September 15, 2023
Dear Interested Readers,
My Story Continues
My medical training occurred in the shadow of the Vietnam Era draft. Early on, college students were protected as long as they were enrolled. The result was that there was social inequity. Within the above link we learn that:
American forces in Vietnam were 55% working-class, 25% percent poor, 20% middle-class. Many soldiers came from urban areas or farming communities.
In response to criticism of the draft’s inequities, on December 1, 1969, the Selective Service System conducted two lottery drawings…
The draft lottery was based on birth dates. There were 366 blue plastic capsules containing birth dates (including February 29) placed into a glass container. The capsules were drawn by hand, opened one by one, and then assigned to a sequence from 1 until 366. The first date drawn was September 14, followed by April 24, which was assigned to “001” and “002” respectively. The process continued until each day of the year was assigned to a lottery number.
The lower the number was, the higher the probability was that men with that birthday would be called to serve. Eventually all men with number 195 or lower were called in order to report for physical examinations in 1970.
Draft lotteries were conducted again in 1970, 1971, and 1972. With the Paris Peace Accords signed in January 1973, active American involvement in Vietnam came to an end and the draft saw the the last men conscripted on December 7, 1972.
My draft number in that first lottery was 108 which would certainly have sent me into the service, but I was protected by my student status and doubly protected by the fact that I was “married with a child.”
I was quite surprised to learn near the end of medical school that the moment someone graduated from medical school they reverted to draftable as a “general medical officer” which often meant possible service in dangerous areas near the combat front. Think “MASH.” To avoid this service there were a few alternative ways to serve. Several of my classmates who had a research interest joined the Public Health Service and secured positions at the NIH. Others joined the Indian Health Service. The option that I chose was to apply for a “Berry Plan” deferment. With a Berry Plan, a doctor would have a physical and if passed, one could defer service to complete a residency before entering the medical branch of one of the military services. I applied for and was granted a Berry Plan during my internship. My understanding was that as a board-certified internist, I would serve in a military hospital far from any fighting.
As I have described before, I was told to show up at a recruiting office in Boston for my recruitment physical. As I have also mentioned, I have been treated for high blood pressure since my senior year in high school. The night before my Army physical I had been on call in the hospital. As fate would have it, I never got to bed. It was a very busy night with multiple admissions and emergencies. To help me get through the night I had consumed a lot of black coffee, and I had eaten plenty of the salty processed food that was available in the hospital cafeteria for the doctors who were on call.
When I arrived at the recruiting office, I saw two Greyhound buses waiting at the curbside. I was directed to board one of the buses and climbed aboard along with dozens of other young recruits. I did not know that we were headed to “The South Boston Naval Annex” where we would have our physicals in a very large warehouse-like building that was on a pier in the harbor. As we piled off the bus, those of us who were destined to be officers were directed toward a special area where we would be processed. Perhaps, we got special treatment like being able to remain in our underwear because we were going to be officers.
Before going for the physical, I had no idea that my blood pressure would be a factor in determining my future. My experience when my blood pressure was measured in the doctor’s office was that my systolic pressure would often be near 200, and my diastolic pressure would be 100-110 on the initial reading. Like many other “hypertensives” my pressure would usually fall as I relaxed. By the end of most visits, I would be down to something like 160/90. For several years, I had been on a variety of meds that were available at the time including diuretics and other meds like hydralazine, reserpine, and guanethidine which are rarely used now.
After my exam which had occurred mostly in a large open place where you went from one station to another, I was directed to a single room and asked to lie down on an exam table. After waiting and resting, my blood pressure was taken several more times. I could tell by the frustrated look on the face of the medical corpsman that he did not like the readings he was getting. I was told that my pressure was quite high, I think the number was something like 220-240/120. I explained that I had a history of high blood pressure, and I had not been able to sleep for over forty hours because I had been working. It was decided that I would return the next day for repeat testing.
The next day I rode the bus again. After my blood pressure readings were found to be elevated again, I was told that I would be rejected from the Berry Plan. At the time I was not sure what would happen, but in a short time, I was notified that my draft status had changed again. I was 4F which meant that I was medically not qualified for military service. I went back to my doctor and we tried another combination of meds, but the biggest benefit to me assuming that I was not about to have a stroke was that I could begin to think about a fellowship in a specialty after completing my senior residency. I had been given a gift of two years.
Failing my Army physical gave me the opportunity to consider two years of fellowship training in some specialty of medicine. It was as if I was at a restaurant with a menu with many choices all of which appealed to me. I considered fellowships in all the sub-specialties within internal medicine. I was not immediately sure that I wanted to do a fellowship in cardiology. In medical school, I discovered that as I was going through the various specialty rotations I was “trying on” the idea of following that discipline. During surgery, I was thinking about being a surgeon. When I was on my psychiatry rotation I contemplated being a psychiatrist, and so it wasn’t until I had “tried on” enough different ideas like sweaters of different sizes and weaves that I knew that the best fit for me was Internal Medicine. Now I faced another big decision that would impact the rest of my life. In the end, my decision boiled down to a choice between cardiology and hematology/oncology. Both programs were quite strong at the Brigham, and I felt that I had an insider advantage for selection in either discipline. getting a fellowship at the Brigham would mean that I would not have to move my family and that my wife could continue her professional plans.
I decided to apply for a cardiology fellowship for two reasons. First, I reasoned that cardiovascular diseases and concerns were perhaps the largest component of practice in internal medicine plus there were interesting hospital challenges and many issues of chronic disease management in the ambulatory environment. My second reason for choosing cardiology was the reality of avoiding the experience of continual loss in hematology and oncology. Again and again, the heme-onc patients came into the hospital and died despite our best efforts. In contrast, cardiac issues could often be resolved, and if not cured, cardiac patients could very likely be returned to a full life of family, play, work, and community with good medical management. Cardiology seemed to me to be a very good fit with my long-term interests in primary care. Most of the cardiologists I had known before I went to medical school had practices that were a mixture of hospital and ambulatory practice with both cardiac patients and patients who had other conditions.
Part of my decision to do a cardiology fellowship was the influence of the cardiology environment of the Brigham in the early seventies. Many of my cardiology mentors at the Brigham like Dr. Dexter, Dr. Braunwald, and Dr. Richard Gorlin were extremely competent in every aspect of medicine. The Brigham was top-heavy with well-known cardiologists even before Eugene Braunwald was hired to be the chief of medicine beginning in July 1972. There was not one cardiology program. There were three!
I recently mentioned Dr. Lewis Dexter in my reminiscences about my first day as an intern. Dr. Dexter had his own “service” complete with his own cath lab. Located on the floor just above Dr. Dexter was Dr. Richard Gorlin’s team. Dr. Gorlin was famous for the formula that he derived working with his father who was an engineer that allowed for the calculation of the size of the orifice of the mitral valve from hemodynamic data. The Gorlin fellows and associates included my chief resident, Dr. Michael Lesch, Dr. Louis Teichholz who devised formulas for LV size from early echo data, Dr. Michael Heman, Dr. Peter Cohn, and Dr. Edward Sonnenblick. All of them eventually left the Brigham to become professors at other medical schools in the few years of sorting out that occurred after Dr. Braunwald took over as the chief. The third noteworthy cardiology service belonged to Dr. Bernard Lown. Dr. Lown ran the CCU and focused on research in arrhythmias and sudden death. He was a pioneer of cardioversion, the inventor of the first practical defibrillator, and a master in the use of various forms of digitalis. Dr. Lown is famous for many things including his work to eliminate nuclear weapons for which he received the Nobel Peace Prize.
Each of these “services” had cardiology fellows. I was excited to be offered a fellowship by Dr. Gorlin as soon as I let it be known that I was interested in a cardiology fellowship. Once again the path forward was so easy that it seemed almost preordained. During the first year of the cardiology fellowship, all of the clinical fellows participated in a series of rotations through the various cardiology services and activities. In reality, it was a year when all the fellows from the various programs were thrown together and spent time with each of the well-known services.
In the second year of the fellowship, the activities were segregated by research interests under the direction of the individual cardiology services. During that first year, I rotated through Dr. Dexter’s cath lab, Dr. Gorlin’s cath service, a rotation in pediatric cardiology at Children’s Hospital, hospital consultations, the exercise lab, rudimentary ECHOs (echocardiography was a new activity in 1973), EKG reading, and postoperative management of cardiac surgical patients. It was a great experience and all of my teachers were well-known cardiologists.
Despite the fact that my first year of cardiology fellowship was very positive, I knew that I was not interested in climbing an academic ladder in the world of “publish or perish.” I had done enough bench science to know that I wanted a life of contact with patients and not a life of research and grant pursuit.
My work that first year did result in the publication of one paper In The American Heart Journal that I am surprised to discover can still be found on the Internet. The paper occurred following a conversation that Dr. Peter Cohn and I had one day as we were making rounds on patients who had been admitted for cardiac cath prior to either bypass surgery or valve replacement. At that time it was still about ten years prior to the use of angioplasties in America which were pioneered by Dr. Andreas Grüntzig in Switzerland in the mid and late 70s before becoming one of our most common interventions in the early 80s.
At that time a cardiac cath required a five-day admission to the hospital. For the first two days, non-invasive testing was done, including stress tests, and meds were modified. Patients were often enrolled in research protocols that required baseline evaluations and medication modifications. On day three, the catheterization was performed. Days four and five were for med resumption and changes in management often in preparation for elective bypass surgery on a subsequent admission.
Dr. Cohn and I noticed that a significant number of the patients we were seeing had suffered prior cardiac events without much warning. Many of these same patients would have strongly positive exercise tests without developing angina. Despite their lack of symptoms, they often had severe coronary disease that was equal to or at times even worse than other patients who did have angina with their exercise tests. As we discussed the observation we realized that angina was a “warning system” that usually resulted in patients avoiding the activities that caused pain. They lived in a “collapsing” world. Patients who had ischemia with exertion without angina had no warning system. They were like someone driving a car without a gas gauge who would not know they were about to be empty and stranded far from home. We presented our findings and theory at the annual meeting of the American College of Cardiology, and Dr. Cohn continued to do research and write about “silent ischemia” after he moved on to be a professor of cardiology at Stony Brook. I moved on to use the knowledge in my practice at Harvard Community Health Plan.
There were several cardiologists at the Brigham who were not currently affiliated with any group. Perhaps one of the grandest practitioners who had connections to the earliest days of cardiology was Dr. Harold Levine. His uncle was the famous Brigham cardiologist and pioneer in post-infarction cardiac care, Dr. Samuel Levine. Dr. Harold Levine was a wealth of expertise as a pioneer in electrocardiography, but most of all he was a quiet demonstration of medical professionalism. There is a comment about his character in the Harvard obituary written by several cardiologists at the Brigham. Dr. Levine died in 1993 at the age of 86. They wrote:
Harold Levine was a humble and gentle man, in both senses of the word gentle. He was greatly admired and respected by his many students and colleagues. He practiced the highest standard of medicine’s art and science, and was as devoted to his patients as they were to him. Family and Judaism were of vital importance in his life, and travel was one of his few diversions. Medicine was all-absorbing to him. He followed the Osler tradition inculcated into him in his years of training under Henry Christian, himself an Osler trainee.
The quote references Dr. Henry Asbury Christain, the first Chief of Medicine at the Brigham, Dr. Christain was trained at Hopkins by Osler. I guess that since Osler trained Christain, Christain trained Levine, and I learned a lot from Dr. Levine, I can place myself in a genealogy that really cares about the care of the patient.
Another Brigham physician who had connections to but was not a part of one of the three cardiology groups and who had even more influence over me during my training was Dr. Marshall Wolfe. Marshall had also been a medical student, intern, resident, and fellow in cardiology at the Brigham. He spent time training with Dr. Bernard Lown at the Brigham and Dr. David Littman at the West Roxbury VA who was famous as the inverter of the very popular Littman stethoscope which I am sure most of my readers have used. I had a brief experience with Dr. Littman as I rotated through the West Roxbury VA as a resident.
Long before I met Dr. Wolfe, I had noticed his notes written as a medical student, intern, or resident in the medical records of many of the patients that I saw on the medical ward service. It was always exciting to discover that I was seeing a patient previously managed by Marshall Wolfe. His notes were textbook examples of clinically useful communications. As an intern and resident, I had admitted many of his patients. By that time he was the cardiologist at the fledgling Harvard Community Health Plan. I don’t know if he was aware of a sense of competition, but every day I would try to see his patients and get my clinical impression in the medical record before he did. He frequently beat me to the bedside.
Near the end of my first year of cardiology fellowship, I learned that Marshall was leaving HCHP to devote more time at the Brigham to his new position as House Staff Director. Marshall knew me well and suggested that I take his place at HCHP as their cardiologist during my second year of fellowship. That year there was to be an expected cut back in funds available to pay fellows, and by becoming the cardiologist at HCHP I could more than double what I could earn as a fellow. I would also get credit for my second year of fellowship and be eligible to take the boards in cardiology. Marshall knew that like him, I imagined a life of clinical practice. He knew that like him, I enjoyed primary care and saw myself as an internist and primary care physician who just happened to also be a cardiologist.
Once again, my path was prepared for me. All that I needed to do was to recognize the opportunity and say, “Yes!” HCHP was perfect for me and had been great for Marshall because we both enjoyed being part of the complete care of the patient. All of the “specialists” at HCHP also functioned as primary care physicians. The Chief of Medicine, Lee Younger, was a hematologist/ oncologist. That unique practice of having all specialists be generalists as well was part of HCHP’s original formation. It was an innovation that I always thought was beneficial and produced referral efficiencies and greater patient satisfaction, but not everyone liked it. The idea has been lost to “efficiency.” I never gave up my primary care practice, and by 2008 when I left full-time practice to become the CEO, I was the only specialist in our practice who was also a PCP.
Next week I will continue the story with my early experiences at Harvard Community Health Plan where I started the rest of my life one week short of my thirtieth birthday on July 1, 1975.
A Week Away In the Maritimes
I have written to you this week while my wife drives us back from a week of traveling on Prince Edward Island and Cape Breton Island. We saw plenty of New Brunswick going to PEI and coming back from Cape Breton. I love great scenery against the background of almost universal civility. It is not a joke. Much of Canada and its Maritime Provinces are a marvelous combination of great natural scenery interrupted by neat little towns and farms that are populated by people who are congenitally afflicted with polite behavior. Charlottetown is the largest town in PEI and its population is less than 50,000. The whole province comes in under 180,000. There may be more cows and chickens on PEI than people. There is virtually no traffic. I kept asking myself, “Why don’t I live here?” Perhaps, I would not ask that question if I came back in January.
The people were so nice that I wondered if everyone was a descendant of Anne of Green Gables. The header for today was taken behind the sand dunes at Cavendish Beach in the National Park near the house with green gables that was the inspiration for the many books written by Lucy Maud Montgomery.
It was my first time back to Cape Breton Island where forty years ago I spent a week sailing with friends and my oldest son on the Bra d’Or in a fine old wooden double-masted sailboat. Was it a yawl or a ketch? I get lost in the terminology of sailboats. It was great fun and great scenery. I was eager to return and spend some time on The Cabot Trail.
I am looking forward to a little more sailing and swimming in my little lake over the next month before it gets really cold. This next week looks good with highs around seventy with bright skies after the passing over the weekend of Hurricane Lee which is hitting Maine and Canada and giving us a little blow on the way. I hope the skies will be sunny and the temperature pleasant where you are this weekend.
All the best,
Gene
