Dr. Jack M. Zimmerman: The Reluctant Pioneer

#012 - Join host Dr. Red Hoffman as she interviews Dr. Jack M. Zimmerman, a retired cardiothoracic surgeon who served as the chief of surgery at Church Hospital in Baltimore, Maryland and as an associate professor of surgery at Johns Hopkins.  Jack first developed his interest in surgical palliation during his surgical residency, when he learned of the Souttar, a tube meant to help patients with esophageal cancer.   He then went on to start one of the very first hospice programs in the United States.  Jack discusses his memories of training under Dr. Alfred Blalock and of how meeting Dr. Balfour Mount convinced him to invest his time in opening a hospice at Church Hospital.  For those interested in surgical history, this is a fascinating discussion!

Read more about Dr. Zimmerman's work with the Souttar tube here.

To learn more about Dr. Alfred Blalock and Dr. Vivien Thomas, watch Something the Lord Made here.

To learn more about the surgical palliative care community, visit us on twitter @surgpallcare.

Transcript

spk_0:   0:13
surgical. Palliative care may seem counterintuitive, but surgeons have a rich history of pallid both their patients and their families. I am Red Hoffman in acute care surgeon in Asheville, North Carolina, and one of 79 surgeons currently board certified in hospice and palliative medicine. Join me as I interviewed the founders and the leaders of the Surgical Palliative care movement, a diverse group of surgeons dedicated to providing a high quality pallid of medicine to all surgical and trauma patients. Welcome to the surgical palliative care podcast. We heal with more than steel. Hi, everyone. This is Red Hoffman. Thank you so much for joining me for another episode of the surgical palliative care podcast. Today. I am so excited to be interviewing Dr Jack Zimmerman. Jack is a retired cardiothoracic surgeon. He served as the chief of surgery at Church Hospital in Baltimore and was an associate professor of surgery at Johns Hopkins. Jack is also known as a very early adopter of palliative care. Jack, thank you so much for being with us today.

spk_1:   1:43
Thank you for having me Red

spk_0:   1:46
Jack as we're getting started. Can you share a little bit about yourself where you grew up where you trained and why you decided to become a surgeon.

spk_1:   1:57
Unless it's interesting. I I grew up in, uh, the Westchester County area of New York, came to Ah Johns Hopkins in 1949 as a first year medical student and stayed for 10 years for medical school and had my surgical training under Dr Alfred Blaylock, finishing my residency in 1959 and then went on to Kansas City, where I was responsible for starting an open heart program at the Veteran's Hospital in Kansas City and then return to Baltimore in 1965 as chief of surgery at Church Hospital and as associate professor of surgery at Johns Hopkins, where I continued until I retired in 1997. What got me into surgery when I came first came to medical school. The only thing I knew I didn't want to do was surgery. I really never saw myself is particularly gifted with hand doing work with my hands, but two things turned me totally around. One was my exposure to Dr Blaylock as they when I was a medical student. Hey was dynamic. He had within the last five years just begun doing Blue Baby operations, and he was just a very exciting person. The other factor was that I spent the summer after my second year in medical school at the Grand Film Mission in northern Newfoundland, right up on the Belle Isle Straits, right across from Labrador. And like all mission hospitals, it was largely a surgical hospital, and I spent a lot of time in the operating room and felt very at home there. Those were the two factors that drew me into surgery,

spk_0:   3:57
Jack. For those members of our audience who don't know who Dr Blaylock is, can you please tell us

spk_1:   4:03
he was really a true pioneer of cardiac surgery? The heart was really largely off limits until the mid 19 forties, when he developed a procedure to treat Children with what was called tetralogy of fellow, a multiple birth defects involving the heart. And, uh, he achieved fame. He and Dr Helen Taussig developed the procedure, and then, in order to make it really physically feasible to do it, he worked with his black lab technician, Vivian Thomas, to develop the technique to a nasty most to connect blood vessels in a different way. Thio treat the Blue Babies and did the first procedure in 1945. And then it was enormously successful. And that really was the first true, uh, operation on the heart Since then, of course, we've moved way forward to open heart procedures where the circulation is totally stopped through the heart and the surgeon can open the heart and work on it. But that wasn't feasible in 1945. So, in a sense, Dr Blaylock was not only a cardiac surgery pie in here, but a surgical pal, e ation pioneer. Because those blue babies he wasn't correcting the defect that created their problem. He was relieving their symptoms. Many of the Children he operated on later, when open heart surgery became possible, were operated on and their defects actually corrected. So in a way, he was a surgical pal. E ation pioneer.

spk_0:   6:04
Jack, Did you see the movie on HBO about him? Something the Lord made?

spk_1:   6:09
Yes, I did. Do

spk_0:   6:10
you think it captured who he waas?

spk_1:   6:13
It did. I thought it was a little bit hard on him. In his relationship with Vivian. Vivian was not only a mental Rabban, but a very good friend. And, uh was an important factor in my surgical training. He ran the surgical research laboratory, and all of us who came through the surgical training program spent time with Vivian. I thought the HBO show was excellent. It kind of painted Dr Blaylock in places as an ogre. He really wasn't. His relationship with Vivian was one of enormous respect, but other than that, I thought it was a superb presentation. Dr. Blaylock himself was outside the operating room. Hey was the consummate Southern gentleman in the operating room. He was something else. He was not easy to help. One of his favorite expressions was Jack. If you can't help me, at least don't hinder May.

spk_0:   7:20
Oh, wow. It's just fascinating for me to hear the history. It's really incredible. Well,

spk_1:   7:29
it was an important part of history.

spk_0:   7:33
Well, so, Jack, how did you end up getting interested in surgical pal e ation?

spk_1:   7:40
Well, as I came through the surgical residency at Hopkins, I saw the treatment was being given to patients with a soft Agiel loan, pancreatic cancer, and realized that we were curing oh, between five and 10% for those types of tumors, and I became very concerned about what we were doing to the other 90 to 95%. And that really is what stimulated my interest in what surgeons could do to make that 90 or 95% of. But patients with lona soft deal and pancreatic cancer more comfortable,

spk_0:   8:24
can you tell us a little more details about how that worked for you?

spk_1:   8:27
Well, what the what I started with was patients with a soft A geo cancer. But we're having great problems swallowing, which led thio severe nutritional deficiency intonation on also regurgitation. They would get try to swallow food that would regurgitate it, and that often lead to the development of pneumonia, which hasten their death not not only hastening their debt but made them much more uncomfortable. So I really worked to find something that could relieve the problems of intonation and aspiration. Dr. Philip Alison, who was the chairman of the Department of surgery at Leeds in England, came as a visiting professor in 1958 while I was resident, and among his presentations was one about his use of a thing called the Soutar to S O u T T A R tube, which is a gold plated nickel tube with the flanges, the top, which could be passed through the tumor. And I was fascinated by that and decided to try using it. One of the, uh, members of the full time faculty was Doctor, you're Jim Jim Cantrell, and I talked with him about it, and he was excited. And so in 19 fall of 1958 I put in my first Soutar tube. You have to be patient, has to be esophagus scoped, and a boo ji passed through the tumor, and then the tube advanced through the tumor. And that was my first venture into, uh, palliative care. And it turned out to be really quick, quite helpful. I thought too many patients.

spk_0:   10:30
What was the obviously surgeons for The most part are trained to cure. I'm so I'm wondering what was the response to other members of the surgical department when you were investing your time in a procedure that was certainly meant to palley eight or make people feel better but might not change the trajectory of the disease?

spk_1:   10:57
That's a, uh, an interesting question, because I think the answer is a wide range of response. Some colleagues thought that's a strange way for a surgeon to be acting really dealing with an important problem that we face off quite frequently. So I think there was a range of reaction to it. Locally. I presented in 1968 at the Southern Surgical Association. I presented 50 cases of Soutar tube insertion and, uh, Wes. When one of my colleagues saw that on the program, he said, That doesn't sound very surgical to me. Wow. But on the other hand, in the discussion of that paper, ah, number of surgeons stood up and recited their experience with the misery of patients with esophageal cancer and how they thought this was an important advance.

spk_0:   12:06
So I recently spoke with Jeff Dunn and he made sure to point out to me that palliative surgical procedures such as the Sow Tarr tube G tubes, intestinal bypasses are really just one aspect of surgical palliative care and that the practice of surgical palliative care is really meant to encompass so much more than just procedures. It's meant to encompass excellent symptom management, excellent communication skills where we make certain that we're providing gold concordant care for our patients and sometimes even encompasses crisis management so I'm wondering your thoughts about this. Do you think back in the fifties and sixties and early seventies that surgeons were thinking about pal e ation? Beyond just procedures?

spk_1:   12:59
I think this is really a critical point when we use the term surgical pal e ation. To me, it has two very different but important aspects. One is the performance of by surgeons of operative procedures that can contribute too pal e ation. But the other, and equally important part is surgeons response to symptoms with techniques that don't involve a procedure but simply involved principals of providing good relief of symptoms. So I think there are indeed two aspects to surgical pollination when we use that term, and it's important for surgeons to be trained in both.

spk_0:   13:52
Do you think that that was happening back in those early days that focus on symptoms and communication? Or do you think that has kind of changed over time?

spk_1:   14:06
I think it's changed tremendously over time, and I think that one very important factor in the change has been the arrival of hospice care. I think that made people generally medical people in particular and surgeons specifically quite conscious of the fact that pal e ation was an important part of providing medical care.

spk_0:   14:35
You know in your article that you sent me this 2011 article that you wrote for the American College of Surgeons bulletin, and I'll put a link to that in the show notes you were discussing early surgical contributions to palliative care. And you shared a quote that I loved from Dr Dunphy, who was ah Prior president of the American College of Surgeons, in which he said, The secret of the care of the patient is in caring for the patient. And I just loved that.

spk_1:   15:07
So do I. Bert Dunphy was present when I presented a paper at the Southern Surgical Association. I don't recall that he was a discuss it, but we did get to talk about the work, the one of the great features of the Southern Surgical Association meeting or the extracurricular activities of which the tennis tournament is a particular favorite. That year I was paired with Bert. Uh, I don't think a za part, the doubles, and so we got a lot of time between sets to talk, and he was very, very encouraging about what Soutar tube and such maneuvers would offer to patients that couldn't be cured.

spk_0:   16:04
So, Jack, I'm wondering, How did thinking about Pal e ation in your early surgical career change you as both a person and as a surgeon?

spk_1:   16:16
Now that's an interesting question. Read that I've never really thought about HOTA, but, you know, I had said earlier than I came to medical school. Not wanting to be a surgeon, I really came to medical school thinking I wanted to be probably a general what we then called a general practitioner now known. This family practice I loved the Brett of coverage the general practice offered, and one of my main inspire, Er's Thio enter medicine was our family doctor who was a general practitioner. So from the very beginning, I think I had an interest in things will beyond surgery. So I'm not sure, really. If I try to struggle with that question of whether I changed, I'm not sure that I did change, particularly as I got involved in palliative care. I do know that it brought me in a closer relationship with patients because it's impossible to be serious about palliative care unless you are really in very close

spk_0:   17:33
again. That's okay. Siri wants to get in on the conversation. That's all.

spk_1:   17:44
She is intrusive, but s. So I don't really think in answer to your question that I didn't change.

spk_0:   17:51
I think I really appreciate the answer to your question because as I'm interviewing more people, it's almost like it's not as if we changed. It's almost like we found our police and surgery that, yes, we love to be in the operating room and perhaps love to be the captain of the ship, but really love to have those very deep connections with patients and their families and can acknowledge that surgical intervention does have its limits. And we want to kind of go beyond those limits in supporting the patient on their families.

spk_1:   18:26
Very, very well put. I think that's when I look at people like Jeff Dunn. I have the feeling that from the very beginning of their careers they were very broad in their concept of what surgery could and should offer.

spk_0:   18:47
So, Jack, I know that you eventually ended up starting Ah, hospice program at Church Hospital, and I really want to talk about how that all happened. Like I would love to hear some stories about you meeting Dame Cicely Saunders and about you meeting Dr Bao Foreman and starting this hospice program.

spk_1:   19:07
Well, I'm always glad to have to talk about our hospice experience. The program at Church Hospital was one of the earliest in the United States at the time it began, there was the Hospice of Connecticut on the East Coast, and there were a few hospices on the West Coast. But there really were not very many hospices around. Our chaplain at George Hospital, which is a, was a roughly 300 bed private hospital two blocks south of Johns Hopkins on Broadway in Baltimore. Our chaplain, Paul Dawson, heard about hospice and approach me about starting a hospice program at Church Hospital. I told Paul at the time, I said, You know, that's a marvelous idea. I think it's just great, but I've got my hands full. I'm the large practice. I'm chief of the service. I'm teaching at Hopkins, and I just can't take on something. Maur. No, Paul would not let things go like that, so he began to invite speakers to come to speak about hospice, and we had speakers from Hospice of Connecticut and even some from England, and nothing really rang a bell with May till about amount came. And he began his talk with a picture of a lovely young student nurse with I believe It was over advanced ovarian cancer that he was carrying Foreign, the palliative care program, which he had started some years ago at the Royal Victoria Hospital in Montreal. By the time Val was finished speaking, I was convinced that if it could work at the Royal Vic could work a church hospital. And so we approached. We talked to other members of the medical staff, and they were enthusiastic about it. We went to the governing board and they were enthusiastic, and so are we. A team of six of us was sent to England for Ah, two week study of hospice. We began, of course, ST Christopher's with the Dame Cicely Saunders, founder of ST Christopher's, who couldn't have been more charming and more generous in her gift of time and knowledge. And I spent a lot of time with Tom West, who was kind of her right hand. He was a surgeon who had been a missionary in Africa and had worked with the Dame Cicely for quite some time once Tom and I got through the language barrier. You know, we say the English and Americans are have a common culture of common history and her separated only by a common land. Once Tom got through that, I learned so much about the treatment of specific symptoms pain, nausea, constipation, depression. And then after ST Christopher's, we visited a number of other hospices in England and came back and admitted our first patient to the hospice program and the program grew from that point on. And I, uh, wound up writing a book, Hospice, Complete Care of the terminally Ill, which summarized our experience and continued my interest in hospice care over the years. Paul Dawson, who had recruited me initially, very charitably referred to me, a za reluctant pioneer of hospitals.

spk_0:   22:51
That will be a very wonderful name for this episode of the podcast. That's amazing. So how I'm curious, since the hospice benefit really didn't go into effect until I think 1984. So how was this hospice funded?

spk_1:   23:09
That's that's a very interesting question, and my recollection of it is a little bit vague. Att This point But it turned out that we approached. And there's a chapter in my book written by Gloria Cameron, who was the vice president of Church Hospital at the time and dealt with the finances of our program. But I do remember we went to the leaders of Blue Cross Blue Shield, which was the main insurer for our patients, who came largely from the steel industry in Dundalk and suburbs of Baltimore. And we approached them about funding this and emphasize the fact that probably hospice care was an economic sieving for them, in that it avoided the long efforts that sure that were terribly expensive, really, we were treating terminally ill patients with an aggressive effort to try to cure them, and the whole concept of hospice to replace that with palliative care not aimed at cure might be a savings to them. And they bought into that idea. And so that was the help. And then hospice hospice Medicare benefit came kicked in, and that was made things much better, much easier. But before that, private insurance really did help us out.

spk_0:   24:46
That's interesting, Jack. What were the responses of the surgical community in Baltimore when you were doing this

spk_1:   24:55
again varied, like our experience with Soutar, Tube and other palliative measures, there was a wide range of response, but by and large it was favorable so that within not too many years, other hospitals in Baltimore Union Memorial Hospital started its hospice program. One of the interesting points about hospice care that has always fascinated me. The history of hospice areas that it is the only major development that I can think of only major development in medicine that has come from outside major academic medical centers. The Hospice of Connecticut started without any help from Yale New Haven Hospital. Johns Hopkins started its program long after Union Memorial and other hospitals in Baltimore ahead started. There's So it was one of the very few, if not the only development of the 20th century and medical care that originated and moved ahead outside of academic medical centers.

spk_0:   26:11
I've never thought of That's a really pretty fascinating point. What are your thoughts about how the surgical palliative care movement has matured over the last several decades?

spk_1:   26:22
I think it's been great. Jeff Dunn and so many others have done so much to get surgeons and general aware of this. Surgeons have a role in palliative care, and I think the growth has been really quite remarkable. The College American College certainly gets a large share of credit for this From back at the very beginning of hospice, when Rollo Hanlon was the first director of the college, he was an enormous supporter of hospice care. I had known Rollo before because he had come through the very competitive surgical residency program at Johns Hopkins quite some years before May. So I've known Raul Oh well. And when he first heard that we were starting hospice program at Church home, Rather contacted me and offered support of any kind with college would give the surgical palliative care task Force was formed. Surgical pal e Ation Residents guide was pumped. And I think the growth has been just quite remarkable. Thanks to you, you, Jeff and a bunch of others.

spk_0:   27:43
Well say thanks to Jeff and a bunch of others. I feel like I'm riding on all of these amazing people's coattails right now, which is also great. So I'm wondering Jack as we're wrapping up, if there's anything else you'd like to add from a personal standpoint or a professional standpoint,

spk_1:   28:03
not not really. I think we've covered most of what I have to say about palliative care, except that I think there is much work yet to be done. I'm not sure a TTE this point. I'm not very clear on how many residency programs incorporate some meaningful training in surgical palliative care. But I think there is enormous room for improvement in what we do, so that more and more surgeons finishing their training are familiar with and somewhat skill that surgical palliative care.

spk_0:   28:46
That's a good point. I was just speaking with Dr Zara Cooper recently, and she was saying that, you know, while it's easy to kind of check the boxes when you're looking at the American Board of Surgery or a C G M E, that yes, we meet these requirements we really haven't gotten to the point where we look at something like communication about gold concordant care or really excellent symptom management as skills that are taught and are expected of our residents, and that we really need to have that built into the curriculum of it. Better because, you know, from my opinion, the reality is is that the majority of surgeons are not going to pursue a fellowship and hospice and palliative medicine. Nor do I think they should, but that we should be able to provide some very basic primary palliative care to all of our surgical patients. So I think that is something that we need to continue to work on. Moving forward.

spk_1:   29:49
I couldn't agree more. I'm a big believer in the, uh, acid test of whether something is important is whether it appears on the final exam. And I'm not clear point whether the American Board of Surgery in its certification process has questions about surgical palate.

spk_0:   30:12
They actually do ask some on some questions on our board exams. So I think there's a recognition that this is important. I just don't think we've figured out how Thio properly teach it yet. Perhaps. Right. Great. Yeah. Well, Jack, thank you so much. This has been so interesting for me. Um, I'm a huge fan of stories, and you certainly have a lot of them. So I appreciate your sharing them with me and with the listeners of this podcast.

spk_1:   30:43
Well, I sure appreciate your having me on this podcast. And I feel like they joined a very elite club of people that you've interviewed many. Thanks for having.

spk_0:   30:56
Thanks, Doc. I hope you continue to feel well. Well. D'oh, Thank you for joining us for another episode of the surgical palliative care podcast. Be sure to subscribe to stay up to date on the latest episodes. Toe. Learn more about the surgical palliative care community. Follow us on Twitter at Serge Pal care. If you'd like to get more involved with the surgical, palliative care Social media team, please reach out on Twitter or via e mail at surgical palliative care at gmail dot com. Lastly, take good care of yourselves and take good care of each other.