Author: Lawrence Hurwitz, MD

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Uncertainty to Despair to Hope and Redemption: My Professional Life Battling an RNA Virus

I feel  like I am reliving a bad dream. The race to find a treatment and/or cure to SARS-CoV-2 is reminiscent of decades of practicing gastroenterology while hepatitis C roamed the hospital wards as a death sentence for many. I found myself recently recalling a patient whose story ends with science finding a cure.  The story begins in a community hospital’s ICU.

 As I peered around the ICU curtain, I could see the outline of a motionless ill man. I was visually greeted by a panoply of colors not usually seen in human health. Yellow skin and eyes, violaceous bumps on his extremities and blue hued fingertips. As I entered the room, I recognized him as the car salesman I had spoken to several months ago discussing the pros and cons of  an SUV versus a minivan. His labs and physical exam delivered the bad news that his liver and kidneys were not working and he had vasculitis, an inflammation of the blood vessels. While he had a case that medical students study intently, private doctors rarely see in decades of practice: essential mixed cryoglobulinemia secondary to Hepatitis C. In an attempt to curtail the virus, antibodies bind to viral proteins. Excess antibody-protein complexes, instead of being  cleared from the blood circulation, get deposited in the blood vessel walls causing inflammation and sometimes closure of the vessel. He was in danger of losing his kidneys, his liver and his life. A National Institute of Health study had shown a few years earlier that the immune stimulating natural agent interferon could have a beneficial effect on Hepatitis C. Interferon was started and miraculously the bumps disappeared, the kidneys started to make urine, dialysis was stopped and the jaundice receded. He left the hospital and completed 12 months of interferon, combating fatigue, low white blood counts and depression due to drug side effects. He had been cured of Hepatitis C and had dodged a fatal complication of the virus using a toxic biologic agent.  

This early success had been a rare gold nugget amidst multiple disappointing and tragic events in my experience with the RNA virus, hepatitis C. The lessons learned from this virus are worth retelling as this is a story that parallels our current ordeal with another RNA virus, SARS-CoV-2. 

The biologic veil of Hepatitis C was heavy and was only lifted in fits and starts. In the alphabet soup of hepatitis viruses, A and B were discovered early but “C” was undetectable and given the placeholder non-A-non-B for years until special techniques were devised to recognize its presence. Infection was through blood transmission, usually through blood transfusion, sharing of needles or instruments that were contaminated with the virus and inadvertently inoculated through the skin. In contrast to SARS-CoV-2, which has a presymptomatic stage of a few days, Hepatitis C’s silent period was years or decades before disaster would take hold. Cirrhosis, or significant scar tissue in the liver could impair the sieve like blood circulation within the liver shunting blood to places it normally wouldn’t go resulting in gastrointestinal bleeding, ascites and encephalopathy. Years of infection can lead to liver cancer with a dismal prognosis. 

My early encounters with hepatitis C felt like bailing water from the Titanic while it was taking on water. I could band bleeding blood vessels, start water pills and limit salt in those with fluid overload and give antibiotics to reduce the toxin burden and reduce hepatic coma risks. But without specific treatment for the virus, we were on a slowly sinking ship. Then the drug interferon came along. It was a mixed blessing. It was toxic, causing fatigue in most and depression in a significant minority. It could lower white blood counts and damage the nervous system. It worked in only 10% of patients with the most common genotype of the virus. Most diabolically, those who needed it most were cirrhotics, and for patients with this condition, it was the most toxic and had the lowest response rate. I saw harsh drug side effects that included suicidal thoughts, absenteeism from work on the drug and plummeting white blood counts in countless patients. I questioned whether it was worth the one in ten chance that the drug would work. Slow progress (too slow for patients on the liver transplant waiting list) was the rule of the day. Ribavirin, an oral drug, used with interferon, raised the response rate to over 40% at the expense of the new side effects of anemia and potential birth defects. Most of my discussions with afflicted patients were often discouraging treatment, waiting for “some breakthrough in the future.”

The initial breakthrough came: direct acting antiviral drugs were available in 2011. They were protease inhibitors, drugs that blocked the assembly of viral proteins within the cell. The first generation protease inhibitors had novel side effects including disabling rash, headaches and mouth sores.

I came to dread the newly diagnosed hepatitis C consult. It felt like a “pick your poison” option.  I could offer an imperfect and potentially toxic mix of therapy, not unlike the oncologist administering chemotherapy to a cancer victim. 

This all changed with the synthesis of the drug sofosbuvir, an RNA polymerase inhibitor not unlike Remdesivir, an encouraging agent for SARS-CoV-2. Sofosbuvir, coupled with new protease inhibitors was the miracle I had not witnessed in my four decades rendering care to my patients. It’s side effect profile was no different than placebo and amazingly the cure rate would climb to over 98%. It worked equally well in patients with cirrhosis and the course of therapy was “weeks” rather than “years.” And, it was a cure! Patients who would have been candidates for liver transplantation saw improvement and were removed from the transplant lists. Liver cancer risks were reduced. Other non-liver conditions like heart disease, immune function and cognitive function improved with eradication of the virus. I felt my office was the equivalent of a Lourdes destination for the hepatitis C patient.

Science rendered a disease that afflicted 3.5 million Americans and killed up to 20,000 people a year to an affliction that most likely will be eradicated from the planet in our lifetime. The success of the treatment for hepatitis C can be looked upon as a template for our next RNA viral battle: SARS-CoV-2.  Hopefully, we can build from the success of the hepatitis C RNA polymerase inhibitor and extrapolate to a drug combination that can treat the disease as we wait for a definitive cure and vaccine.  Covid-19’s fate must be one that someday, when I reminisce about this time, I write another science driven medical success story.

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The Art and Science of Barriers

“Good Fences make good neighbors” is a memorable and salient line from Robert Frost’s poem, “Mending Walls.”  While the context of its meaning is a plea for the importance of privacy, it is a useful phrase for the COVID-19 pandemic as we all try social distancing as our physical defense and protective barrier from the Coronavirus. Six feet away from one another and swathed with a nose and face covering mask seems to be the barrier du jour. It has been that throughout life we must deal with barriers that represent either obstacles, as in the poetic verse of Robert Frost, or provide succor to our existence. In our current COVID-19 world, our imposed barrier, a protective mask, will be critical to manage our “new normal” prior to a transformative drug or vaccine. In essence, we need a science driven mask that is effective, comfortable and re-wearable.

Biologic barriers are present from conception. Surrounded by the amniotic membrane, we are protected from most pathogens. Upon its rupture and our ride down the birth canal we start the self versus society struggle.  Hepatitis B, polio, rotavirus, diphtheria, tetanus and pneumococcal vaccinations are our initial immune barrier. Child proofing mechanical barriers (plug locks, stair locks, edge protectors) are present during our formative years. Car seats and later seat belts protect us from motor vehicle morbidity. Science has driven these medical protections and public health measures have orchestrated their distribution to the public and their acceptances as standards of care.

Societal barriers have protected humans for eons from human aggression, accidents and microbes. The Caves of Lascaux  protected Paleolithic man, The Great Wall of China retarded invasion by the Mongols. The Roman emperor Hadrian built his namesake “wall” in Northern England to keep out the “barbarians.” Ramparts and moats around European castles in the Middle Ages slowed the devastation wrought by the Vikings. In our lifetime we put up with anti-terrorist barriers at TSA checkpoints at all U.S. airports. Physical barriers and screening techniques have been shown over time to decrease disease and death from outside threats to our well-being.

Our protection from COVID-19 now demands a barrier to our nasopharynx. We are now safely surrounded by our homes’ four walls and limited “world” contact through our UPS and Amazon delivery services. In order to integrate into society we need extra protection from the virus. A mask or “facial condom” could provide us with the protection and turn human interaction into an acceptable risk. We are now familiar with the N95, surgical, and home-made masks. We have YouTube videos of media celebrities constructing masks. Now,  “mask science” is the next logical step to assure that our efforts are working to prevent Covid-19 transmission. What we really need is some evidence based guidelines developed from a controlled study.

 The geometry is well known: N95 keeps out 95% of particles that are as small as 0.3 microns; droplets containing COVID-19 are 50 microns or less. Droplet spread is 6 feet, more if sneezing or aerosol transmission is involved from the contact. What we don’t know is what materials and layering are most effective against virus spread when used in a real world scenario.

Compliance and comfort are inextricably linked. When I donned a mask in the OR, my face felt like I was in the microclimate of Miami during the summer and my eyeglasses fogged up like winter in London. We have designers and aerosol engineers that can overcome “wearability” issues that could lead to improved compliance. We have industry and universities that have the capability of testing combinations of fabric under simulated and actual environmental conditions.  Distribution capabilities are available to send masks to every household in the United States utilizing the Postal Service.

Americans have internalized the use of seatbelts and TSA screenings in my lifetime. Introducing and complying with  a “new fence” is easier when the alternative may be a painful respiratory death. Wearing a fashionable, comfortable and effective face mask should become the “new normal.”  The design, efficacy and distribution is simply just one more barrier for science to overcome.

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Soup Saviors: Chicken and Matzo Ball Soup Stories

Chicken soup has long been an off-label medicinal treatment for the common cold and flu as long as most of us can remember. So, it seems in these troubled times of COVID-19, we are hearing of its use in both healthy and coronavirus inflicted patients. An elixir from antiquity, chicken soup and its Passover-inspired cousin, matzo ball soup, are the “magic potions” from yesteryear that have been a proven adjuvant to analgesics and cough suppressants. However an Amazon search for chicken soup brings up a dizzying array of “out of stock” and “delayed delivery” for dozens of pre-made poultry influenced self-prescribed potions.  Chicken noodle, chicken and stars, old-fashioned chicken noodle, low sodium, healthy request, chunky, cream of chicken and every conceivable form of soup on a grocery shelf is starkly absent. In fact, chicken soup is one of two most requested items on Amazon. When I took a moment to ponder why, my memory was flooded with memories of my grandmother, aunt and mother serving up large bowls of chicken soup for every childhood illness that befell me. And, to be quite frank, I almost instantly felt better after its consumption.

My maternal grandmother, Nan, unveiled her divine Matzo Ball Soup at the start of each Passover Seder. Even a “soup skeptic” like my father, devoured the contents of the bowl. I can still hear the clanking of his soup spoon on the bottom of the porcelain dish. My nuclear family had matzo ball soup anticipation throughout the year, and not unlike McDonald’s McRibs strategy, Nan would bring it out during random Erev Shabbat gatherings. While there were many proponents of Nan’s soup credentials there was not unanimous agreement. Aunt Rose’s Matzo Ball Soup was touted as the gold standard by my relatives north of the Bronx. The debate on the best soup went on for decades.

Chickens can incubate avian influenza but they can provide sustenance through their soup derivatives. The 12th century Jewish physician and rabbi, Maimonides declared the medicinal properties of chicken soup back in the 12th century. Modern science has weighed in on its medicinal values. Chicken soup can slow  the entry of white cells into the nasal cavity, explaining the improvement in airflow. Medical researchers at Mt. Sinai in Miami Beach ascertaned chicken soup challenge in humans showed an improvement in nasal mucus flow, a marker of viral clearance. Chicken soup can also improve cilia function, the hair-like projections on naso-respiratory cells that “clean up” the nasal and respiratory passages, The soup additives, onions and garlic can have antiviral effects.

As Jews celebrate Passover and recall the 10 plagues of antiquity while living through a 21st Century pandemic, let us remember the benefits and memories that our loved ones provided: the humble Matzo ball/chicken soup miracle.

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COVID-19: Musings of a Baby Boomer: The Human Challenge

I was quite young but I could sense the unease in my mother when she first sent me off to elementary school amidst an uncertain risk of paralytic polio in the 1950’s era. She maintained her frightened countenance until 1960 when the Sabin vaccine miraculously appeared.  Many years later, my wife, a pediatrician, had intubated a young patient with measles who needed ventilatory support. A few days later, she staggered into my office, ashen and lightheaded. Her blood pressure was 70 and her sclerae were icteric. She had contracted rubeola and measles hepatitis. Looking up from her hospital bed she uttered, “if I don’t make it, you’ll need to find someone to help raise our (1 year old) son.  My nurse is wonderful and I give you permission to date her if I die.” My wife recovered and is my social distance partner 35 years later. These are but a few of my anecdotal “high anxiety” moments of contagious disease in my “baby boomer” memory. And that’s the point. These events are distant memories, rarely surface and are almost never mentioned. We move on and forget the lessons they taught until the next infectious insult makes us scramble for direction and hopefully solutions. In fact, throughout history this repetition is startling.

Humans have constructed great civilizations in only 10,000 years, surmounting  challenges and establishing the supply chains that provide food, clothing and shelter for the billions that inhabit this planet.  Yet we are impeded by one major human foible: selective long term memory loss in order to cope with the next medical task at hand. What do I mean?  Take human memory and the history of contagious disease in society. We learn, at an early age, that American and international history were shaped by infectious disease. Early settlements in Virginia in the 16th century failed due to malaria outbreaks. In 18th century Philadelphia, an outbreak of yellow fever forced our founding fathers to flee the city.  Bubonic plague outbreaks in Europe in the 6th and 14th centuries killed 50% of the inhabitants and changed Roman and Medieval society. The medieval citizens fled the crowded cities for pastoral domiciles sensing that social distancing would prevent the deadly illness. Great armies were felled by typhus and cholera during the Napoleonic Wars and World War II.  We don’t have to go back very far to see a world where our parents and grandparents had a stark recollection of epidemic infectious disease. Diphtheria, polio and measles, to name a few childhood illnesses were part of their daily reality. Parents banned their children from community swimming pools, recognizing that distancing them from the source was paramount.  I, born in 1953, recall fellow students in my class with leg braces from polio following summers spent hospitalized. As I entered medicine in the 1970’s, there were reminders of past epidemics on the wards. I rounded in iron lung wards in Rancho Los Amigos Hospital in Downey, California. I ambulated the pediatric wards at L.A. County-USC Medical Center, puzzled by the prominent parapets outside the patient rooms. “They were there so that physicians could round and quarantine themselves during polio outbreaks,” my attending noted.  Again, in the early 1980s a mystery illness with a severely immunocompromised picture in the patient appeared in daunting numbers. The AIDS epidemic was upon us as we scrambled for its cause and cure. As time passed, the memories of these debilitating epidemics receded whereupon complacency and the rise of the anti-vaccination movement became the cause celebré of the 1980’s and beyond. The resurgence of the measles due to lack of sufficient vaccination in the 1980’s did little to discourage the anti-science crowd. Perhaps a lack of firsthand experience with the measles contributed in part to their anti-vaccine stance.  As I gazed into the mouth of a patient during the measles outbreak and saw a Koplik spot, a physical finding that indicates measles, I realized that the outdated knowledge of this physical finding I learned 10 years prior was not so archaic. Actually, I had simply forgotten about this pathognomonic signal of impending rubeola. “Out of sight,out of mind,” I said to myself.

Now, the COVID-19 pandemic has arrived and upended our lives as did the many infectious diseases of bygone years.  Initial roll-out efforts for mass testing, tracking and isolating has been less than adequate. We have finally resorted to social distancing, an ancient form of infection avoidance.  Clearly, the same weapons seen in the great mortality known as the Bubonic Plague during the 14th century. Ultimately, a vaccine will rescue us along with medical mitigation via drugs and antibody rich plasma from those who have recovered. Let us take the lessons of this catastrophic time and the stories from our heroes: the first responders, the healthcare team and informed public servants with us for centuries to come.  Otherwise, we sentence ourselves to repeat the same mistakes.

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Society of Acquired Pathogens (S.O.A.P.)


The following is an edited transcript of infectious agents seminar against human health, October, 2019:

Moderator: Thank you for taking the time out from afflicting disease to attend this seminar and welcome our latest pathogen in training, SARS-CoV-2. Viral agents and Rickettsia should take the first few rows that contain cell cultures. It is my pleasure to introduce our guest speaker,  inflicting misery on Homo sapiens for centuries, our President, Yersinia pestis.

Yersinia pestis: Thank you. For those of you who are unfamiliar with my resumé, I am responsible for bubonic, pneumonic and septic plague. Partnering with the black rat and rat flea, I have inflicted death rates of 50-80% for generations. I helped take down the Roman Empire in the 6th century by killing thousands of farmers.  Since the farmers were now not available to pay their Roman taxes to support the military, this led to the collapse of the Roman armies. My greatest hit was 1346-1353 where I took out half of the population of Europe. I started out in China, traveled with traders overland and with the shipping trade and went west, south and northwest, tightening the noose of misery on millions. I took on one of the greatest city-states at the time, Florence, and annihilated hundreds of thousands. For those Florentines that had a false sense of security and fled to the countryside, my coterie of fleas and bacilli followed them and finished them off. I rushed into Avignon, then the seat of the papacy, and inflicted so much suffering that the Pope blessed the Rhône River as a burial site. As the centuries passed and I lost some of my virulence, I came back every few generations of humans to remind them of my sordid deeds.

 Of course, I couldn’t do it alone so I’d like to introduce my fellow “partners in crime.”

Bacillus anthracis: Thank you, Yersinia. Some may say I take a backseat to the Plague but others recognize me as a formidable foe. I cause Anthrax. I received some kudos from human terrorists who used my spores to infect others through the U.S. mail in 2001. I am crafty and can infect humans through the skin, lungs and gut. Proudly,  I can kill 85% of victims within hours or days. What about those deaths in England in 1348-1349? Yes, I chipped in with Yersinia by killing cattle, transmitting my disease through eating meat and leaving my spores in burial graves. My spores can stay viable in soil for over 40 years! Now, THAT is staying power.

Moderator: We acknowledge the lesser known genera, Rickettsia and their contribution to human suffering.

Rickettsia prowazekii: I’ll be brief as I cannot stay long outside my cell culture medium. I may be intracellular but even humans acknowledge my clout: my disease is called EPIDEMIC typhus. My ride is the human louse, pediculus humanus corporis. I thrive with poverty, war and overcrowding and feel at home in endothelium, the cell that lines blood vessels. I cause rash, headache, cough, muscle pain and then progress to shock and delirium and then death. I have caused more deaths than all the wars combined. I was there during the Peloponnesian War in ancient Greece, the Thirty Years’ War and the Napoleonic Wars. In fact, I killed more of Napoleon’s troops than did the Russians. I caused misery and death during the Great Irish Potato Famine in 1846 and spread to England. The English called it the “Irish fever,” blaming the Irish instead of giving me full credit for the disease. While poverty and hygiene has improved recently and the human louse is in short supply, I jumped to the flying squirrel to cause intermittent disease in modern humans. Please be assured, I am still in the game and doing my part.

Moderator: My thanks to all of the innovative microbes that have stricken so many for so many centuries. Now, we welcome our latest entry to the world of human virulence,  an RNA virus from an unheralded family. Let’s give a warm welcome and a round of applause for SARS-CoV-2.

SARS-CoV-2:  I am humbled to take my place among the greats of infectious disease. I want to express my gratitude to our “think tank” and mammalian assistant, the bat, who has unselfishly provided incubation over the centuries to improve our infectivity.  I proudly come from the family of Coronaviruses. We have been in the human disease business for over 800 years, but have been underwhelming as we have only succeeded in causing the common cold with our first 4 family members. We showed promise in 2003 with the release of my brother, SARS-1, and a later cousin, MERS. SARS-1 had an encouraging mortality of 50% and we were packing the ICU’s in Asia. We did not plan for high transmission rates and with public health measures we were stymied early in the game. I inherited 85% of the genome and fine tuned my transmission rates. In contrast to my ancestor SARS-1, who was most infectious during severe illness, I made sure I could jump to another human even before they were experiencing my infective presence. This was the magic bullet for my success and I am honored to be nominated for rookie pathogen of the year.

Yersinia pestis: I want to thank all in participating in this important update. Let me remind you that Homo sapiens are adaptable and we must be vigilant. In Florence, after several generations of plague, they formed isolation hospitals, board of health administrators and invoked quarantining measures to restrict my spread. They finally got the tools to see some of us in 1683 (early microscope, van Leeuwenhoek). Our fellow microbes have been betraying us starting in the 20th century with penicillin (the mold Penicillium notatum), streptomycin (the bacteria Streptomyces griseus), and tetracycline (Streptomyces aureofaciens). Our machinery has been co-opted  (DNA polymerase) and our bacterial tools to prevent viral infections in us have been discovered (CRISPR technology). We can take solace in that humans have short memories and often make irrational choices and blame others that have nothing to do with their plight. But we must stay vigilant: It is never too late to mutate! Let me call this meeting adjourned and we all look forward to next year’s gathering.

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Coronavirus: ICU and the Human Factor

The summer of 1979 is permanently etched into my memory. I walked into the Intensive Care Unit at U.C. San Diego Medical Center as a newly minted intern. I walked over to ICU-Bed 1 to be introduced to my first patient, a frail teen aged boy who was tethered to a ventilator. “He is day 30 with respiratory failure from disseminated coccidioidomycosis,” my internal medicine resident informed me. “He is your responsibility now, and don’t f__ it up.” An impending wave of anxiety enveloped me as I visually tracked the unending array of IV’s, feeding tube, central line, temporary pacemaker leads and monitoring equipment surrounding his bed. Over the next 6 weeks, I quickly learned that I was a small cog in the care that navigated his course away from almost certain mortality. As the credits to a movie may roll for minutes with names that do not have an apparent effect on the finished product, so too is the list of people who render care to the ICU patient. The pulmonologist, critical care specialist, critical care nurses, respiratory therapists and anesthesiologists represent a core team. Integral to their support are those that are in the supply chain providing meds, equipment (lines, pacemakers, intubation equipment, personal protective equipment, monitors, ventilators) and those that support and repair these items. Additionally, consultative services such as cardiology, infectious disease, gastroenterology, neurology, hematology, surgery and ENT to name a few, are involved with medical and surgical issues that arise from the prolonged hospital course and many complications that arise in patients that cannot provide critical organ function. Furthermore, ICU patients consume intensive utilization of laboratory and radiology service. Ethics committee members may be involved in deciding end of life and medical futility issues. Family adjustment and bereavement may also need social work and psychiatric services to cope with these psychosocial issues. The work day of the ICU is punctuated by “crisis moments” as each patient may have a life threatening arrhythmia, mucous plug in a large airway preventing oxygenation, massive gastrointestinal bleed, pneumothorax from high ventilator pressures to name a few of the “falling dominoes” of the critically ill patient.

Universal precaution implementation is, in an ideal world, best adopted in a slow, compliant fashion with a critical care or scrub nurse equivalent monitoring the provider for breaches in technique while putting on and removing personal protective equipment. In real life, emergent events require rushed donning of masks and gowns with possible gaps in the mechanical barriers. Of course, infective risks are greater with the lack of N95 respirators and the use of less protective surgical masks. Now, let’s look at the public risks of community exposure when the family equation is factored in. At least a dozen or more providers may enter an ICU bed in a given day. Most of the health care professionals are young, have families and extended families that they interface with on a daily basis. A four person household with a dozen personnel exposed to COVID-19 and a national number of 85,000 ICU beds creates a potential exponential source of infection in the community.

More masks, more providers and infrastructure are needed now. Can this be possible? Innovation in equipment, medical therapy and healthcare delivery are possible given the resiliency of Americans devoted to the well being of the United States. Is it possible? I have faith that this can be overcome. And, yes, my teenage patient  in 1979, after 30 more days in the ICU, walked out of the hospital with a smile on his face and his health intact.

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Portland Exposed

Asian Dumplings from Afuri Ramen and Dumplings

Xylophone Recital at the Trailblazer Game

  • Food truck in Pioneer Square
  • Voodoo Donuts
Multnomah Falls

One of the perks of retirement is opening up a map, seeing a destination you’ve never been to and then booking it. I had never been to Portland and was curious if it’s reputation as a city of second chances, a foodie haven, a city planning Mecca or a hiking haven was reality. So with the help of Costco Travel Services, I journeyed to the Pacific Northwest for a fact finding mission. 

After touching down at the Portland Airport, the expected nightmare of big city surface transportation began. Would it be Uber/Lyft at a cost approaching the price of the plane ticket or a New York City Taxi $80-$100 price from JFK/Newark to Manhattan? To my surprise, the trip to the inner city involved use of the ubiquitous light rail (MAX). At $1.25 for a senior citizen and $2.50 for an adult it allowed a stress free ½ hour commute close to the doorstep of our hotel in downtown Portland. The light rail went about to every important destination in the city environs. The Embassy Suites was our destination abode. Formerly, The Multnomah Hotel, it had hosted the iconic Elvis Presley, Charles Lindbergh and all presidents from Teddy Roosevelt to Richard Nixon.

The sign “Keep Portland Weird” was a few blocks from the hotel and it wasn’t long before I encountered support for its message. It was on a subsequent rail experience, an elderly male with a thinning hairline and walker entered our car clutching a flask of vodka. “I honor the Ten Commandments but I can’t love my neighbor more than myself,” he exclaimed as he swigged from his flask. A dark haired man with an earring engaged him in debate of the Ten Commandments, later joined by a guy carting a bicycle on the train who also participated. As the vodka bottle was passed around to the discussants, I realized I was witnessing a Portland exclusive.

The cuisine in downtown Portland was eclectic but stellar. As craft beer had revitalized the brewing industry, Voodoo Donuts had the imprimatur of craft donuts. I went into dessert nirvana with “Old Dirty Bastard,” a donut with fudge and peanut butter capped with an Oreo-cookie dusting. The dumplings at Afuri Ramen and Dumpling, a Tokyo based Ramen restaurant were also divine. The noodle experience was accompanied with a peak into the future because artificial intelligent iPads substituted for waiters. 

To our delight, the Trailblazers were at home hosting the San Antonio Spurs in our second day in Portland. I had always wondered why my Lakers had such a difficult time in Portland, even when they had championship caliber teams. A trip to the Moda Center provided some clues. It was a Thursday night and the place was packed. A portly fan two rows up started a “Let’s Go Blazers” chant well before the singing of the national anthem. The crowd was warmed up with a swarm of 5th graders playing rhythm xylophone followed by the governor of Oregon presenting a certificate of appreciation to the team on its 50th year anniversary. The game was close and the fans were so vocal it felt like game 7 of the NBA Finals. On our light rail trip back to the hotel, a long term fan explained the phenomena in personal terms. “I’m a recovering alcoholic, been sober for 7 years and a ticket holder that long. The basketball team is all we have.” 

As a neophyte Portland tourist, the next stop was a popular destination, the Pittock Mansion. This was an early 20th century home built by Henry Pittock, the successful editor of the Oregonian. Overlooking the Williamette River and surrounded by Oregonian Pines, it was a beacon of 20th century ingenuity and a magnificent home. While I was wandering past the fine silks, wondered how a newspaper editor could amass a fortune. I came across a clue. Henry Winslow Corbett, the senator from Oregon, had provided a cash infusion to the paper in 1872 averting bankruptcy and temporarily taking control of the city newspaper. Corbett made his initial fortune by selling farm equipment and dry goods to the farmers and families newly arrived from the Oregon Trail. When the San Francisco merchants raised their prices during the California Gold Rush, Corbett was able to undercut their prices and achieve market share. You could say he was the Pacific Northwest Walmart of the 19th century! He used the paper’s influence to back  the successful campaign of Rutherford B. Hayes, the Republican candidate for President in 1876. With political influence, both Corbett and Pittock went on to amass a fortune in banking and real estate.

The Portland experience was not complete until we took an excursion down the Columbia River Gorge. Multiple waterfalls grace the shoulders of the Columbia River Scenic Highway. We stopped at the 627 foot Multnomah Falls, the largest waterfall in Oregon. It was spotted by Lewis and Clark in 1805 and does not disappoint. Hiking was challenging during the winter due to muddy trails but swathed in a conifer blanket, the ascent was still exhilarating.

If natural beauty, great food, a workable transit system and NBA basketball is your thing, I encourage you to seek out the Portland high.

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Ode to Kobe and Basketball

Kobe and the NBA Finals
Entering Staples Center Lakers v. Magic 2009

A few weeks ago I was in Palm Springs participating in the lugubrious task of looking for an assisted living facility for a relative when I received a phone call from my son. “Kobe Bryant just died in a helicopter crash,” he uttered in disbelief. After a short period of “it can’t be,” a wave of sadness and tears enveloped me. Crying does not come easily to this sexagenarian, especially for the demise of such a public figure. 

Why was I so profoundly affected? Of course, the tragedy of losing his young daughter and the others who were in the prime of life was obvious. But, after a few days of reflection, I realized that basketball had been a refuge of joy for my children and I, and that the sanctity of entertainment that it had provided was breached by this terrible event. 

Those of us born in New York City were introduced to the game at an early age. There were hoops in every indoor and outdoor gym. Living a few doors down from us was the City College of New York center who had won the NCAA and NIT tournament in one year, a feat never since duplicated. Phil Jackson, then a reserve player for the New York Knicks, lived in Queens and played pick-up at my elementary school. Everyone  in public school had to play and I did. And I stunk, though fleeting accomplishments are burnished into my memory: my 6th grade teacher, Mr. Axelrod, giving me a thumbs up after sinking two foul shots for my only points of the year; sinking the winning layup in overtime to lift the intramural Bayside High School Newspaper team over the Chess Club (OK so they were not physically gifted but they did think two passes ahead). And through family lore: my 70 year old 4 foot 8 inch aunt recounting her brush with basketball greatness: “Lawrence,  I got out of the car and was looking at his belt-buckle. I looked up and saw him and almost fell over.” She was describing meeting Wilt Chamberlain, then a bellhop at Kutscher’s Hotel in the Catskills, NY where he played summer ball in between semesters at University of Kansas. But it was fandom for the NBA that refined my love of the game. It was the rise of the NY Knicks in the late 60’s after decades of futility that energized me and the city. My high school buddies going to Madison Square Garden on December, 31, 1968 and watching the likes of Willis Reed and Walt Frazier dismantle the Baltimore Bullets; listening to the Knicks win their first championship on radio in 1970 (not televised in the NYC area back then). Going out west and living in Los Angeles and later San Diego, I came under the Laker spell. A lifelong friend had gone to Michigan State grad school and first informed me of a freshman sensation, Earvin Johnson. As a junior gastroenterologist in a large multispecialty group in LA County, I found a coterie of docs who worshipped the Lakers. One, who had season tickets since the team came from Minneapolis, was especially passionate. “Anytime you need a partner, I’m ready to go,” I pleaded with him as I informed him of his patient’s polyp burden. After a year, I got the call and accompanied him to Showtime in the Forum in Inglewood. We were center court, one row behind Karem Abdul Jabbar’s dad. And then there were 48 minutes of watching Magic Johnson’s craft with no look passes, Jabbar skyhooks and basketball magic that pushed Newtonian physics to its extreme. The day I interviewed for hospital privileges at Whittier Presbyterian hospital was the day the Lakers signed Shaquille O’Neal. I don’t remember any of the interview questions I was asked that day, but I do remember the excitement of an all-star center coming to LA. What followed was joyful hours of watching the Kobe-Shaq and later the Kobe-Gasol Lakers on TV and at Staples Center. Kobe picked up the mantle  of Laker greatness and pushed the athletic limits of great basketball. We were treated to over two decades of multiple winning seasons.

 Kobe’s greatness extended beyond the court. My son was the recipient of a Kobe “high five” after seeing him leave U.C. Irvine Basketball Practice Facility one summer day 10 years ago. And following in the erudite tradition of great former NBA players, Kobe thought outside the box and was able to deconstruct greatness for the average fan, allowing us mortals a glimpse of a higher level of performance. And so, with a bit of satisfaction, I watched my younger son embrace the Washington Wizards when he went to Georgetown and my older son participate in the well being and fandom of the Miami Heat. Basketball is a team game and mirrors the collective nature of human kind but also rewards individual great talents. We can only imagine what insights were lost with the passing of Kobe Bryant. What my family and I  have is the joy and memories of watching the Mamba play the game in such a way that it sketched us a blueprint for life.

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The Art of the Golf Excuse

With retirement comes the end of one of golf’s most prized excuses: “I don’t have enough time to practice.” Realizing that my golf foundation has been built on the art of the golf excuse, my anxiety level naturally elevated. While there are plenty of golf instructional books and videos, there is a dearth of expert commentary on the golf excuse. I will detail my excuse tree as generated over 50 years to help the struggling golfer with alibis for their own game.

  1. The Physician Golfer: I grew up watching golf on TV. There was Dr. Stone, Donna Reed’s pediatrician husband on “The Donna Reed Show” playing a Wednesday round; Dr. Cary Middlecoff and Dr. Gil Morgan (OK a dentist and optometrist but still in healthcare) were skilled PGA professionals with doctorates. Sitting for the MCAT (Medical College Admission Test) in 1974, the general knowledge section had the question: “Which sport do you take a divot?” Checking off golf, I dreamed of a future of an expanding medical knowledge and a shrinking handicap. Reality ensued over the years with the rise of HMO’s, IPA’s and 80 hour work weeks that left little time for golf. And the realization that pharmaceutical reps are the scratch golfers in healthcare.
  2. Learning the Game at the WRONG COURSE at the WRONG TIME: Few serious golfers seek New York City for their home base for learning and living the game. But that was not the case in the late 19th century when golf was brought over the Pond from Scotland. Willie Tucker was one of the first golfing emigres . Willie was was born in Scotland. His father was a greenskeeper in Wimbledon and his maternal grandfather competed against Old Tom Morris in the British Open. His brother in law, William Dunn, had the happenstance of meeting William Vanderbilt, the grand son of Cornelius, who was in the vanguard of the gilded age tycoons. Vanderbilt met Dunn in Biarritz, France where he was teaching his guilded age cronies the art of the game.Dunn summoned Willie to assist him in France., Willie realized his talents and funding were aligned in NYC where gilded age money was waiting to build golf courses for the privileged few. And build them they did. Willie Dunn designed Shinnecock Hills and their contemporary, Dr. Alister Mackenzie ( yes, of Augusta fame and a trained surgeon) designed the Bayside Links, just steps from my high school.  Willie Tucker got into the act, constructing the less heralded Clearview Golf Course and Yacht Club and Douglaston Golf Course, both in Queens. Golfing nirvana in Queens? Well, in 1920, New York City government took over management of Willie Tucker’s courses, cut down the trees to speed up play and put a goldfish pond near the clubhouse to (?) placate the golfers waiting hours to play a round. The end of World War II brought peace but golfing disharmony to the Queens tract. Robert Moses, the NYC Parks Commissioner, (see Robert Caro, The Power Broker, an in depth view of Moses) built the Clearview Expressway and Cross Island Parkway that further diminished the golf course acreage. New homes for returning veterans led to the closure of several golf tracts. Alister Mackenzie’s Bayside Links was closed and replaced with tract homes but Willie Tucker’s Clearview Golf Course was given a pardon. By the 1960’s, Clearview Golf Course had few trees, few traps, a busy expressway adjacent to the 5th hole, no practice areas and a typical 5 hour wait on the weekends. My first golfing lessons at Clearview were 1) aim is secondary and 2)always have a hammer ready to get your tee in the ground. If you got frustrated there was always meditation near the goldfish pond. 
  3. Golf magazine overdose: My first Golf magazine subscription was mid 1960s:take it back slowly, take it back quickly, stand close, stand far, take a lot of sand, take little sand: 50 years of golf tips was enough to prove the “paralysis by analysis” hypothesis. Luckily, I was spared of the launch monitor and spin rate statistics of the 21st century. 
  4. NYC High School Golf Team: under normal circumstances, competitive golf would be a boost to excellence. Our team played at the infamous Clearview course (vide Supra) and our golf coach was moonlighting from his usual job as the  the High School basketball coach. Not being familiar with the game, the team schooled him in the finer points of golf. We received “let’s press,” and “dig deeper” from his basketball motivational speeches. Bogey golf was the order of the day. 
  5. Getting Older: the only legitimate excuse in retirement. Loss of elasticity, lumbar and cervical discs on the move, degenerative joint disease, forgetfulness. The only benefit of dementia is vaccination against #3 and insures the golfing edict, “stay in the moment.”

The human mind (aka neocortex) is resourceful and resourceful hackers (the golf variety) can contribute to the “golf excuse” online community. I welcome your comments.

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Now What? The Retired Doc Manifesto


My thoughts wandered back to my first year in college, afflicted with infectious mononucleosis during my first semester. After spending 3 days in a University infirmary, my dad flew me back to NYC for a second opinion with his company doctor. “So you’re majoring in political science. You know there’s not a real world job out there,” declared Dr. Sussman behind his mahogany desk on Park Avenue. “You should try for medicine,” he counseled. Fifty years later, mentally replete with the teachings of Hans Krebs, Bert Vogelstein, Sidney Winawer and a host of others, I walked out of the endoscopy center, bid adieu to colleagues, staff and my endoscopes and entered the world of the “retired doc.” Now what? Travel the world, sleep in and watch “Get Smart” reruns, volunteer in indigent clinics, hangout in hospital dining rooms and talk about the good old days? Turning to the internet, I found a plethora of sites advising me on finances, providing lists of post-doc duties but no voices of the retired physician community describing the journey of the medical retiree. In this blog, I hope to stimulate discussion of meaningful and whimsical topics of value to the retired physician community. Let’s go!