married and father of two daughters, both under 3 years. He had cancer of a
rare kind (adenoid cystic carcinoma) extending from the lower end of the
trachea (windpipe), along the entire left main bronchus, down to its
bifurcation into two lobes. The patientÕs family understood the severity of the
situation. I remember his motherÕs emotional appeal: ÒDoctor, gouge my eyes
out, but save my childÓ.
The surgical treatment of this kind of neoplasm involves resection of
the entire left lung, a procedure that requires opening the chest on the left
side. But because of the extension of the tumor to the trachea, the resection
must involve the lower end of the trachea as well, and connecting the trachea to
the bronchus of the right lung – the only lung left to the patient. This
procedure cannot be performed from the left side, because the aorta obstructs
the surgeonÕs approach to the trachea (Fig. 51). It was necessary, therefore,
to open the chest on both sides – a very traumatic operation. I knew of
the exceedingly great danger to the patient, but this kind of cancer was not
sensitive to radiotherapy and there was no effective chemotherapy. The only
hope was in resection as described, with two operating teams working
simultaneously on both sides of the patient.
Fig. 51. Schematic drawing of the operative finding
and the procedure. A. Criss-crossed area indicates the tumor. Broken lines mark
the limits of the resection. B. The left lung had been resected together with
the lower part of the trachea and the right bronchial stump. The right bronchus
had been sutured to the trachea.
The operation was technically successful, but at the end, the patient
was unable to breath spontaneously, and it was impossible to detach him from
the artificial respirator. He remained in the operating room, ventilated by the
machine until the late evening – the time of his death. It is difficult
to describe the conversation with his mother and wife – and I will not
try. For me, it was an exceptionally traumatic experience.
* * *
Another tragic case was that of a girl, less than three years old, from
a religious agricultural settlement. She played in the yard in front of her
house, near her fatherÕs tractor. The father did not notice his daughter,
climbed the tractor and went to work. When he heard his daughterÕs screams, it
was too late. The girl suffered a severe head injury and was hospitalized for a
prolonged time. Her breathing ability was temporarily impaired, and she was
ventilated artificially for three weeks. The breathing tube inserted into her
trachea caused an inflammatory reaction, resulting in a scar with obstruction
of the trachea. The obstructed segment had to be resected, and the girl was
transferred to my service (Fig. 52). The operation itself and the immediate
postoperative course were uneventful, but after several weeks the breathing
difficulties recurred. Bronchoscopy disclosed excessive growth of connective
tissue (granuloma), with narrowing at the suture line. I removed the granuloma
with forceps, and normal breathing was immediately restored. After another
three-week period, early symptoms of narrowing recurred. One Friday night the
breathing difficulties increased. Because of the onset of the Sabbath, the
parents decided to postpone the hospital visit until Sunday. That night at
dinner, the girl aspirated a small morsel of food into the trachea and the
airway became obstructed. Sabbath notwithstanding, the parents took her to the
hospital, but she was dead on arrival. Resuscitative measures were ineffective.
According to the parents wish, autopsy was not performed. There was no doubt
about the cause of death. The parents – deeply religious – accepted
theirs daughterÕs death as fate and GodÕs wish.
Fig. 52. A strange
conjunction: artificial opening into the windpipe and the pacifier...
* * *
Medical negligence is bad. It may cause patientÕs deterioration and
death, and must always be avoided. But it is not always the physicians who are
at fault. It may be the patientÕs own ignorance or plain stupidity that
prevents the necessary treatment. An unforgettable case comes to mind, from the
times of my surgical residency in New York, 40 years ago. A woman in her early
forties visited the outpatient department because of a ÒwoundÓ in her chest. On
examination there was a shocking
view of the womanÕs chest. The left breast was missing. In its place there was
a deep crater, 15 cm in diameter, muscles and other soft tissues destroyed. At
the bottom of the wound one could see uncovered ribs. The entire cave was full
of pus, dissipating offensive stench. It was an obvious case of an extremely
neglected breast cancer. It must have taken years to reach this level of
breakdown. To my questioning about presence of a mass in her breast at some
earlier time, the patient answered Òyes, there had been a mass and it grew over
several years. Afterwards the skin ulcerated, and that wound too kept growing.Ó
She added, that she avoided an examination by a physician, because of her worry
that it might be cancer, and the doctor would suggest an operation. During all
those years she even managed to conceal the horror from her husband. ÒSo why
did you come now to the hospital?Ó ÒBecause last week my husband discovered the
wound and forced me to come.Ó At that time, the management of breast cancer,
this advanced, involved resection of both ovaries (oophorectomy) because of
their hormonal influence on this neoplasm. This was the first case of
oophorectomy in my career.
* * *
The following story illustrates the importance of experience in
clinical practice – a feature that does not depend on a high level of
education. I remember an incident from my internship in Hadassah, during my
rotation on the pediatric service. One night I was called to see an infant. One
of the older nurses did not ÒlikeÓ the babyÕs breathing. I examined the infant
and found nothing wrong, but because I did not have previous experience with
little babies, I decided to alert the pediatrician on call. He came, examined
the infant, and also did not find anything exceptional. He calmed the nurse,
and we both went to sleep. Before dawn the infant died. What happened? We never
found out. But it is clear to me that the nurse had extensive clinical experience
and knew something about newborn babies. She was right in her impression that
something was wrong. The infant was not saved, but my decision to alert the
pediatrician was correct. Perhaps he should have alerted a more experienced,
senior pediatrician?
* * *
Following is an example of a Òmedical miracleÓ. This is a story about
an 11-year-old boy with a huge mass inside his chest on the left side (Fig.
53). He was sent to me in 1976 for a possible resection. The tumor was
malignant; it invaded the mediastinum and the chest wall (Fig. 54). Resection
was impossible. I took a biopsy and closed the chest. Histological examination
disclosed neuroblastoma, a malignant tumor of the nervous system in children,
with a very bad prognosis. The child was referred to the oncological service
for treatment, but his parents procrastinated, and he was not treated. He also
never came for a follow-up examination. Several years later, when I reviewed
the experience of my department with similar tumors in the lung, I was unable
to trace this patient and to find out what had happened to him. I assumed that
he must have died. However, 23 years after the operation, a physician from
another hospital called me, requesting detailed information about this patient.
It turned out that he was hospitalized for a condition not related to his
childhood tumor. He did not keep his hospital discharge summary from 1976 and
did not know much about his disease, but he remembered my name, which helped
his physician to find me. The tumor had vanished without a trace.[23]
What is a medical miracle? I use this term to describe a clinical
course that is contrary to all expectations and cannot be explained. This
phenomenon does exist.
Fig. 53. Chest
roentgenogram shows a huge mass filling the chest cavity on the left side.
Fig. 54. The patient on
the operating table, just before start of the operation. There is a
considerable bulge on the left side of the chest, due to tumor invading from
within.
* * *
I will conclude this bunch of clinical cases with a story about a
patient with BŸrgerÕs disease (occlusion of blood vessels in limbs), a
chain-smoker, incurable and without hope. All his limbs were amputated, but his
wounds still would not heal because of lack of blood supply. I was involved in
his treatment in the Rambam Hospital in 1958. Every week or two we had to
amputate a further part of one of his extremities in order to reach a healthier
level of tissue, with a chance to heal. His suffering was beyond description.
His pain did not react to drugs, including morphine that he received without
restriction. His wife was sitting at his bedside, holding a cigarette in his
mouth – the cause of his disease, but also his last and only pleasure. No
one would stop her from doing it. He told me: ÒThis is not life; I prefer to
die, I want to dieÓ. He meant it. It was clear to all that his death was
close and no treatment could save or prolong his life; we could only prolong
his suffering.
Such patients are not a rarity, today as then. We have no right, legal
or moral, to shorten their lives. But do we have the right to prolong their
agony?
8
Widening of horizons
There are limits to the knowledge and experience that a young surgeon
can acquire in a surgical department throughout the period of his training. The
knowledge conveyed to the trainee by the department chief and his group of
associates is inevitably limited by the volume of their experience and by their
own personal prejudices.
Departments differ in their experience and in their
approaches to various problems. When I first saw these differences, they seemed
to me disorderly and I doubted their value. In one of our conversations, Dr.
Erlik pointed out my mistake. There are no absolute rules of surgical wisdom.
One has to learn from experience of others, become acquainted with methods
different from our own and widen horizons. Policy differences between various
departments are thus justified and exchange of ideas should be encouraged.
Hence the importance of visiting other medical centers, both in Israel and
abroad.
The custom to send young physicians abroad became
routine in some hospitals in Israel, mainly in the largest and most developed
ones; less so in others, with limited possibilities. In those poor hospitals,
traveling arrangements are often a matter of personal initiative of every
physician and each one has to care for himself. And so did I.
William J. Mayo wrote in 1910: ÒTake frequent vacation
from active work, to attend clinics and walk hospital wards. See things for
yourself; reading alone is not enough.Ó Following his advice, I used some of my
free time, while in the United States and Canada, to visit the most prestigious
medical centers and to observe surgeons of great fame, about whom I had read or
heard before. I visited the Lahey Clinic and the Peter Bent Brigham Hospital in
Boston, Johns Hopkins in Baltimore, the Mayo Clinic, the University of
Minnesota, the Mount Sinai and Beth Israel hospitals in New York, and several
medical centers in Houston. At the beginning of each visit I usually introduced
myself in the public relations office and told them the purpose of my visit. I
was always welcomed. They toured the hospital with me and let me observe the
surgeons of my choice operate. Among those were some who today are part of
medical history. I saw Henry Bahnson, Michael Ellis DeBakey and Denton Cooley
operate on blood vessels and the heart, John Garlock and Leon Ginzburg on the
gastrointestinal tract, and many others. Initially, my visits were not focused
on specific kinds of operations. I just wanted to see the ÒgreatÒ ones at work.
I learned a little and I was left with formidable impressions. In later years I
organized these visits in a more orderly way, directing them at specific
subjects.
* * *
Thoracic outlet syndrome is the result of an anatomic abnormality in
the area where blood vessels and nerves pass from the chest to the arm. This
narrow passage is surrounded by the clavicle (the collarbone), the first rib,
ligaments of tough fibrous tissue and muscles (Fig. 55).
Various local anatomic derangements, such as fractures and
posttraumatic scars, congenital anomalies and other deviations from normal, may
cause an additional narrowing of this passageway, exerting pressure on the
enclosed structures. This excessive pressure causes pain, sensory disturbances,
and limitations of movements in the arm and hand. For effective treatment of
this condition, the entire first rib has to be resected. A wider passage
between the clavicle and the second rib is thus created, and the pressure is
relieved. This operation was devised and first performed by Dr. David Roos of
Denver. However, the surgical approach to the first rib is difficult, and the
resection of the entire rib, hazardous. Because of its immediate proximity to
the vessels and nerves, manipulation around the rib may cause injury to these
structures. I felt that the best way to learn this operation would be to visit
Dr. Roos and learn his method directly from him.
Fig. 55. Anatomic preparation
of the thoracic outlet dissected by Dr. ZeÕev Zurkowski, resident in my
department in the 1970s.
A. The first rib, B. The
clavicle, C. The tunnel for nerves and vessels.
I made an appointment, and in January 1978, I flew to Denver. For
economic reasons I decided to stay at the YMCA. My choice of hotel caused Dr.
Roos some embarrassment. He could not tolerate a guest of his staying at the
YMCA. After a short forewarning by telephone, he arrived at the hotel, took me
out nearly by force and brought me to his home, where I stayed for the
remainder of my visit. During all this time I remained in his company,
participated in his operations, visited his clinic and laboratory and learned
all aspects of his work. I met and befriended the Roos family, and before
leaving Denver, I addressed staff meetings in the two hospitals in which he
used to operate (Fig. 56). Soon afterwards I introduced the first rib resection
as routine in our treatment of patients with the thoracic outlet syndrome. A
year later I visited Dr. Roos again and learned the most recent developments in
his methods of diagnosis and operation. From Denver I went to Dallas, to see
the work of Dr. Harold Urschel – another expert on thoracic outlet
syndrome.
Fig. 56. Letter from Dr.
Roos, following my visit in Denver.
* * *
Congenital deformities of the chest are infrequent. The most commonly
encountered ones are pectus excavatum (a congenital depression of the
breastbone) and pectus carinatum (a protrusion, usually asymmetric). The cause
of these deformities is uneven development of the ribs. Due to a genetic
defect, some ribs grow excessively, becoming longer than normal. While growing,
the ribs push the sternum (breastbone) out of its normal place. If the
defective ribs push the sternum inside (backwards), a depression is formed
(Fig. 57); if the sternum is pushed forward, a bulge forms (Fig. 58). There are
several operations to correct these defects. The most common one consists of
excising excessive lengths of ribs and restoring the breastbone to its proper
location, sometimes aided by plastic correction of the deformed bone.
Fig. 57. A pair of twins
with pectus excavatum.
For a long time I considered going to see this
operation performed by one of the renowned masters. After corresponding with
several authorities, I decided to visit Dr. Francis Robicsek in Charlotte,
North Carolina. After seeing him operate, I used his method routinely on our
patients (Figs 59 and 60). In addition to his prominent place in surgery, Dr.
Robicsek is also an accomplished amateur archeologist and wrote several books
on South American archeology.
Fig. 58. An asymmetric
pectus carinatum.
Fig. 59. Normal
appearing chest wall following operative correction of pectus excavatum.
Fig. 60. The same
teenager as in Fig. 58, after operative correction of the carinatum defect.
* * *
Surgery of the trachea is a relatively new field that requires special
expertise. I learned operations on the trachea from F.G. Pearson in Canada,
during the two years of my fellowship, and started doing them myself soon after
my return to Israel in 1971. To the best of my knowledge, no such operations
were done in Israel prior to my return. In fact, nearly all the patients on
whom I operated, were referred to me from other hospitals.
The actual ÒfatherÓ of operations on the trachea is Hermes C. Grillo
from the Massachusetts General Hospital and the Harvard University in Boston.
Grillo is an old friend of F.G. PearsonÕs, and I met him while still working in
Toronto. In order to see him operate, I contacted him, and in February 1978,
after visiting David Roos in Denver, I went to Boston. There, I participated
with Grillo in an unforgettable 9-hour operation. We were three surgeons on the
case: Dr. Grillo who actually performed the operation, his chief resident Dr.
Lowe and I. The patient had an extensive stricture of the trachea and of both
main bronchi – the result of long lasting tuberculosis. In order to
enable her to breathe normally, the major part of her trachea and segments of
both bronchi had to be resected, with secondary, nearly impossible connections.
An exceptionally difficult and trying operation. But there was no limit to
GrilloÕs patience and his technical abilities. He worked slowly and with great
precision. The operation started at 8 a.m. and came to a successful conclusion
at 5 p.m.
Heavy snow started falling in the morning and kept falling for the
whole day; I saw it through the operating room window. In the evening Grillo
took me out to a restaurant for dinner, and after that to my hotel (Suisse
Chalet Motor Lodge). All this time the heavy snowing did not stop.
We were supposed to meet the next morning and operate
again, but the snowstorm continued, all roads and highways were blocked by heaps
of snow, and there was no possibility to leave the hotel. Dr. Grillo also
stayed at home and we communicated only by telephone. This famous Òsnowstorm of
the centuryÓ continued uninterruptedly for six days. The snow accumulated to
the height of several meters (Fig. 61). Only ambulances, fire engines and
police vehicles were permitted the use of the roads. Meanwhile, the day of my
return home was approaching. I was supposed to fly to Israel from New York, but
I could not reach New York by plane, because the Boston airport was closed.
Grillo obtained a special police permit to drive me in his car to the railway
station. I went to New York by train and caught my flight to Israel literally
at the last moment. I was home on time.
Fig. 61. Boston covered with snow after the Òstorm of the centuryÓ.
* * *
Besides travels for learning specific operations or diagnostic methods,
I participated in international surgical conventions twice every year. One trip
was to North America, to attend the Annual Congress of the American College of
Surgeons or the meeting of the Society of Thoracic Surgeons. Participation in
these conventions was mostly for the purpose of learning. The other trip,
usually to a congress in Europe, was to present something from my own
experience.
To some of these conventions I traveled as an invited
speaker. The first such invitation came from the American College of Surgeons.
In 1975 their annual congress took place in San Francisco. A postgraduate
course in thoracic surgery was organized as part of the convention. I was
invited to talk on the subject of tumors of the bronchial glands. This
invitation to lecture at one of the worldÕs most prestigious conventions gave
me great satisfaction, and I made a considerable effort to be well prepared and
to not disappoint the organizers. Following this lecture, I received many more
invitations for addresses at conventions and also requests for writing book
chapters on this and related subjects. One of these chapters was for PearsonÕs
textbook Thoracic Surgery (Figs. 62 and 63).
Fig. 62. F.G.PearsonÕs book Thoracic Surgery.
Fig. 63. The first page of my chapter.
* * *
In 1988 Dr. John Odell of Cape Town invited me to the Biennial
Convention of Thoracic Surgeons and Cardiologists of South Africa. Odell asked
me to lecture and lead a discussion on lung abscess and empyema. These are my
favorite subjects on which I had written several articles. When I arrived with
Milka in Cape Town, I was surprised to discover that my presentation was
scheduled as the opening lecture of the congress. At dinner I asked Dr. Odell
why he chose me. There are many thoracic surgeons of great fame, worldwide, who
have extensive experience in pulmonary and pleural infections. Odell answered
that the members of his team had read and discussed my articles and wanted to
hear more.
During the convention I visited the University of Cape
Town Medical Center and Groote Schoor Hospital. This was the institution at
which my teacher, Dr. Robert Goetz, conducted his most important experimental
work, before coming to the United States. It was here that Christian Barnard
performed the worldÕs first successful human heart transplantation. This
hospital is considered a historic site and has a fascinating museum. After the convention
we participated in a sightseeing tour of South Africa, specially organized for
invited speakers. The tour lasted a whole week and included the Kruger National
Park, the entire southern seashore of South Africa, major cities, and more. We
were left with unforgettable memories.
* * *
Particularly important for me was the Centenary
Congress of the Polish Surgical Association. It took place in Krak—w (Cracow)
in September 1989, on the 100th anniversary of the Association, the
200th anniversary of University Surgery in Poland and 50 years after
outbreak of World War II.
This international meeting was bilingual – one
could present the submissions either in Polish or in English. After 39 years of
absence from Poland and without knowledge of Polish medical terminology, I
hesitated a lot what language to use. I could get mixed up with the Polish
terminology and thus fail in my presentations. As a matter of fact, all
physicians who left Poland just a few years earlier, chose to deliver their presentations
in English, sometimes after a short apology for using a foreign language.
However, I thought that it would be unbecoming to lecture at a Polish
convention in English, while Polish was my native tongue. I submitted seven
subjects for presentation at the meeting, all in Polish. The result was a
standing ovation after each one of my presentations, and close friendly
relations with surgeons who appreciated my effort and my flawless Polish. As a
result of my new relations with the leaders of surgery in Poland, this trip to
Poland, initially intended to be one-of-a-kind, turned to a nearly annual
event. During the 12 years since the congress in Krak—w, I have been to Poland
eight more times, in most instances to participate in various surgical conventions.
On four occasions (Warsaw, Lublin and twice in Wrocław) I came as an
invited speaker. In 1993, in Lublin, I was elected Member of the Editorial
Board of the Polski Przegląd Chirurgiczny (Polish Journal of Surgery), and
my cooperation with people on the top of surgery in Poland continues to blossom.
My trip to Poland in 1989 had another important
implication. It helped me to renew relations with old friends. In 1999, on the
fiftieth anniversary of matriculation, I participated in an emotional reunion
of my high school class. I took advantage of those trips to visit sites to
which I had been emotionally attached, such as places of my hiding during the
war, and more.
Under similar circumstances I visited the city of my
birth Lw—w (today Lviv in the Ukraine) on two occasions: the first time on the
fiftieth anniversary of the extermination of the Lw—w Ghetto, and two years
later, as an invited speaker at a surgical convention.
During the following years, the trips to the
congresses as an invited speaker became more common, and included conventions
in Belgrade (Yugoslavia), Moscow, ‚eşme (Turkey), Genoa (Italy) and
Dresden (Germany).
* * *
Besides the conventions, I received invitations from various medical
centers to come as a visiting professor. In 1979 Dr. William Drucker invited me
to the University of Rochester. Dr. Drucker, who had served as Chairman of the
Department of Surgery at the University of Toronto at the time when I worked
there, prepared for me a tight four-day schedule of lectures, seminars and
clinical conferences with the surgical staff and students. At the conclusion of
my work, I addressed the staff meeting, lecturing on the subject ÒChest
injuries during the Yom Kippur WarÓ (Fig. 64). That visit was followed by
another invitation two years later, when I spent another four days in
Rochester, lecturing and teaching (Fig. 65).
Fig. 64. The visit was
concluded with my lecture on chest injuries during the Yom Kippur War.
Fig. 65. The concluding
lecture, 1981.
In 1982 Dr. James Hardy invited me for a similar working visit at the
University of Mississippi – the place of my residency in thoracic surgery
15 years earlier. This invitation was for me a symbol of Dr. HardyÕs pride in
the progress and success of his former resident.
Among all my visits to various medical centers, I had particular
pleasure visiting Toronto many times. I always feel at home among my friends in
that city and at the Toronto General Hospital.
In October 1989, at the initiative of Dr. Clifford Straehley, a
thoracic surgeon and professor at the University of Hawaii, I went to Honolulu,
where I spent two weeks, lecturing in six university-affiliated hospitals. I
was quite busy, but still found time for sightseeing, and Milka defined our
trip as Òtwo weeks in Paradise.Ó We have wonderful memories from that trip, and
many friends in Hawaii (Figs. 66 and 67).
Fig. 66. Certificate of
Visiting Professor.
Fig. 67. Letter from the
Chairman of the Department of Surgery, Dr. Whelan.
* * *
I will conclude this chapter with the description of my mission in
China.
During the past decade there has been a considerable growth of
cooperation between Israel and China in the areas of agriculture, industry and
medicine. Experts from Israel are traveling to China, usually for several
weeks, where they work together with their Chinese counterparts, teaching and
updating them on recent progress in the field of their expertise. Individuals
involved in this activity introduced me to Mr. Yossi Marek, President of the
ÒMatat – Knowledge from IsraelÓ, and through him, to the Shandong-Jining
Association for International Exchange of Personnel. During several meetings,
appropriate topics were selected and a working plan was formulated. Eventually,
in June 2000, I went to Qufu, a city of 600,000 in the Province of Shandong,
China. I was scheduled to work in the Department of Thoracic Surgery of the
Qufu PeopleÕs Hospital.
My functions in the hospital included participation in operations,
clinical consultations, bedside rounds, outpatient clinic and lectures. To make
my work possible, I was assigned two interpreters who accompanied me at all
times, not only during my professional activity, but also on sightseeing tours,
receptions, all meals (in restaurants and hotels), and even on my shopping
excursions in stores, where their help was not really needed. One of my
interpreters was a physician, a cardiologist from the same hospital, Dr. Mu
Jin. He spoke reasonably good English, but we had problems with medical terms,
because no international terminology (English or Latin) is taught in the
medical schools in China. All instruction is conducted in Chinese (Mandarin),
including textbooks – with Chinese terminology. However, using
dictionaries, explanations and plenty of patience and good will on both sides,
we managed to understand each other and worked together. Before every lecture,
I had to thoroughly prepare Dr. Mu Jin. Later, during the ÒrealÓ lecture, we
stood together on the podium, or sat together at a table with the audience
around us. Each one of my sentences in English was followed by Dr. Mu JinÕs
translation into Chinese. This, in my opinion, kills the spirit of a lecture
and is the most certain method to convert it from interesting to dull, but
there was no other way. The Chinese audience listened patiently, and in their
extraordinary politeness, seemed happy. This exceeding politeness exists only
in China.
My second interpreter was a postgraduate student and teacher of
English. Her English, while quite rich, was heavily Chinese-accented, which
made it difficult for me to understand. But she was beautiful, elegant and very
nice (Fig. 68). Another person who helped me in every possible way, was Dr. Gao
Xian-cheng, an expert in pulmonary medicine and the hospital director. One of
his hobbies was Chinese calligraphy. He gave me a lesson in Chinese script and
made a poster for me with my name and a citation from Confucius (Fig. 69).
My most important activity was, of course, the clinical work. This is
well illustrated by the following example. A female patient, a candidate for
resection of esophageal cancer, was presented to me at bedside rounds. She had
not undergone esophagoscopy,[24]
no biopsy of the tumor and no roentgenograms of the entire gastrointestinal
tract, as required in patients with suspected cancer of the esophagus. There
was only one single roentgenogram of the esophagus, taken with a swallow of the
contrast medium, which showed a filling defect in the esophagus. While such
filling defect does arise suspicion, it does not prove cancer. Moreover, the
patient had palpable masses over both collarbones – undoubtedly
metastases – a clear-cut contraindication to the operation. I recommended
postponing the operation and, instead, obtaining biopsies from the esophageal
lesion and from both masses in the neck. But her physicians would not consider
such an option. ÒThe patient had already paid for the operation and there is no
possibility to cancel it. She would be very disappointed. Besides, it is
impossible to refund her money.Ó Despite my objections, the operation was
carried out the next day. The patient did have cancer of the esophagus with
metastatic spread. The operation was extensive by any definition and included
resection of the entire esophagus, transposition of the stomach into the chest,
and reconstitution of continuity of the digestive tract in the neck. It lasted
only three hours and was performed
with great skill and elegance,
without
Fig. 68. With my
interpreters, Miss Cai Wen-jing
and Dr. Mu Jin at ConfuciusÕ tomb.
Fig. 69. A lesson in
Chinese calligraphy.
significant blood loss and with minimal trauma to
tissues. I admired the excellent operative technique of Dr. Lian Shi-fa, but
not his clinical judgment (Fig. 70). In the West, a patient with such
widespread metastases as this one, would have been treated by other oncologic means,
not by operation. Because the purpose of my visit was to teach, I discussed
this case widely with the team, pointing at modern diagnostic methods and
concentrating on indications and contraindications to operative procedures on
cancer.
I encountered similar problems in patients with lung
cancer. Again, as with resection of the esophagus, I was greatly impressed by
the skillful surgical technique of my hosts and by their extensive operative
experience, but the level of diagnostic evaluation and the disregard for
indications and contraindications – all the medical aspects of the
case, were unacceptable.
Diagnostic
procedures, such as mediastinoscopy, pleuroscopy and pericardioscopy[25]
were unknown to physicians in Qufu. I taught them these procedures, using a set
of instruments brought with me, and recommended that they purchase a similar
inexpensive set.
One morning I was supposed to demonstrate to Dr. Lian
Shi-fa pericardioscopy on a patient with accumulation of liquid in the
pericardium. Dr. Lian arrived in the hospital with severe pain in his knee,
unable to bend it or to step on his leg and, obviously, unable to operate. The
pericardioscopy was cancelled and we went to the Acupuncture Clinic for
treatment. Dr. Lian joined the group of patients lying on a row of ten
treatment tables, acupuncture needles protruding from various parts of their
bodies. I observed the steps of Dr. LianÕs treatment: insertion of needles,
illuminating the painful knee with a special lamp (ultraviolet? infrared?), mild electric shocks to the leg for
Fig. 70. Dr. Lian Shi-fa
and the author operate on the esophagus.
10 minutes, and massages. At the end of
the treatment he rose from
the table – able to function. The change was dramatic and most
impressive. It is difficult to ascribe this to psychological effect only,
although this factor must have played a major role. Another occasion to observe
ancestral Chinese medicine came, when I visited the China Academy of
Traditional Chinese Medicine in Beijing. At the hostsÕ invitation, I
volunteered to undergo Òpulse and tongue examinationÓ conducted by an
accomplished expert in this field. The examination consisted of observing my
tongue and palpating my pulse in both hands, for 10 minutes. At the end, the
expert delivered a list of diagnoses and recommended treatment. I was diagnosed
with infertility, kidney weakness, mental tiredness, dizziness, and
disinclination to speak. For treatment of these disorders, as well as for
Ònourishing the spleen, tranquilizing the mind and strengthening the legsÓ, I
was offered several kinds of quite expensive pills of the expertÕs own
production and composed of undisclosed ingredients. According to the booklet
distributed to people seeking treatment, the ingredients are Òbased on a secret
recipe from a famous expertÓ (quoted literally). Medical witchcraft at its
best.
While visiting a ward in the Qufu Hospital, I had an opportunity to see
an important aspect of human relations in the Chinese society. I was shown a
VIP room – it was spacious, clean, luxuriously furnished and richly
decorated. It contrasted sharply with the neglected rooms for ordinary
people. It was an impressive example of ÒequalityÓ in the communist
society.
My hosts pampered me
throughout my stay. My free time was filled with excursions to places of
historic or cultural interest, such as ConfuciusÕ birthplace and tomb, a
selection of temples, the Qufu University, the City High School and others. A
stage show – program of Chinese ethnic music and dance was arranged especially
for me: only I and my usual entourage were present. At the meals there was
always great selection of Chinese dishes, among them rarities prepared
especially for me.
In my excursions to places of interest in the Province of Shandong, we
often passed through the countryside. I saw long stretches of highway covered
with thick layers of straw, alternating with yellowish granular material, which
appeared to me to be sand. My interpreters explained that it was actually grain
of wheat and straw, spread out for drying. During threshing, the grain is still
moist. If it is stored humid, it might sprout or rot. In the absence of a
better drying contrivance, the peasants spread the grain and straw on the
highways, where it remains during the daytime. Before nightfall they collect it
into sacs. This is a backbreaking labor, and the highway traffic causes
incredible waste, but at least a major part of the grain and straw is saved
(Figs. 71 and 72).
Fig 71. Drying
contrivance: straw spread over highway.
Fig 72. Peasant laborers
in Shandong.
My mission in Qufu completed, I still had two days for sightseeing,
which I spent in Beijing. Of all the places visited, the most impressive
one was the Great Wall of China
(Fig. 73).
Fig. 73. On the Great
Wall of China.
Epilogue
I have devoted 43 years of my life to surgery. This
experience brought me to several basic conclusions.
The first one involves the choice of profession. My
choice seems to have been correct. It is no exaggeration to state, that in all
my professional life I did not have one single day of boredom. There were times
of satisfaction and joy, and others, of sad, even tragic events. But never
boredom. Surgery was always attractive and always interested me. Have I chosen
the worldÕs most interesting occupation? Yes, for me surgery was just
that. Of course, it is not for everybody. The interest in vocation depends on
every individualÕs character. Not everybody likes to see blood, to cut human
flesh or to examine a sick human being.
I remember well a conversation with my friend, more
than 50 years ago. We were close to graduation from high school, and we were
discussing choice of our future occupations. I always wanted to be a doctor and
never had any doubts about my choice. My friend wanted to study Chinese
culture. I told him that one has to make a living from oneÕs occupation. Can
one do that from studying Chinese culture? My friend did not take this argument
seriously, and said: ÒI can repair shoes. If necessary, I will make a living
from that. But I will study what interests me.Ó He was consistent, studied
Chinese culture and became a great expert on China and professor at a famous
university. Of course, he did make a living from his vocation. In retrospect,
it is obvious that he was right.
None of my four children has chosen surgery, although
I have one physician-daughter. But like me, they all have chosen whatever
interested them. My son studies Japanese culture. I believe that he, as my old
friend, will make a living from his profession, because this is the one thing
that interests him most. My conclusion is, that whoever chooses an occupation
based on genuine interest, assures himself of success. My work was interesting,
and I enjoyed it. Those who chose an occupation because of ill-founded
considerations, such as prospective wealth, prestige or any other concern not
based on true curiosity, condemn themselves to a life of boredom,
disappointment and failure.
The second point concerns the choice of the branch of
medicine. This consideration stretches beyond mere interest, because any person
with interest in medicine should be able to adjust himself to one or another
branch. However, the choice involves the psychological background and
disposition of each person.
As a rule, clinical investigation in internal medicine
entails gathering of the greatest possible amount of information, which
requires time. In surgery, the time factor is much more limited. Under threat
of emergency, the surgeon is forced to restrict his investigation and must make
a decision on the basis of data available at the moment. Hence, surgery
attracts a different type of person than internal medicine – one who
wants to see results quickly. According to William Nolen, the surgeon prefers
the quick cure of a scalpel to the slow healing by pills. But what he lacks in
patience, he makes up in decisiveness.[26] When in
a hurry, one is prone to make mistakes. Later, in retrospect, many volunteering
ÒconsultantsÓ are ready to give advice and point to what could have been done
better, but at the time they were not present. In the moment of crisis, when
there is no time for consultation, the surgeon must decide by himself and
immediately.
I like decisiveness, hate hesitations, and usually
make my decisions quickly, sometimes perhaps too quickly. These features
predispose to surgery and they led me to make my choice. I believe, that choice was correct.
The third point pertains to gaining experience. One
cannot learn surgery by just observing others and reading books. One learns from
experience, and this comes from practical work. Experience of others is good
for others. While working and gaining experience, we make mistakes. Our errors
may result in somebodyÕs death. But can experience be gained without it? Some
errors, particularly those resulting from lack of experience cannot always be
prevented, but it is important to learn from them and to avoid them in the
future.
Progress in surgery is a slow and complicated process,
but it creates a mature surgeon, confident of himself. I enjoyed this process
all along.
I RememberÉ
(Holocaust memoir),
Freund Publishing House, Ltd, 1998
התעוררתי
משריקת הקטר (Holocaust memoir,
Hebrew edition), Freund Publishing
House, Ltd, 1998
Zbudził mnie gwizd
parowozu (Holocaust
memoir, Polish edition), Freund
Publishing House, Ltd, 1999
בחרתי
בכירורגיה (A surgeonÕs memoir,
Hebrew edition), Freund Publishing
House, Ltd, 2001
ועוד
סיפורים
מהחיים (Some more stories from life)
Self-published,
Rehovot, 2004
Idioms, proverbs, thoughts (Book of quotations)
Self-published,
Rehovot, 2004
Handbook of Practical Pleuroscopy,
Futura Publishing Company, Inc,
Mt. Kisko, New York, 1991
[1] Observing inside of the larynx through a specially devised instrument.
[2] Male gender was used in this paragraph, as nearly all surgeons and trainees in surgery (well over 90%) were men. In the 1960s a female surgeon was a rare exception.
[3] I wish to emphasize that this shocking story is not invented.
It really happened, exactly as described.
[4] Vascular anastomosis: connection of blood vessels, allowing
blood to flow between them.
[5] Recently an interesting article was published about Dr. Goetz
and his scientific work: Igor E. Konstantinov: Robert H. Goetz: The
surgeon who performed the first successful clinical coronary artery bypass
operation. Ann. Thorac. Surg. 2000; 69: 1966-1972.
[6] The main artery supplying blood to the lung.
[7] Direct observation of the bronchi through the bronchoscope.
[8] Roentgenography of the bronchi with the use of contrast medium.
[9] Mediastinum is the central area of the chest, located between
the two lungs.
[10] For
historic accuracy I wish to point out, that prior to the establishment of this
service, no department or division of general thoracic surgery (separate
from heart surgery) existed anywhere. The new division was the first of its
kind in the world, and F.G. Pearson was the first person to ever head this kind
of service, which makes him the Father of General Thoracic Surgery.
[11] Windpipe.
[12] Thymus: a gland located in
the mediastinum, important in immunologic processes.
[13] For a non-Israeli reader I must clarify that in Israel, after one year of uninterrupted work, every government employee is automatically guaranteed tenure and cannot be fired, no matter how inadequate his work may be. Exceptions include major crimes, but never ÒminorÓ misdemeanors such as absenteeism, negligence, or any kind of inadequacy at work. My dissatisfaction with the two surgeons on my team could never have served as a reason for discontinuing their employment.
[14] Dr. Kaufman died in April 2001 of incurable illness. A close friend, an excellent surgeon, and a gentleman.
[15] Pleuroscopy – observation of the inside of the chest cavity through an instrument inserted between the ribs. This procedure enables performance of certain lung operations.
[16] This operation lowers the blood pressure in vessels bringing blood from the intestines to the liver. It is indicated in patients who suffer major bleedings because of cirrhosis (a chronic liver disease).
[17] Operation for prevention of the flow of gastric contents into the esophagus.
[18] Roentgenography of blood vessels with simultaneous injection of contrast medium.
[19] My work and personal relations with Dr. Goetz are described in Chapter 3.
[20] D. Weissberg. Treatment of thoracic injuries. Annals of Thoracic Surgery 1986; 42: 348.
[21] AVISHAI: Avi – in Hebrew Òmy fatherÓ; Sh – short for Shmuel, MilkaÕs father; I – short for Israel, my father. Moshe was the name of my late brother.
[22] See Chapter 5.
[23] A similar case with spontaneous complete disappearance of an invasive neuroblastoma has been described by William A. Nolen in his book ÒThe Making of a SurgeonÓ, Random House, New York, 1968, p. 201.
[24] Direct observation of the esophagus through a special instrument, with biopsies from areas suspected as abnormal.
[25] Pericardioscopy: direct look inside the pericardium (the membranous sac enclosing the heart).
[26] William A. Nolen: The Making of a Surgeon. Random House, New York, 1968.