Advertisement

Advertisement

Blogs

The Other Night

0

No applauses yet

As I write this we are already half way through the summer, and I have spent a fair amount of the time on vacation.  The other night, I woke up at about 2 a.m., and for some unknown reason started thinking about my first clinical rotation as a medical student during the summer of 1973 (in those days clinical work at U of Toronto started in fourth year with virtually no break after third year finished).  It was in obstetrics and gynaecology at the Toronto General Hospital and I had an incredible time.  I was able to do 8 deliveries all by myself, and the majority of the delivery in another 25, numbers that I suspect few medical students could match today.  It was also my first introduction to the power of communication (or more accurately miscommunication) and how it affects patient care.  I met one young Chinese couple who were furious because of their poor care.  The wife spoke no English and her husband spoke only minimal English.  They had sought advice about birth control at the hospital’s gynaecology clinic, but despite that the young woman was pregnant.  The husband was particularly indignant, as he had taken the birth control pills as directed without missing even once!  Another young woman had received a years supply of a sequential BCP with placebos for the last 7 days of the cycle.  These pills thus came in three colours.  She put all the pills in a large glass dish, and selected each morning the colour pill that matched her mood most appropriately.  She too was indignant that medical science had not been able to prevent an unwanted pregnancy.  I also had a great privilege on that rotation.  In the previous 2000 years of recorded history only one immaculate conception had been recorded.  I was privileged to see two in just two weeks in clinic.

Still unable to sleep, my morbid memory then moved to the suicides I saw while in training.  That same year I was a fourth year clinical clerk, one intern killed himself, and one patient snuck out of her medical ward and cut her wrists in a closet on the radiology floor (to be discovered by a radiologist hanging up his coat the next morning).  The most frightening episode was a double suicide that occurred in January of my PGY2 year.  I had been in Florida for a conference followed by a vacation, and one of the residents on neurosurgery had been in Florida at the same time.  The week after returning to work, I bumped into that resident and asked him how he was doing.  He replied, I am depressed and without much thought I replied, yeah me too it’s tough getting back to work after a great vacation.  Two days later a young woman was admitted to psychiatry after an overdose.  Unfortunately, she conned the staff physician into giving her a four hour pass the next morning.  She immediately went to the rooftop bar at the Park Plaza Hotel and jumped off, hitting the Avenue Road bus head first.  The bus driver fainted (he was fine) and the girl (obviously dead) and he were brought to the ER.  Despite the futility of the intervention, neurosurgery was paged stat to assess the woman.  Unknown to all of us, the resident on call (the one I mentioned above) had just hung himself that same morning and his body was discovered by his three year old son.  We did not know till later that in fact we were paging a dead man to minister to a dead woman.  I still get the shakes to this day when I think of it.  Enough of this morbid thinking, enjoy the rest of the summer.

Regards,

Barry Goldlist

Random thoughts about teaching hospitals

0

No applauses yet

When you work at a teaching hospital, there is often a layer between you and hospitalized patients.  That layer of course is composed of residents.  They insulate us from many of the day to day tasks of caring for sick patients, but they also insulate us from the pleasure we get from interacting with (and sometimes actually helping) patients. For much of this week I have had no residents on my service, so have been seeing in patients on my own.  This morning after rounds I left Mount Sinai to follow up on a consult I had seen yesterday at Toronto Western Hospital.  This woman is the wife of  a prominent physician, and had become delirious on medications.  It was wonderful to see that she had almost recovered, and particularly impressive to see how fabulous her children were in staying at her side throughout the 48 hours of delirium to ensure that a familiar voice and face was always available during her period of confusion.  I followed this up with a family conference at Toronto General Hospital.  Once again meeting the daughter of a severely demented woman whom I had consulted on two days earlier, I was overwhelmed by how dedicated some caregivers are.  The daughter (herself a grandmother) knows that her mother never wanted to enter a nursing home, and has spared no physical effort or expense to help her mother stay in her own home (which is a few houses away from hers). I then returned to Mount Sinai, where I met a 91 year old retired nurse who lives by herself and still drives.  Unfortunately she tripped over a kitchen stool and had a fracture adjacent to her previous knee replacement.  She intended to return to her apartment and to continue driving after rehab.  I then met an indomitable 83 year old woman who had survived bladder cancer (ileal conduit in place), lung cancer (second hand smoke exposure from her husband), two hip replacements, and unstable angina.  She had tried to put something on a high shelf and instead of getting a step ladder, she stood on a rickety chair, and fell and broke her shoulder.  Her embarrassment was greater than her pain!  My sojourn on the orthopaedic ward ended with a delightful consult on a retired psychiatrist who tripped getting out of the shower (diabetic peripheral neuropathy) and broke his tibia.  He was an absolute delight to chat with. These type of direct interactions with patients are always special.  Community physicians have these types of interactions every day, and on days like today I envy them.  I see patients on my own in clinic all the time, but it is a different type of interaction (although still satisfying).  They are not in crisis when I see them in clinic, so the interaction is not as intense.  So for those of you who are thinking ‘If I only had residents’, think again.  Something is lost by having them around.  Enjoy the weekend, Barry Goldlist

Things that fascinate me about radiology

0

No applauses yet

I was a family physician for 7 years before becoming a radiologist. There are some things I miss about family practice. I miss the longitudinal relationship that I often had with multiple generations of family members.

There are also some things that fascinate me about radiology. For instance, improving computer and imaging technology has translated into imaging developments that can be used to benefit patients. Just a few years ago, we wouldn’t have thought we could adequately screen the colon for colon cancer and pre-cancerous lesions such as polyps. Now, in patients who cannot have a colonoscopy, we routinely perform CT colonoscopy (CTC), giving an alternative means of screening and diagnosis in these patients.

An article in the New England Journal of Medicine suggests that CTC could be used for primary screening, however, we mainly use it for patients who have failed colonoscopy – often because of a redundant sigmoid colon which cannot be navigated by the scope. We can even do the study the same day, as the patient has already undergone a bowel preparation. We do give them contrast to tag any residual fluid and stool in the colon to be able to differentiate it from colonic pathology.

We perform CT prone and supine to allow us to exam all the walls of the colon without any overlying fluid. Then we use computer software to generate 3 dimensional images of the colon that we can “fly through” to assess for mucosal lesions. Of course, the CT images are also examined for any extra- mucosal findings. I have diagnosed an unsuspected renal cell carcinoma on a patient being screened for colon cancer.

Below is a picture from my practice. It shows the colon distended with carbon dioxide – we use a small rectal tube and a regulated pump to inflate the colon. The technique readily shows the “napkin-ring” constricting lesion in the cecum. The 3D images show the lesion as it would be seen by the scope!

I would love to hear how imaging has affected your practice, both positive and negative.

Reference:
CT Colonography versus Colonoscopy for the Detection of Advanced Neoplasia
David H. Kim, M.D., Perry J. Pickhardt, M.D., Andrew J. Taylor, M.D., Winifred K. Leung, M.D., Thomas C. Winter, M.D., J. Louis Hinshaw, M.D., Deepak V. Gopal, M.D., Mark Reichelderfer, M.D., Richard H. Hsu, M.D., and Patrick R. Pfau, M.D.
N Engl J Med 2007; 357:1403-1412; October 4, 2007

 


Axial view with the “Napkin-ring” mass seen in the region of the cecum-ascending colon.

 


Coronal Image showing the lesion.

 


3D image showing the lesion almost identical to how it would appear on Colonoscopy, had this patient been able to have colonoscopy.

Egypt Memories

0

No applauses yet

The closest I came to Egypt was the Sinai Peninsula which was under Israeli control following the Six-Day War before it reverted back in 1979 to Egypt’s jurisdiction under the Sadat-Begin accord stewarded by then President Carter. From 1970-71, during my service in the Israel Air Force as a physician, I would rotate for duty at Rephidim Air Base which was the Hebrew re-name of Bir Gifgafa, which was the Egyptian name for the isolated air strip 90 km east of the Suez Canal. It would be my home for three days every month to make sure our advance station pilots had round the clock medical access. They literally sat in their Mirage interceptors for hours on end. I and the other doctors were there to care for them and the crews that serviced their planes. The mosquitoes at night were terrible and I recall looking at the blood speckled wall, where I had successfully swatted my nemesis. No matter how often the screens were repaired they always managed to enter my Spartan room, my nose and ears and every part of my skin even though I slept, despite the heat, covered from head to toe by blankets.

From Rephidim we performed helicopter evacuations all along the Bar Lev line. This was the first line of defense on the Suez Canal. We also covered the armor and infantry bases spread around the Sinai as part of the defense against Egypt with whom during the period of my service, the War of Attrition: in essence an air, artillery and missile war took place. Sometimes a mission required the helicopter evacuation crew to move closer to the Canal Zone if we were in a situation in which forces might cross the Canal and might need to be evacuated from enemy territory.


Serving as an Israeli Air Force base doctor

I recall one such mission where our base for over-night readiness was a Hawk anti-aircraft missile encampment. I watched mesmerized: the battery of Hawk missiles rotated rapidly and whiningly every time an Egyptian plane took off from beyond the Canal and headed towards Israel even for only a few moments before it veered in a different direction. I had a vivid nightmare of having crossed the Canal to extricate a soldier and being pursued by Egyptian soldiers to whom I was trying to explain that I was a doctor from Brooklyn and would not be much of a prisoner pleading my case while brandishing my Beretta side arm which I had learned to use months earlier during my officer’s training course. When I awoke in the morning, having slept fully clothed in my khaki multi-zippered flight suit, the sun was rising, the Hawks were quiet and the helicopter captain was giving orders to my medics and paratrooper crew to pack our things as we were “going home” (“ha beita”) -- a phrase I mastered early in my quest to learn Hebrew, literally “on the job” during my air force service.

During my last six weeks of military service, by then as a reservist, after having completed my regular military duties and just prior to my leaving Israel for post-graduate training in Montreal, our helicopter got a call to evacuate a Bedouin boy with measles and severe dehydration from the Sinai Peninsula in the region of Santa Katarina. This was the site of an ancient monastery at the foot of Mount Sinai where according to the Old Testament; Moses received the Ten Commandments from God. With the setting sun swathing the desert with pink and purple hues, the monastery loomed ahead, barely visible in the darkening horizon. As we landed near the spot, illuminated by a few flares lit by a district field nurse, we could see a small make-shift stretcher holding a boy who, when I got close, I could see was covered in a measles rash and was severely dehydrated and delirious with fever. His father looked at me as the nurse explained who we were and I said my “salam aleykim” greeting as the boy was prepared for the flight to Eilat, where we had arranged for his treatment. I managed to get an intravenous into him before loading him into the Bell helicopter knowing how difficult it would be to successfully undertake such a maneuver with the jolting, undulating and bouncing movements, once the helicopter was in flight.


Santa Katarina Monastery with the Sinai range in the background, Egypt

The father followed in after the boy, his eyes wide in wonderment. The flight did not take that long and I felt the comfort of the dripping of the intravenous into the boy’s arm and anticipated that he would be fine once he received enough fluids. This was confirmed the next day when the hospital was contacted for follow-up so I could complete my medical evacuation report.

It would have been nice if my associations with Egypt, which had just recently made the front pages of newspapers, computers and television world wide, as the population successfully revolted against its dictator Hosni Mubarak, could have been more positive. While trying to empathize with those demonstrating in the streets I could not suppress my negative experiences as the air base medical officer who had to bear witness to the Egyptian military treatment of two of the pilots from my air base whom they had captured. As the television news continually showed the mounting political crises, I happened to be reading David Grossman’s latest book To the End of the Land in which one of the main characters recalls his torture and suffering at the hands of his Egyptian captors and another character describes the terror experienced by the soldiers left in the bunkers on the Suez Canal’s Bar Lev Line, having learned that massacres had occurred to their colleagues in bunkers that had been overrun by Egyptian soldiers who had crossed the waterway at other junctures at the beginning of the 1973 Yom Kippur war.

My first actual associations with Egypt related to Israel, occurred during the early summer of 1967 after I had finished a 5 month internship in obstetrics and gynecology at Rambam Hospital in Haifa. This followed a 6 month internship in Aberdeen Scotland which took place after my graduation from my medical school in Dundee Scotland in June 1966. I left Israel in late May 1967 to visit my sister who was a Peace Corps worker in Tunisia. As I left Israel during those late days in May and arrived in Tunisia in early June, the atmosphere in Israel was foreboding as Egypt’s president; Abdul Gamel Nasser amassed his army in the Sinai Peninsula and closed the Straits of Tiran, choking Israeli’s water access to the Red Sea. Within two days of arriving in Hammam Sousse, a small Tunisian village where my sister was developing a pre-school program, the Six-Day War broke out on June 5th. For three days the only radio contact I could get, using a battery powered old short-wave radio, was local Arabic broadcasts which my sister could translate, and an English transmission from Egypt which chronicled the gradual and graphic destruction of Israel. The broadcasts were accompanied by martial music and the most vicious language to describe the country I had just left and the people with whom I felt a very strong bond, whose utter destruction was predicted. Fortunately all that was being broadcast were Egyptian lies and the truth came out to the world a few days into the war with Egypt eventually surrendering a few days later – but the words of the English broadcaster have remained vivid in my memory and those images although erroneous of Tel-Aviv burning from Egyptian victories cannot be erased.

The graphic and emotionally compelling account of the character in Grossman’s book brought back memories of my pilot neighbor on the air base at which I served. He was a Phantom F4 pilot and his co-pilot and navigator/weapons control person was, like all of the airman on the base, one of my patients who in keeping with their love of flying would do anything humanly possible to avoid my grounding them because of, for example, an upper respiratory condition which for them could be very dangerous with the sudden changes in air pressure but which they nevertheless tended to minimize. He was a very handsome and likeable young man with deep blue eyes and fair hair, the kind of person about whom, those who do not understand the Israeli/Jewish mosaic of appearance might say, “He does not look Jewish with his blond hair and blue eyes.”


IAF F4 Phantom

One day on the radio I heard that a Phantom had been shot down and the two crew members had been observed ejecting from the plane and parachuting to land. I was driving at the time and like anyone in my position I felt a pang even without knowing if the crew was from my base but knew that it could be the case as we were one of the bases with Phantom squadrons. When I returned to the base I discovered that not only were they from my base but indeed they were my neighbor and his co-pilot. I was devastated but immediately took on my professional role as the base doctor and visited the pilot’s wife who lived next door. She, like the wives of most pilots, had her way of dealing with this potentially impending tragedy and was receiving, as best she could all the base staff, pilots and their wives who visited to give her moral support – “after all he had parachuted out and there were international rules of war and prisoners”, even though many knew that the practice by Egyptians towards military prisoners was not always what it was supposed to be.

A few days later the news came that the two crew members were both alive but that one was “very severely injured” and the other had a fractured leg. Then weeks of quiet until I received a call at the base medical office that the co-pilot had “died” from his wounds and was being returned to Israel in exchange for some Egyptian prisoners. I heard quietly a few days later that there was evidence that his death had been due to or aggravated by electric shocks to his body. There was no new word about my neighbor.

One early evening while driving back to the base from one of my stints of working on the local kibbutzim or moshavim (communal farms) as a locum, while their doctor was often doing their reserve duty, I heard that my neighbor had been returned to Israel, very ill and was at Tel Hashomer Hospital. I wheeled around and drove to the hospital in Tel Aviv and found that he had gangrene of his broken leg and was in renal failure. As I arrived I heard that he had just been taken to the operating room for an amputation and would be going on to renal dialysis. His prognosis appeared awful and I could hear murmurs from the doctors in the hall about what terrible shape he was in and how awful had been his medical treatment in Egypt. Despite low expectations because of his terrible condition, he survived and eventually after rehabilitation and a refresher course was accepted to medical school-- something he would often talk to me about, during some of our nighttime neighborly chats, calling it a suppressed wish of his.

The last time I saw him was in the parking lot of the Tel Aviv University Medical School where unless you knew him very well you would not know he was walking with a leg prosthesis -- he greeted me warmly and told me how much he was enjoying his medical studies.

A few years ago, while visiting a family member of my wife’s brother who had immigrated to Israel, as we sat on her roof-top patio in Tel-Aviv she started talking about how strange the world could be in terms of where experiences and occurrences take you. She mentioned someone she knew “who had been a pilot, was shot down, almost died and then went to medical school….”- as she continued I sat up in my chair and asked her if she was talking about my neighbor and she looked at me and said, “you know him?” to which I said, “I was his neighbor on the base, of course.” She then told me he in fact had become a very senior physician in the air force and was just finishing his career and was focusing on archeology as a new career path. And the last piece of information was that he lived across the street. He was not home that afternoon when I ventured to his apartment but I told a young lady who said she was his daughter who I was and I wrote a little note. I was leaving the country that night so it was not until a year later that I connected with him.

After a very warm greeting he filled me in on his life and I marveled at how he managed to turn his near tragedy into a great success and was now redirecting his energies away from medicine altogether into another career. We talked about mutual friends from the base and he showed me the picture of the chief of the air force to be who was another neighbor and a star pilot who took me on a most exhilarating flight in an F4 phantom as his gift to me for having completed the first Israeli fight surgeon’s course which they allowed me to take even though my tour of regular duty was coming to an end.


Israeli Air Force days

My recollection of my neighbor who survived his captivity and torture and his co-pilot who did not, kept intruding on my thoughts as I observed in repeated episodes of televised world news, reports of what was happening in Egypt. Would these people, now free from the shackles of a military dictatorship currently at least at “cold peace” with Israel, find a way to resurrect their hostility to the country and join those whose agenda was an existential threat to the country that I love so much. As I presently follow the press reports from Egypt I feel frightened that some of the potential future leaders of the new government are those who have even during the period of the peace treaty, expressed enormous hostility towards Israel.

The confluence of thoughts and personal experiences related to the Egypt of the past made it difficult for me to share in what seemed to be a general optimism in the West about its future. I have become obsessed with the news out of that country hoping for signs that the situation will not regress and become part of a regional threat that appears to gain traction around the world that threatens Israel’s ability to defend itself and its wonderful, inclusive, creative way of life. How Egypt goes in the next little while may presage what Israel will be facing in the years to come. I hope that my personal recollections and associations will be able to be filed away as the “then” as will the literary depictions in Grossman’s book.

As someone who witnessed the sorrows of the war, if there is a return to the past hostility, with the pre-eminence of Egypt in the Middle East, my deep distrust and associations will be justified. Whatever one can hope for as a future should include Egyptian and Israeli populations that have learned from the past and will focus on peace and a desire to build a Middle East in which both Egypt and Israel can have a “warm peace” to replace the cold one that has existed for so many years.

Dr. Michael Gordon is currently medical program director of Palliative Care at Baycrest, co-director of their ethics program and a professor of Medicine at the University of Toronto. He is a prolific writer with his latest book Moments that Matter: Cases in Ethical Eldercare followed shortly on his memoir: Brooklyn Beginnings-A Geriatrician’s Odyssey. For more information log on to www.drmichaelgordon.com

There is always something to learn in medicine

0

No applauses yet

I have been in practice so long, that I sometimes get the illusion that I actually know what I am doing.  Big mistake!  Despite my long experience in geriatric medicine, one family this month has outwitted me continuously in keeping their mother in hospital.  The number of family meetings to discuss disposition seems to have hit double figures.  Each ends with a decisive and reasonable plan that the family is able to sabotage the next day.  Perhaps this week’s meeting will produce some results! I had the unfortunate experience of admitting a lovely young police officer with recurrent, and untreatable, osteosarcoma.  I learned from my oncology colleagues that there has been a mini epidemic of osteosarcoma in police officers in Ontario.  The connecting link is radar guns that are kept on and cradled in the officers’ lap between possible speeders.  If you think you are the one who suffered the most from a speeding ticket, think again. We admitted a 91 year old man with an ischemic leg who developed complication after complication post amputation.  There was obviously no reasonable hope for his survival despite his family’s optimism.  He has bounced back and is now doing very well while awaiting rehab to master independent transfers before going home.  So much for my erudite prognostications. I am also continuously astounded by the grace and courage that many patients exhibit despite their grim outlooks.  The police officer mentioned above was a particular example of grace under fire.  She seemed to spend more time comforting the hospital care-givers about her prognosis than we did comforting her.  Another 80 year old man who was diagnosed with metastatic colon cancer (including liver metastases) explained to us that he understood his impending death, but just needed to regain enough strength to be able to die at home. Heading back to the wards now, where I undoubtedly will learn even more. Regards, Barry

“Jack of all trades and the master of none”

0

No applauses yet

As Medical Director of HealthPlexus.net and the Journal of Current Clinical Care, I welcome you to our CME Internet portal. I hope that you will benefit from using it to achieve all your CME needs.

I feel very lucky to have had an extremely varied medical career. I originally studied Family Medicine at the University of Toronto and undertook a fellowship in care of the elderly at Baycrest Centre for Geriatric Care while starting practice at an inner city health centre in Toronto.

I worked at the health centre for about 7 years, dealing with very challenging medical, social and legal issues in the immigrant and refugee population, in patients with major mental illness and in housebound seniors.

During my practice, I sometimes wondered if becoming a specialist would help me to overcome a feeling I had that I was, in essence, a “jack of all trades and the master of none”.

After a lengthy reentry application process, I was accepted to complete a second residency in Diagnostic Imaging at the University of Toronto.

The process came at some cost to my young family. A second residency is nothing to sneeze at.


Figure 1: My son Alex watching me study for my Radiology Board Exams.

Subsequently, however, I have become a radiologist for several hospitals in Toronto, as well as others in southern and northern Ontario.

I am currently really enjoying the process of integrating my hard-won clinical knowledge my recently acquired visual expertise.

Recently, I was called in at 4:30 am to rule out pulmonary embolism in a young woman. I had been informed that the patient was acutely short of breath with pleuritic chest pain that the D-dimer was elevated.

I called the CT technologist in and took a short walk back to the hospital. While the CT was being performed I looked at the patient’s chest x ray. There were subtle linear lucent streaks in the mediastinum …. findings compatible with pneumomediastinum. The ER doc had not noticed them, and looking back as a family physician I likely would not have noted them either.


Figure 2: Chest x ray showing linear lucencies in the mediastinum compatible with pneumomediastinum.

A quick check of the CT pulmonary embolism study revealed no pulmonary embolism, but did confirm the presence of pneumomediastinum, as well as bilateral small pleural effusions and a hiatus hernia.

More clinical history revealed the patient had had an episode of wretching just before the acute respiratory symptoms started.

The patient was still on the CT table, so I administered oral contrast (which we normally do not do for pulmonary embolism studies).

A subsequent scan revealed a small amount of contrast extravasting from the esophagus into the mediastinum.


Figure 3: CT of the chest confirming pneumomediastinum and showing focal extravasation of contrast from the esophagus into the mediastinum.

I discussed the case with the ER physician. The clinical and imaging findings pointed to a diagnosis of Boerhaave’s Syndrome, a syndrome consisting of rupture of the esophageal wall due to vomiting.

The condition is associated with a high morbidity and mortality and is fatal in the absence of surgical therapy. The somewhat nonspecific nature of the symptoms of the syndrome, however, have sometimes been described to contribute to a delay in diagnosis. The patient was transferred to tertiary surgical centre within an hour of her chest x ray.

In the end, being a radiologist has not really solved my issues of being a “jack of all trades and the master of none”. I am a general radiologist, and my scope of knowledge and procedural skills is just as broad as in family practice. However, being a radiologist has reminded me how much physicians need to work together and acknowledge our collective strengths to solve the challenging clinical problems with which we are faced on a regular basis.


Figure 4: My son, Alex, thinks he’s up for the challenge, too. Here he is “brushing up” on ultrasound imaging.

Geriatrics: An Unintended Journey

0

No applauses yet

I looked at the certificate that came as registered mail in early December 1981. I already knew that I had passed the first Geriatric Medicine Royal College examination, with the oral taking place in Winnipeg, which when compared to Toronto was bitterly cold. I recall thinking as the examiner asked me questions that he was asking me more of an internal medicine examination than a geriatric medicine oral, but I wasn’t going to quibble with him as the encounter seemed to be going well. By the end of the day I knew I had been successful but the contents of the envelope held a surprise. In the right-hand corner of the certificate was the number one. I had received the first Canadian certificate of specialization in Geriatric Medicine which I knew was not because I was the first successful candidate but because my name must have been the first in the series of those who passed. But that number one has held a symbolic place in my life and career from the day I received that elongated piece of paper with the Royal College coat of arms in its middle.


Certificate #1 of the Royal College of Physicians and Surgeons of Canada

The journey started about 38 years earlier when I as a young boy moved from Dearborn Michigan to Brighton Beach in Brooklyn to live with my maternal grandmother. She was divorced and living alone a few blocks from the actual finely sanded Brighton Beach on the Atlantic Ocean. The apartment had only one large bedroom which I shared with her and my younger sister. My parents slept in the living room which was divided by a low-set bookcase into the sleeping area and guest area. In the guest area besides a sofa and a few large chairs was a Sohmer baby grand piano, which had been purchased by my grandmother for my mother during the depression years, being paid for by a weekly payment plan on which they never defaulted. Therefore this gorgeous piano was mine to learn on a few years later and now sits in the home of my eldest daughter who carries on the tradition of ownership.

“Tell me again about why you came to America and what was it like when you came.”  That was a recurrent question I asked my grandmother, affectionately called by the Yiddish “bubby”, especially when the lights were out in the room before we went to sleep. She would recount the stories from Eishyshok , the small shtetl in Lithuania where which was her home prior to her immigration to the United States. I heard about her village and her family and then the pogrom which left many people injured and killed which precipitated the decision by her family to go to America where they already had some distant relatives.


Eishyshok in its glory

I heard about the terrible ship voyage and how so many people died because of the awful primitive conditions. She told me about living in the immigrant Jewish neighborhood on the lower East Side of Manhattan and how she got into the garment industry as a seamstress, work that was very common amongst young female immigrants. I heard from her the tragedy of the Triangle Factory fire of 1911 in which 146 of the 500 employees, mostly recent Italian and European Jewish immigrants had died, many brutal deaths from the flames and smoke or from leaping from the upper floors of the factory.

The event propelled my grandmother like others of her background and experience to become members of the Ladies' Garment Workers' Union (ILGWU), which I heard about from her and their meetings as I grew up. I did not realize until many years after her death, while cleaning up my parents’ house after my mother’s death, that my bubby had in fact completed high school in New York, at night, a feat that was quite remarkable in those days for a woman with her background.

My bubby had a beautiful voice and sang in a Yiddish Choir and often attended performances of the Yiddish theatre to which she took me when I was old enough to accompany her and appreciate what were often massive productions of song and dance. One of my tasks as my mastery of the piano became sufficient was to accompany her on the piano when she practiced for recitals. With my mother often out of the house working, my bubby was very critical to my childhood development and I loved being with her, whether it was watching her prepare gefilte fish for Friday night, chopping the fish with a hand chopper in a large oval wooden bowl or bringing her the forvitz (the Yiddish paper Forward) which she read from front to back. I recall once asking her how it was that she spoke what seemed to me so many languages and she said with a short laugh, “Where I grew up, you didn’t know from day to day who was in charge, so in order to survive you spoke all the languages you might need to get by.”

My bubby died when I was 12 years old after an illness the first evidence of which I witnessed on the way back from a Yiddish Theatre production to which she took me. It was a glorious event. On the subway platform of Brighton Beach she suddenly said she did not feel well, staggered a bit and then threw up. After a few minutes of this, she said she felt better and we got home by bus. That was the beginning of the evidence of what apparently were brain metastases from what I think was breast cancer, only because I once saw her coming out of the bathtub and even with my imperfect understanding of female anatomy I recognized that one of her breasts was missing and there was a scar in its place. Her death left a serious lonely void in my life which of course passed with time, but she was always present in my consciousness.

I loved to take things apart, put them back together and figure out how they worked. My father was an engineer and he was a whiz at fixing things. I cannot recall ever having a tradesperson in the house to repair a sink, a roof or an electric appliance. I loved the sciences and math in school and decided I would be an engineer like my father. I even went to one of New York’s special schools within the public system that catered to students with special interests and talents, Brooklyn Technical High School, geared for those interested in careers in engineering. I loved the school, especially the various “shops” which were done after the regular curriculum – woodworking, foundry, sheet metal and best of all machine shop- where one learned to use very complex and sophisticated lathes and punches and drills. Throughout my life I have used the skills learned at “Tech” as we called it, to build and fix the same things my father did during my childhood.


Brooklyn Technical High School

I was so focused on engineering that when it came time to apply to university; the schools I looked at all had special reputations in engineering or were of the high quality technical universities such as the so-called Polytechnic Institutes. Although I excelled in the sciences and mathematics in high school I enjoyed other studies and activities, especially English literature, photography and music. I had developed the habit of reading as a child when one of the weekly activities my father exposed me and my sister to was a trip on Saturday morning to the public library where as we left he always said, “The library is the greatest institution in the world” to which when we knowingly asked, “why daddy?” he would answer with, “because it contains all the knowledge of the world.”

In my last year of high school, while in the process of preparing for and applying to university, I picked up the book that changed my life, The Citadel by the physician-author, Archibald Joseph Cronin(his nom de plum being A.J. Cronin). The book so enthralled stimulated and consumed me that by the time I finished it I decided that I might change my studies from engineering to medicine. I recall visiting the home of a very dear friend-girl to differentiate her from someone with whom I had a romantic relationship, although I actually had hoped to develop one at some point. I mentioned to her that I was thinking of medicine instead of engineering, to which she replied with words that became in many ways the essential step in my decision-making process, “You’d be a much better doctor than engineer. I think you should do it.” That statement was the sum total of my career counseling.

When I broke the news to my parents, my mother’s initial reply was, “It will take so many years,” but I could see from the look on her and my father’s face that they were pleased with my decision. I therefore changed all my university applications to read “pre- medicine” in the field of interest and career goals. For reasons of finance I ended up going to our Brooklyn College, one of New York’s five schools of higher education that later on would coalesce into the City University of New York. I was a chemistry major within the “pre-med” program but managed to focus heavily on arts subjects whenever I had the option and in those days it was required to do a whole range of the so-called 101 courses in English, Philosophy, History, Classics, Social Studies and languages- to which I added a few extra English literature and Philosophy courses which looking back were among the most important educational exposures in my life and which formed the basis in many ways of my future academic and creative interests.


Brooklyn College

One of the profound influences on my education and life was Professor Edgar Z. Friedenberg whose seminal workComing of Age in America, had a profound impact on education in America. He was my Professor in my first 101 Social Studies course and indirectly stimulated me to want to travel in Europe, which at that time (the late 1950’s) was not yet in vogue and certainly not something readily accomplished by people in my socio-economic situation. My parents, being the very unusual and progressive people that they were agreed to my taking six months off from Brooklyn College as long as part of the plan was for “educational” purposes which was accomplished by attending a summer language program in Lausanne Switzerland.

That six month journey changed my life and attitudes towards education and adventure. The last part of the journey which was spent in Copenhagen, much of it in the company of a group of primarily female medical students helped formulate my determination to study medicine on the other side of the Atlantic rather than in the United States which would have been part of the “normal” chain of events. The experience overseas also exposed me to a whole new world of “other” than what were the traditional values and cultural mores and practices of America. I broke the news of my idea of studying overseas to my parents and couched the reasoning into financial terms which was one of the factors that allowed them to agree to consider the proposition. As a reflection of their progressive view of the world, the agreement stipulated a tentative agreement to include having my then 16 year old sister visit me during my fist summer to travel in Europe with me.

My original plan to study in Denmark or other Scandinavian country fell through but I was very fortunate in being accepted to the University of St. Andrews, Scotland’s first university and the third oldest in the English speaking world, founded in 1413 with the medical school being founded in 1450 somewhat after Oxford and before Cambridge in England. I was very fortunate to have been accepted a year earlier than initially anticipated and into second year because of my pre-medical education at Brooklyn College because as I only found out after my first year when my class-mates felt comfortable telling me, one of their classmates died in first year, leaving an empty place in second year. That vacant place went to me so from the tragedy of one young medical school student’s premature death, my future opened up- a bitter-sweet tale when told to me by a few of my closest class-mates.


Medical School in Dundee, Geddes Quadrangle

Medical school in Dundee where the medical was actually situated was wonderful. Once I accommodated to the dreary gray weather, the strong at times unintelligible Dundee accent, the paucity of any food worth eating other than fish and chips and the damp cold of the housing, I had a fabulous experience. The main point of my studying abroad was to travel and indeed with almost five months off a year and a system where medical students could choose places to go and get foreign experience based on place, area of study and time I managed over the years to travel and work in Scandinavia, various Eastern and Western European countries, different places in the United Kingdom, and what became another seminal experience in my life, Israel.

I was exposed to geriatric medicine as a medical student where the Geriatric rotation and ward proved to be one of my favorites because of the instructors and wonderful experience with the “old wifies” as the elderly Scottish ladies were called. One of the geriatric wards in Maryfield Hospital was made of a large room with a potbelly stove at its centre and in the evening all those women patients who could sat around in their easy chairs, drinking tea, chatting and knitting- it was a glorious warm vision and experience as they just loved us young medical students.

Following a student placement in obstetrics and gynecology in Haifa Israel I unexpectedly won the prize in Obstetrics and Gynecology in my final year based on my final examination. The 500 pound sterling prize allowed me to return to Haifa for a 5 month internship on the same ob/gyn service which ended just prior to the 1967 six-day war. I had already fallen in love with the country as a student, but this prolonged period confirmed my initial impression.


Serving as an Israeli Air Force base doctor

I returned to the United States for my U.S. internship at the height of the Vietnam War and chose to move north to Canada following which I immigrated to Israel with my then Israel wife who I had met just prior to the six-day war. I did a six month pathology training rotation when I first came to Israel because of lack of language skills and then unexpectedly was invited and accepted a commission as a physician in the Israel Air Force where I served as an Air Force based doctor which included a monthly rotation as a helicopter evacuation crew member which was among the most exciting experiences I ever had.

On my release from the Air Force I took a position as a senior and then chief medical resident at the Shaare Zedek (Gates of Righteousness). It was during this two year residency that I became involved for the first time since medical school with geriatrics- Shaare Zedek had one of the first dedicated geriatric units in Israel. It was a remarkable experience and I witnessed outcomes that I had not seen on our general medical wards and the idea of a true multidisciplinary approach was taking shape. I also found much humour and good feeling among the staff and patients on the unit as we endeavored to improve the function and quality of life of older patients who had in many ways been dismissed as “not likely to improve” from other medical and surgical sources- this of course changed as our reputation in the hospital and in the city grew.


Israeli Air Force helicopters

I returned to Canada in 1973 with the goal initially of studying nuclear medicine with the plan to return to Israel and help develop that specialty at Shaare Zedek Hospital. Two things happened to change that plan the first being that I realized after a very short time that nuclear medicine did not satisfy my clinical and human interests- although I could master the technical aspects of the profession I missed the deep interactions with patients as people. I therefore decided to transfer back into Internal Medicine. The next major issue was the recognition that my marriage was beginning to unravel and going back to Israel was not going to happen in the near future or at all.

While trying to figure out what aspect of internal medicine or one of its specialties I would pursue I remembered my meeting in Jerusalem with Dr. Abe Rapoport from the Toronto Western Hospital who when being driven back to his hotel by me after presenting as a visiting professor at Hadassah Hospital offered to meet with me if I ever needed his help or advice. I went to him and after explaining what I wanted to do and how much I loved general internal medicine he asked me, “Have you thought of geriatrics?” to which I responded, “I did not know it was a recognized specialty in Canada.” He replied, “No it isn’t but there is a great institution called Baycrest and if you take the position offered to you by Dr. Berris at Mount Sinai as chief medical resident, I am sure he would let you do some work with or for Baycrest which is closely allied with Mt. Sinai.”


Baycrest Hospital for Seniors

I followed his advice and met the staff at Baycrest. I was impressed. I took the position at Mt. Sinai and started doing consultation for Baycrest for applicants and for those seniors transferred to Mt. Sinai for treatment. Within two weeks I knew that I had found my place in Medicine. The rest is history: working to get Royal College Certification which came in 1981, helping to build the capacity and reputation of Baycrest, returning to study Ethics and receiving my Master’s degree in 2001 and having a most satisfying career in academic geriatrics and ethics at Baycrest, Mt. Sinai and the University of Toronto- an unintended but most wonderful journey.

Dr. Michael Gordon is currently medical program director of Palliative Care at Baycrest, co-director of their ethics program and a professor of Medicine at the University of Toronto. He is a prolific writer with his latest book Moments that Matter: Cases in Ethical Eldercare followed shortly on his memoir: Brooklyn Beginnings-A Geriatrician’s Odyssey. For more information log on to www.drmichaelgordon.com

Attending on General Medicine

0

No applauses yet

As is my usual pattern, this December I am attending on a general internal medicine unit rather than my usual geriatric service.  Usually there is scant difference in the age distributions of the two services, but this year our general medical service has admitted mostly young or very young patients.  I use the standard definitions of young and very young:  very young means younger than me, young means less than 10 years older than me (note:  my oldest son disputes these definitions and even has the nerve to call me old!).

We have admitted several young people with inflammatory bowel disease (common as Mount Sinai is a magnet for people with IBD), but the scariest issues have been obstetrical and gynaecological.  We admitted a 40 year old woman with obstructive renal failure, who has a small child and who was a childhood victim of severe sexual abuse.  She turns out to have widespread cervical cancer, clearly inoperable.  A 37 year old woman, a breast cancer survivor, was admitted with an end stage sarcoma, but she was pregnant!  Her most heartfelt wish, that she survives long enough to have a healthy baby, is almost certainly unreachable.  Another pregnant young woman was admitted with a movement disorder, likely a conversion reaction.  And people feel that geriatrics is depressing!  It is one thing to face death in your 80’s or 90’s, another when you are in your 30’s.  One of our patients is a 97 year old man who presented with obstructive renal failure secondary to previously unknown metastatic prostate cancer.  He and his family are at peace with the diagnosis, and understand the palliative nature of our therapy.  Needless to say, I find the death of a 37 year old pregnant woman more distressing than that of a 97 year old man who has lived a full and wonderful life.

Best wishes to everybody for the holiday season, and enjoy this exciting new medical resource.

Barry Goldlist
December 13, 2010