2. From Rambam to America

Upon my return to the Rambam Hospital in 1960, I met Jack Abouav. Jack studied medicine in Hadassah, four classes ahead of me. He completed his studies in 1952, and after the internship, 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. Erlik’s department, and will be in charge of all the 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: “If this is how they learn surgery in America, then what the hell am I doing here?!”

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: “Mayo 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.” So I wrote.

fig 6
Fig. 6. Dr. Jack Abouav, Rambam Hospital, 1960.

On September 21st 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
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 those teachers were good and motivated by genuine concern. Both tried to prevent emigration of their pupils, graduates of Israel’s 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 “so you decided to emigrate” 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
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 April 3rd 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 May 22nd boarded in Marseilles the S. S. Zion. We reached New York on June 2nd, and in my pocket I still had $10 for “small expenses”. During the month of June I stayed with my mother’s cousin, Edith Abner, and “learned” New York.

On July 1st 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 residents’ 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. “For your $200 it is good enough,” answered Dr. Henry Friedman.

fig 9
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. “Doctor Weissberg”, I heard his voice. “I am here.” “You are here? And what are you doing?” “This is Mr. Posner”, I responded. I told him the name of the patient, so he would know who I am operating on. “I know that this is Mr. Posner, but what are you doing?” The intonation of Dr. Charendoff’s voice sounded rather severe. “I am doing a bilateral orchiectomy”. “And why are you doing it?”, asked Charendoff. “Because Mr. Posner has cancer of the prostate.” “So why do you do an orchiectomy, not a prostatectomy?!” 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: “You will be allowed to do, when you know how to take care of the complications”. 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. Charendoff’s 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 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 director’s deputy (his assistant, as a matter of fact). He became deeply offended. Assurances had been given to him that he will be the chief, once the department is established. His boss’s 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 training, is granted a visa (Exchange Visitor, Visa J) that enables him to stay in the United States until 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 chief’s 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.