The Alumni Office contacted Dr. Brozinsky for an interview, and he shared his written highlights from almost 40 years in medicine.
Continued, from above:
Dr. Morris Zuckerbrod, an elderly but revered internist was our preceptor. He introduced us to one of his patients and proceeded to percuss out the patient’s heart borders with his short, stubby fingers. We all had to agree on exactly where cardiac dullness ended and pulmonary resonance began. Dr. “Z” then took a sheet of loose leaf paper and traced his patient’s enlarged cardiac contours. The five of us went to the X-ray department where Dr. Z pulled that day’s film and snapped it onto a viewbox. With great fanfare he then whipped out the loose leaf page that he had stuffed in his breast pocket ten minutes earlier, unfolded it, and placed it on the X-ray. The perfect superimposition of cardiac borders was a thing to behold. Dr. Zuckerbrod smiled benevolently, “That, gentleman, is how you percuss out a heart.”
So, now it’s 2016 and it seems that the only person who touches a patient’s chest is the tech who performs the echocardiogram. Then a computer-generated report appears, signed by the cardiologist who may not have even examined the patient that day.
All of my education from kindergarten through medical school had been in Brooklyn. The only exception was in February 1972 when I ventured by bus and subway into Manhattan for an elective rotation in gastroenterology with Dr. Michael J. Lepore at St. Vincent’s Hospital in Greenwich Village. He was a legendary clinician who got to know everything about his patients that might have a bearing on their illness. No wonder the likes of Greta Garbo and Herbert Hoover sought him out as their physician. Upjohn supported his fellowship program at Roosevelt Hospital and then St. Vincent’s, and it was one of the most highly sought after in the east. This was before ultrasound, CT, MRI — diagnoses were crafted from histories obtained by careful questioning and meticulously performed physical examination. No scribe taking notes on an iPad, but rather eye contact, hands on, calm but authoritative voice reassuring countless patients that he was there to help them.
That month was my introduction to the ravages induced by alcohol. From the suburban housewife with cirrhosis to the homeless Korean War veteran with pancreatitis, Lepore treated them all with respect and compassion, qualities sorely missing in many newly minted twenty-first century gastroenterologists whose prowess seems to be measured by adenoma detection and biliary cannulation rates.
I never had the pleasure of working with Henry Janowitz in New York or Joseph Kirsner in Chicago, and only met Yale’s Howard Spiro in the twilight of his career, but dozens of tributes testify to their devotion to their patients. As with Lepore, none of the countless accolades given to these giants speak of their endoscopic dexterity.
From 1972-75 I was a house officer in Internal Medicine at Maimonides. The Chief was David Grob, who was one of the world’s experts on myasthenia gravis. He consulted on Aristotle Onassis’ case. A John’s Hopkins trained clinician, he would frequently wow us on Director’s Rounds by palpating a patient’s radial pulse and then accurately predicting both systolic and diastolic blood pressure.
One night my team admitted a very interesting patient, and instead of having the intern present the case to him at morning report, I asked Dr. Grob if he wouldn’t mind interviewing and examining the patient in an attempt to arrive at what was indeed a rare diagnosis. Dr. Grob thoroughly enjoyed the challenge and we were all amazed at the direction of the questioning and ultimately how carefully he examined her extremities. Now how many patients with Ehlers-Danlos have you ever seen? Grob had the diagnosis in fifteen minutes!
VA Medical Center in Brooklyn
I served my fellowship in gastroenterology at the VA Medical Center in Brooklyn, and remained there as a clinical instructor and assistant professor. In 1975 when I started there, the affiliation with SUNY Downstate was rather weak. In an attempt to strengthen that affiliation and attract American graduates to the joint program with Kings County Hospital, the powers that be recruited Victor Herbert, MD, JD to the position of Chief of Medicine.
Yes, that Victor Herbert, who was named for his distant cousin, the composer. Dr. Herbert was an antiquackery activist who tolerated fools poorly and when he arrived at the Brooklyn VA he certainly encountered many old time physicians who fit that description. Unfortunately his impolitic nature overshadowed his clinical brilliance and despite being given the VA’s Middleton Award “for outstanding achievement in medical research for his work on developing scientific tools to diagnose nutritional deficiencies,” he soon found himself at loggerheads with the Chief of Staff, a psychiatrist. VACO (VA Central Office) in their not-so-infinite wisdom banished both of them, the psychiatrist to Murfreesboro, Tennessee, and Herbert back to the Bronx.
Mission accomplished, however. By the time Herbert left Brooklyn, the old guard at the VA had been replaced by younger, more cutting-edge doctors and the training program in medicine, now more intimately integrated with Kings County Hospital and Downstate’s University Hospital, became one of the most competitive in New York City.
Dr. Herbert got along quite well with me and my GI section chief, Saul Grosberg, perhaps because he sensed that we kept up with the literature and applied this knowledge to the care of our patients. This was when endoscopy was starting to really take off, but Herbert appreciated and made it known that bedside clinical skills would always trump marginally indicated procedures.
No discussion of the Brooklyn VA of the 1970s would be complete without mentioning Harry LeVeen, the brilliant Chief of Surgery. He had some oddball ideas about intraoperative heating of pancreatic malignancies, some of which are being resurrected forty years later. He invented the LeVeen shunt for treating diuretic resistant cirrhotic ascites. In fact, my job as a senior GI fellow was to pick a piece of paper out of a hat to randomize a patient to shunt vs. further intensifying medical therapy. The shunt did work, but unfortunately early on, surgeons did not drain all the ascitic fluid before placing the shunt; hence the inevitable variceal rupture when all that extracellular fluid was returned to the intravascular space. I still recall one bona fide case of hepatorenal syndrome which was successfully treated with the shunt and published in the New York State Journal of Medicine.
University of California, San Diego
In June 1980 I left the borough of my birth to join the faculty at UCSD in the Division of Gastroenterology. This was a very heavily research-oriented group, mostly with Ivy League resumes, and they were looking for young clinicians.
While at UCSD from 1980-1986 I helped to train two dozen fellows, most of whom went into private practice, but several who did well in academia including Loren Laine, Christine Cartright, Salam Zakko and Susan Cummings. I did clinical research with the late Jon Isenberg on acid secretion and worked with the scientists at Hoffmann La Roche, SKF, Glaxo among others. I administered ranitidine (or placebo) to known duodenal ulcer patients and our lab technician extraordinaire Dan Hogan measured their gastric acid secretion.
The drug had not yet been marketed as Zantac. When it was (1983), Tagamet bit the dust. And then, a few years later (1984) Australian physician Barry Marshall ingested a campylobacter-like organism that was subsequently named the Helicobacter pylori. Although initially ridiculed for suggesting that this bacteria caused chronic gastritis and peptic ulceration, he had the last laugh, receiving the Nobel Prize in 2005.
I was one of a small group at UCSD who got along quite well with both Marshall Orloff and Abdool Rahim (Babs) Moossa, the Chiefs of Surgery while I was there. Orloff, at age 37, was the youngest Chief of Surgery in the nation when he was appointed as the school opened in 1968 and held that position for fifteen years. He later became world famous for his unbelievable results with emergency portacaval shunts on variceal bleeders. What was unbelievable was not the 30 day mortality which other centers came close to matching, but the recidivism rate among the alcoholic survivors, which Orloff claimed his personal and team’s intervention kept in the single digits! Alas, hardly anyone is trained to do that procedure in 2016 as we have Interventional Radiology ready, willing and able to perform a TIPS. Orloff’s residents very much appreciated that he never castigated them in public.
Moossa was the go-to surgeon if you had pancreatic cancer. Patients from all over the world sought him out and were generally quite happy with his excellent results. He always asked me how my wife and young children were and more importantly, listened intently as I told him.
The inaugural Chief of Medicine at UCSD was Eugene Braunwald, a cardiologist from the NIH who had fled Vienna in 1939, and while a medical student at NYU in the 1950s was mentored by Ludwig Eichna (my Chair at Downstate 1960-1974). Braunwald came to UCSD with his thoracic surgeon wife Nina Starr but she and Orloff reportedly didn’t get along, and the Braunwalds returned to Harvard in 1972.
Henry Wheeler, another founding member of UCSD Medical School’s faculty, was instrumental in then recruiting his friend from Columbia, Helen Ranney to become the Chief of Medicine in San Diego. It was at Columbia that she conducted world-famous research on sickle cell disease. She was Chair at UCSD from 1973-1986.
After UCSD, I joined Ed Singer in Chula Vista and we’ve been together now for thirty years. Ed grew up in Houston. He and I are the same age, have similar philosophies about patient care, and perform endoscopic procedures only when results stand a good chance of altering diagnosis or changing treatment.
A final word or two about UCSD. UCSD got it right when they made Tom Savides, a 1987 graduate who trained at UCLA and Indiana University, the head of interventional endoscopy. Tom is able, affable and available and it has been a pleasure to send my toughest cases to him – we have each others cell phone numbers and he has earned a well-deserved national reputation as the guru in EUS and double balloon enteroscopy.
Dr. David Brenner is currently Dean of the UCSD School of Medicine and Vice Chancellor for the Health Sciences. In 1986 he was one of my fellows and then went on to academic careers at North Carolina and Columbia. He lived near us in University City. We jogged together thirty years ago. Our daughters played together. He is primarily responsible for convincing Bill Sandborn to leave the Mayo Clinic and establish an IBD Center of Excellence here in San Diego. Kudos to Tom, Dave and Bill – what an incredibly valuable resource these physicians have been for the entire San Diego medical community. The “town-gown” problems which were rife here in the 70s and early 80s are finally starting to fade away.
The eleven consecutive semesters of French I studied in Brooklyn are not much help in Chula Vista. One of the ER admissions my first year in practice was a “mule” from Nigeria whom the border patrol agents at San Ysidro thought was acting suspiciously and sure enough an X-ray revealed two dozen drug-filled condoms scattered about his gut. When I started interviewing him in French, the guards at his bedside were not too amused and insisted I knock it off pronto, or else.
Unlike the hidden agendas in University politics, I came to appreciate that private practice politics were a more up front. Ancestral homeland and building loyalty more than hospital affiliation influenced referrals for office consultations, unless, of course, the patient were a family member, in which case Ed Singer or I had the honor and privilege of seeing them.
Richard Snyder, MD, a really good guy and a beloved and skilled practitioner was one of the gastroenterologists who spoke at a Sharp-sponsored symposium in 2015. He began his remarks by scanning the audience of physicians and nurses and stating that we all must have been good people in previous lives because we were now being rewarded with the privilege of practicing medicine; allowing us to not only make a comfortable living, but to care for our fellow man and use our education, training and skills to help our sick patients get better.
I was an academic for nine years and really loved teaching students, interns, residents, nurses and fellows. But these past thirty years in private practice have been the most enjoyable of my professional career.
The advances in medicine have enabled me to take so much better care of my patients. We can now cure hepatitis C. If banding bleeding esophageal varices doesn’t stop the hemorrhaging my interventional radiology specialists are available 24/7 to perform TIPS. Can you believe that 32 years ago I attended a symposium at the Cleveland Clinic on variceal sclerosis – cutting edge then, but extinct now?
Laparoscopy was in its infancy in 1986. How many of you remember 9″ long cholecystectomy scars and the four week “off work” testimonials?
NOTES (natural orifice transluminal endoscopic surgery) is the new rage although I’m not sure it’ll catch on in the US, but if you go to China you can have your gall bladder stones removed via the rectum! I kid you not. I just read a case report in the American Journal of Gastroenterology and the patient did fine – no visible scars at all – I suspect a little bit meshugi, but no scars!
I’ll probably hang up my shingle before I fully submit to the chazari of the EHR. Sure it’s nice to easily access the lab studies and X-ray reports on my patients – but my God – those ridiculous templates that are being shoved down our throats – they’re for the coders’ benefit and not our patients’.
And now that some patients are complaining about their practitioner (see – no longer their doctors) making eye contact with a tablet or pad instead of them a few practices are hiring scribes, that’s right, scribes to take notes. I’m sure we’d all love to have some total stranger record our symptoms, our history, our fears.
What I’ve cherished the most is the one on one when I meet a new patient for the first time. My favorite ice-breaking question is, “Where are you from way back when?” I know enough US geography to continue that line of questioning and, oh boy, if the patient is from New York I can really put them at ease.
My Spanish-speaking patients very much appreciate that I’m making the effort to converse with them. On occasion they’ll even compliment me on my accent. My bilingual MA Belinda has no equal.
What a pleasure to be able to make a diagnosis that might actually benefit a patient – celiac disease or Whipple Disease and not IBS. Microscopic colitis with instantaneous and dramatic response to budesonide. I have two young ladies in their twenties with Crohn’s who are symptom-free on the new biologic agents. Even the more mundane GI diagnoses GERD, IBS, dyspepsia, fatty liver have new therapies that did not exist a decade ago.
My colleagues in surgery, radiology and pathology are first class. The nurses at Sharp Chula Vista are a cheerful, talented and dedicated bunch. I am proud and honored to have served on the Board of Directors there from 2005-2014. Dr. Snyder is right. I am a lucky man.
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