GP Metamorphosed to EyeMD

Warning: the following saga is very long, read leisurely.

Growing up in Springfield, OH, I was exceptionally impressed with our General Practitioner, Dr. Howard Ingling, a graduate of Case Western Reserve University, School of Medicine in Cleveland OH. He was available in his clinic to all patients, provided free medical care to needy people at a neighborhood church clinic which he instituted, and he was a pioneer in inter-racial medicine. After clinic he even made house calls, seeing me at our home at 10:30 when I had the German measles. Early on he encouraged me to study hard and he’d write me a letter of recommendation to Case Western.

Beginning my studies, I’ve previously related my acceptances to medical schools, and my decision to attend Johns Hopkins, School of Medicine. My goal was to become a good caring general practitioner like Dr. Ingling. But I soon became aware that our Hopkins staff had some distain for (local doctors) the GP’s. At hospital rounds and presentations the local referring doctors were always referred as LMD’s and often besmirched their treatment plans and presented our superior expertise paths. This attitude dissuaded me from being another ‘LMD.’

My first clinical rotation was Pediatrics. Hopkins has a huge 12 story building totally dedicated just for children. The head of the department was Dr. Robert E Cook, a world renowned Pediatrician who founded the Head Start Program and was the advisor to the President of the U.S. I was assigned to be tutored by Dr. Mary Ellen Avery, a pioneer in hyaline membrane disease of the newborn, the cause of death of President Kennedy’s infant son. My project was having received two Rhesus C -sectioned identical monkeys; one was placed in a regular incubator in room air and the other in an identical incubator in 100% oxygen. I documented their respiratory rates, oxygen saturation, and general viability. I also had a pair of human twins on varying levels of oxygen levels to maintain their ability to breathe unlabored. This was ‘cool’ stuff! Additionally I had clinic patients, one with carbon monoxide poisoning, one Arabian girl with growth hormone deficiency, who was normal in intellect and physical ability but at eight years old weighed 42 lb and was only 40 inches tall. For exercises, I played soccer and tennis with her and she was quite good at both. Then I had a 10 year old patient with Wolff-Parkinson-White (WPW) syndrome, a condition in which there is an extra electrical pathway in the heart. This condition can lead to periods of rapid heart rate (tachycardia) and frequently she would pass out. I was hooked. I decided to pursue pediatrics and devoted all my spare time to this discipline. Then I talked to one of my friend’s father who was a practicing pediatrician in Baltimore. I asked to shadow him over a week-end. He was covering for his group and was very busy the entire time. But the cases were mostly kids with mild fever without other symptoms, kids crying without ceasing, some vomiting almost constantly, some with diarrhea. Some mothers were at wit’s end but couldn’t really describe their children’s symptoms. This went on all night, especially after dinner time, Friday, Saturday and Sunday. There were none of the cases I was taking care of at the hospital. The pediatrician told me that was very typical of his career. I suddenly lost interest for I knew then that unless I wanted to stay in academia, general pediatric practice was not for me. My cases were all managed with good results. We discovered that premature babies lacked a substance called ‘surfactant’ to allow proper oxygen exchange at the air sac level. Hyaline membranes formed and further prevented proper oxygen exchange. Also, it was discovered that too much oxygen was detrimental (per my Rhesus monkey study.) My short statue patient was given the newly discovered molecular chain and formula now known as ‘growth hormone.’ My cardiac patient was monitored with Beta blockers. All were good. I stayed very much interested in pediatrics, but was ambivalent about my future.

I thought that my talents were in solving problems and also I liked using my hands in doing procedures and surgery. Consequently I thought perhaps OB/GYN would be of interest. My Auntie Liu, my mother’s eldest sister by 17 years, was the first female graduate from the OB/GYN department of the University of Pennsylvania and was practicing in Chinatown New York. She was extremely busy but leading a satisfying and seemingly happy life.

Accordingly when I inquired and signed up to join the U.S. Public Health, I was thrilled to discover that there was an opening for an OB/GYN internship at Staten Island, NY. As soon as I had an opportunity, I drove up for an interview. The Director of Medical Education, Dr. Emanuel Stein was super cordial and especially direct with me. He told me that he was thrilled that I was the first Hopkins applicant he interviewed. The Staten Island hospital would definitely place me as their first choice for that OB/GYN position. Accordingly, if I also choose U.S. Public Health, Staten Island as my top choice, the position would practically be guaranteed. But I informed Dr. Stein that I just recently selected this field and have had little experience except that I felt this specialty may allow me the use of medical knowledge and hand skills. I was committed to give it an honest try, but if that did not work, what other options might I have. He agreed that many doctors switch fields as they develop. But he assured me that I was so wanted by his educational program that after an honest and sincere trial if I really wanted to switch out, he’d do his best to make that happen. This was a verbal agreement and I placed my full trust in the agreement. I listed Staten Island U.S. Public Health as my first choice and was assigned to start July 1, 1970 after graduation in late May.

There was a low income government subsidized housing unit 3 blocks from the hospital. Since I had no salaried income Jan-June, I secured a one bedroom unit in that building.

I started my internship with a bang. My entire class had the same idea as I had, selecting to serve here instead of joining the armed forces. It was an excellent group of graduates from all corners of the U.S. OB/GYN was a very little department, run by a second year resident and me, the intern, and supervised by a chief resident of a nearby New York hospital. As a ‘super’ intern, a real doctor now, I eagerly ran the daily clinic, ran off to do deliveries when due, and checked on mother/child discharges every morning and after 5pm, I did circumcision on those requested at night after all duties were accomplished and all charts completed. Meanwhile, there were always interruptions for admissions and emergencies. My resident watched over all I was doing and only made suggestions or helped out when I was running behind. The work was hard, but rewarding. The hours were long but passed quickly. I ate as I could, but lost 10 lbs in the first month. I seldom interfaced with my fellow interns because my department was isolated from the rest of the hospital. But I found out that no one else was doing all that I was doing. Some were accusing me of setting an example no one else could or want to duplicate.

Internally, I was feeling a little prideful that indeed, Hopkins doctors were different from the best of the rest. Dr. Stein was aware of my diligence and sought me out to compliment me often. I continued the pace the second month and lost another 12 lbs. One day, I was called to assist an emergency D and C. It turned out to be to repair a botched abortion attempt. The fetus delivered ended up as 5 lbs stillborn, but broken in multiple segments. I was told that I’d be properly taught to do this procedure as a requirement of my training. But this event struck me deeply. I myself was less than 3 lbs when I was born as a seven-month preemie; I didn’t want to do abortions. I could not accept that I’d be expected and required to be doing abortions to be certified. Then I thought about being able to do OB at the time, but what happens after I become older, like what would my life be when I was 40 years old? For the first time in my life, a feeling of depression hit me. After working so hard to get to where I was, now I did not really know what I truly wanted to be!

I consulted with Dr. Stein and expressed my feelings, especially re: the abortion issue. I told him that I wanted to switch out of OB/GYN to Internal Medicine, reasoning that knowing more medicine will not harm any of my future choices. By now it was also time to commit to next year’s assignment. As a result, I committed to Dr. Stein that if he’d change my internship emphasis to Internal Medicine, I’d stay and do another year of internal medicine next year, allowing me more time to consider my ultimate interest. Keeping to his word, Dr. Stein made that change! The OB/GYN department had to create a new budget to hire outside civilians to do what I did. He added me onto the Internal Medicine internship roster, changing my two months of OB/GYN experience as my electives for the term. Life as an internist was much different. Instead of working 24/7, I was on from 6am to 6pm every day except taking 24 hour calls every fourth day.

I have had such little free time before that I had bought 30 sets of underwear, 30 Arrow white shirts, and 30 sets of black socks because I barely had time to do my laundry once a month after midnight at the local Laundromat, using 4 machines at the same time. No wonder my fellow interns were thinking foolish thoughts of me all that time!

Unexpectedly, sometime in February, the chair of the ophthalmology department, Dr. Fredrick Dykstra approached me and invited me to dinner just to chat. He said that he had observed me since my arrival in July, and that he knew I and the others were all ‘dodging the draft.’ But he was also aware through Dr. Stein that I was struggling trying to decide my future. Dr. Dykstra’s other role was as assistant Director of Medical Education. He had consulted with Dr. Stein and suggested that instead of doing a second rotation in Emergency Room, as scheduled for April that I should be allowed to do a rotation in Ophthalmology. Granted, ER would give me more new experiences, but Ophthalmology could provide me a new future. He said he envisioned me doing well in ophthalmology. I told him that I had keen interest in ophthalmology while going through my rotation at Hopkins , but when I asked how to apply to the program, I was told that at Wilmer (Hopkins) there was a waiting list of 5-7 years! (That thought left my consciousness instantly.) Dr. Dykstra laughed and said, that is Wilmer, the most sought after program, and others like Bascom Palmer in Miami, FL or Barnes in St. Louis, MO. But there are plenty of other good programs throughout the country that if I kept up my current work ethic, he’s sure he’d be able to me get into a good program somewhere. He was very persuasive and I was convinced beyond a doubt that he was thinking of my best interest. I concurred with the change in direction on the condition that this was totally agreed upon by Dr. Stein.

Dr. Dykstra served as the department chief. He was a Board Certified Ophthalmologist, but had been in administration and education area for many years. The program was run by the chief resident from Manhattan Eye and Ear Hospital. He best second year assistant was his helper. The on-call back up was the rotating attendant physician at Manhattan Eye and Ear. The U.S. Public Health intern’s duties were to do the grub work during the day and watch over the inpatients at night while the chief and residents take their leave. The philosophy was by watching, asking questions, and “playing” with the intricate instruments, we gained and obtained some insight in the field.

April 1, first day on the rotation, there was a dock worker brought in with a painful swollen R eye, while scrapping the ship dock. The staff said, ‘here he is Dr. Chu, your first eye patient.’ I took him to a slit lamp machine which fortunately I had familiarized myself before, anesthetized his eye so he could let me touch him. On exam, I saw a globe which was indented and out of round. But under observation, it was filling itself! If the globe was gently touched, clear fluid was visibly egressing through a peripheral slit in the cornea. I know he had a penetration and needed surgical repair. I sought and found the resident busily doing something else, he briskly told me, “Well, do what you need to do to get him on the surgical schedule this afternoon.” I returned to the patient, applied topical anesthetic, washed the eye with sterile saline solution, and lavished copious layer of antibiotic ointment, and gently bandaged the eye and protected it with a metal shield. I figured the foreign body most likely was a metal fragment, thus X-ray may help us as to a location. I arranged an exam with my intern friend in radiology and he was all excited, asked me if I wanted a skull ‘Water’s View.’ I told him to do what he felt was necessary, but let’s try to locate an intraocular foreign body.

Mean while I drew blood for a multitude of tests, (in those days we always checked for serology), did a urinalysis, placed him on NPO and readied him to be admitted while I was arranging for a slot in surgery at 2PM. After all were accomplished I hunted down the chief resident and presented my case to him. All of a sudden he got excited and asked how come I waited til now to talk about it. Where was the resident in all this? I told him that he was busy and told me to handle it. So the chief said we got to get x-rays and get him to surgery. I related to him all I had done, and he immediate headed to x-ray department and was pleased to see a definite metallic foreign body in the inferior ciliary area. He applauded me for my insight and diligence and he began to treat me with more respect than just another Public Health Intern, and wanted me to shallow him whenever possible.

That night I read all I could about corneal injuries and penetrating foreign bodies (FB’s). The next day, a woman checked in with severe L eye pain with blurred vision and generalized red eye after having come out of a morning movie session. I determined that she was suffering from the condition known as ‘acute narrow angle closure glaucoma’ and needed urgent surgical peripheral iridectomy. I completed the usual admission and pre-op work, a notified the chief resident who asked me to be his first assistant at surgery. I was getting pumped!

The next day I had a patient with a “lye burn, alkaline’ splashed onto his whole face including one eye. While the others were treating his face, I had to maintain constant saline irrigation of his eye which was denuded of his entire corneal epithelium and was in constant pain. Imagine the severe pain one gets with a little scratch of the cornea his epithelium was totally burned off!! Saline irrigation was a feeble attempt at preventing further chemical penetration into the stroma and causing permanent scarring, requiring future corneal transplant for any possibility of regaining sight.

That week end, watching over all three of these admits, I also managed to read the entire Textbook of Ophthalmology by Adler. The second week was more routine but just as invigorating. I sought out Dr. Dykstra and stated, I’ve decided to devote my career to ophthalmology. I asked “What do I need to do?” He said he can make suggestions to the admission’s board, and the chief resident also had input and already singled me out as a candidate he’d recommend for the next year’s class starting in July, 1971. I thanked him but affirmed that for what the Public Health had done for me, and in particular how he and Dr. Stein had mentored me, I had to fulfill my promise to do another year of residency in Internal Medicine and could not accept the offer. But, I would appreciate his help in exploring other possibilities available for me. He told me that within the U.S. PHS system; the San Francisco Hospital had a residency program structured that the first year was spent completely as out of service training at Barnes Hospital in St. Louis, MO. Then two years in San Francisco. This position was very competitive, but I certainly had a chance, though most candidates intern in San Francisco to gain an inside advantage. He would try his utmost to advocate for me if I was interested. I confirmed, and committed to pursue this course. Worst scenario could be that I try to take the position at Manhattan Eye and Ear the following year.

The month of April passed too rapidly, but my enthusiasm in/for medicine was totally rejuvenated. I decided to devote all my energy into becoming the best and most knowledgeable physician I could be. Choosing to limit my expertise to just the eye was most exciting, but I wanted to be more than just an eye doctor. I finished my second year residency in Internal Medicine in 1972 and became a Board eligible internist, before embarking full time in ophthalmology.