Tìm Kiếm Bài Đã Đăng
|
Diễn Đàn Cựu Sinh Viên Quân Y
© 2015
© 2015
I left Saigon after Christmas 1974 and arrived at Travis Air Force Base in California just in time for the New Year of 1975 not knowing that over four months later I will have to apply for political asylum and looking for way to resume my young medical career in the US. I was supposed to attend four months of Primary Aerospace Medicine training at Brooks AFB in San Antonio then return home to serve as a South Vietnamese Air Force flight surgeon but the brutal events during April of 1975 have altered my plan and pushed me into a new beginning.
During my student years at the University of Saigon Medical School, I developed a love for the study of Internal Medicine and its subspecialty in Cardiology but for my new life in the USA, I felt committed to serve the medically underserved people in the inner city or rural areas. I had applied to take the ECFMG exam in Vietnam in 1973 but did not take it which helped simplify my reapplication process because my credentials are already available at the ECFMG office.
I took the exam in Houston in late 1975 thinking that I may pass the English test because I was already fluent in every day conversation and had scored 92 out of 100 on the Armed Forces ESL test prior to my journey to America, but may not pass the Medical part because I did not have time to fully prepare for it. A strange twist of fate happened, a few months later the results indicated I passed the Medical test but flunked the English part; it was the first time in my life that I have failed an exam of any kind.
Subsequently I got an invitation to participate in an ECFMG Review Course offered at the University of Oklahoma Medical School for Vietnamese refugee physicians; for my part, I will just have to take the English class then take and pass the TOEFL to meet all the ECFMG requirements. In early 1976, I came to Oklahoma City to attend the program where I met old friends and classmates still traumatized by the collapse of our old country. Participants in the review class were all busy studying hard because many had graduated from Medical School several years to decades earlier or had not learned English prior to arriving in the US.
I had plenty of spare time with just going to an English class, which I found easy, in late afternoon so I used that time to help my older classmates with chores and provide tutoring service for some who may not have understood all the medical items explained to them in English earlier during the day. The biggest reward for me to have participated in that ECFMG review course was to have met my wife, who was one of the English teachers in the program, fell in love and married her a few months later. Told you, I was already “very” fluent in English.
We moved to Fridley, Minnesota where I found work as a house officer (intern) in a private hospital while looking for a residency training program in Family Practice so I can fulfill my wish to serve the medically underserved in the USA. It was hard for a foreign medical graduate to get into a residency program but in June 1977, we moved again to warmer climate in Little Rock, AR where I began my residency training in Family Practice.
Life was hectic for a first year Resident but I did well in ambulatory care at the Family Medical Center and on Pediatric ward; as expected, I excelled on Internal Medicine rotation and did well enough at the ER and on Surgical Service. I did not enjoy my OB-Gyn rotation and realized that I just didn’t have the aptitude for it. Toward the end of my second year, I did an elective two month rural practice rotation in Calico Rock, a very small town nestling across the White River and on the Ozark mountain in North Central Arkansas with population of roughly two thousands and a distance of three hour driving from Little Rock, over half of that is on curvy mountain roads.
My mentor was Dr. Meryl Grasse, a graduate of Hahnemann Medical College who came to Calico Rock in late 1940s and set up a General Practice to serve a community of isolated Mennonites who settled there in the old days. For many years, Dr. Grass was the only physician serving Calico Rock and mountainous vicinity; traveling was treacherous and the nearest hospital was thirty miles away without good road to get there. Dr. Grass started treating patients in his house but ended up opening a small twenty bed hospital with ER, 2 bed CCU, 2 bed ICU, X-Ray, Operating Room and of course a clinic.
By the time I got there, the hospital had three physicians doing Family Practice while taking turns to answer calls from the ER. Dr. Grass would do emergency surgical procedures and another doctor served as the anesthetist. Local people were extremely nice and friendly; many are deeply religious, no one ever locks their houses or their cars during that time. My wife stayed in Little Rock because of her job but we managed to see each other during weekends by taking turns to travel every other Friday or Saturday. We both fell in love with the people, their peaceful life style and the natural beauty Calico Rock. At the end of the rotation and during a farewell party, Dr. Grasse said I will be welcome back to join the hospital and clinic practice with him if I so choose after my residency training.
At the beginning of the third year, I was chosen by Dr. Ken Goss, Chairman of Family Practice Department at UAMS to be one of the three Chief Residents, of the other two, one was a graduate of UAMS, the other graduated from Harvard Medical School. During that year, I got to read Dr. Robert Butler’s 1976 Pulitzer prize winner “Why survive? Being old in America” which made me realize that old people are also the medically very underserved in the US. My feeling was reinforced with the case of an elderly man admitted to my service who was restless and wandered on the ward the night before; the psychiatric consultant gave the diagnosis of Organic Brain Syndrome aka Chronic Brain Syndrome and recommended 2mg of Haldol every six hours as needed. The Attending Physician also ordered soft restraint which was changed to four point leather restrain in bed by the On Call Resident the next night.
When I came in to see my patient in the morning, he had received a total of 10 mg of Haldol in past 36 hours, restrained flat in bed with his head moving up and down while saliva and mucus were drooling out of his mouth; his trunk was stiff with muscle twitching on his restrained arms and legs. Fortunately, UAMS and its affiliated VA hospital had opened a Geriatric Medicine Fellowship training program two years earlier (it was one of the only four programs in the US at that time, the other three were at UCLA, Duke and Portland, Oregon), and during lunch break that day,
I ran into a Geriatric Fellow (there are two of them) and talked to him about my elderly patient. He told me my elderly patient most likely suffered from a delirum on top of a dementia; we should avoid the term Chronic Brain Syndrome because it’s insulting to say someone has the syndrome of having a brain in his head for too long. He also advised me to reduce the dosage of Haldol to 0.5mg up to 1mg every six hours as needed and ask the Attending Physician to order a sitter to look out for patient safety instead of restraining him all the time while we treated his medical problem. The change of approach saved my patient and cemented my interest in learning more about Geriatric Medicine to hopefully improve the horrible conditions suffered by elderly patients in American nursing homes as described by Dr. Butler in his book.
My application for a two year Geriatric Fellowship training at UAMS was approved by Dr. Eugene Tobin who, together with Dr. Paul Haber at UCLA were considered to be fathers of modern Geriatric Medicine in the USA. I was assigned to be mentored by Dr. Owen Beard, a cardiologist turned geriatrician who had a special interest in congestive heart failure in old age.
The VA hospital hosted the fellowship program because it has a 15 bed Geriatric Evaluation Unit at the acute care hospital in Little Rock and a 45 bed Geriatric Rehabilitation Unit at the Psychiatric and Extended Care hospital across the Arkansas River in North Little Rock. I spent 90% of my fellowship time at the VA working at those Geriatric units and 10% at UAMS doing Geriatric consultation on the hospital wards. During my first year, Dr. Beard and another Cardiologist on the faculty, Dr. James Doherty, organized an International Conference on the topic of the Aging Heart with the participation of the most revered geriatrician in the world at that time: Professor Sir William Ferguson Anderson, the Scottish geriatrician who was Knighted by the Queen of England for having done so much to modernize medical care for the elderly in the UK.
The second year of fellowship gave me opportunity to pursuit my own fields of interest in Geriatrics for research. I was already collecting outcome data of patients treated at our Geriatric Rehabilitation Unit as a project in Health Service Research and Development (HSR&D) area, but clinically, that old patient with delirium and dementia during my time as Resident physician who was mistreated because of ignorance from the medical team still burned in my memory so I chose to learn more and search for better way to understand and treat patients with Senile Dementia with its most common disorder being Alzheimer’s disease. By the end of my Geriatric training, the approach using cholinergic drugs to treat symptoms of Alzheimer’s was showing promising results at various sites in the US.
While I had a hard time finding a Residency Training position in 1976, at the end of my Fellowship in 1982, I had several offers to be Geriatrician in Arizona and Florida. However, both Dr. Beard (my mentor in Geriatrics) and Dr. Goss (Chairman of Family Practice) asked me to join the faculty at UAMS and with my in-laws still living in Oklahoma City, my wife asked me to stay in Little Rock to be within driving distance to her aging parents . I chose to stay with Geriatrics in order to continue my academic works in HSR&D and Dementia/Alzheimer’s disease. It later turned out to be a very rewarding choice for my career.
In 1984, Dr. Joe Bates, Professor and Chief of Medicine Service at the Little Rock VA hospital, asked me to assume the Medical Directorship of the 200 bed VA Nursing Home Care Units (NHCU) at the North Little Rock Division after a Systematic External Review Program (SERP) survey uncovered some potentially serious deficiencies in patient care. A new Associate Director of Nursing was also appointed to collaborate with the new Medical Director to fix the defects and improve the quality of care. It was a dream comes through for me to have a chance to make a difference by addressing some of the horrific problems mentioned in Dr. Butler’s book that got me interested in Geriatrics. Together with my nursing administrator Mary Ann Parsley we implemented some radical changes in the approach to care of our veteran patients in Nursing Home Care Units.
The goals are set for rehabilitation and optimization of functional status of each patient instead of custodial care by warehousing the chronically ill and disabled elderly. Patients are evaluated periodically to see if care goals are achieved; adjustment in care plans will be made with new goals set as appropriate. Using good data previously published on the adverse consequences of restraint on nursing home patients while restraint free approach resulted in fewer serious injuries from falls, we declared our VA nursing home “restraint free”. I hired four Nurse Practitioners (later became Advance Practice Nurses) to provide primary medical care using clear guidelines and protocols for our 200 nursing home patients with special care programs for sub-acute/intermediary post hospitalization care, dementia/Alzheimer’s special care unit, pressure sore prevention and wound care program.
The interdisciplinary team approach with medical, nursing, physical/occupational/recreational therapists, dietetic, pharmacist, social worker and occasionally psychologist/psychiatrist (when necessary) collaborate on setting and carrying out care plans was universally applied with good results. We passed the next SERP survey and 3 years later got a perfect 100 grid score from the JCAH (now the Joint Commission) survey team. I was invited to help Dr. Phillip Weiler from UC Davis to develop frame works for Adult Day Care Program legislation as alternative for nursing home care for eligible veterans; when it became official, I also served as the Medical Director for our local program.
The Associate Chief of Staff in charge of the North Little Rock VA hospital at that time was Dr. Rodney “Pete” Paterson, an Associate Professor of Medicine and nephrologist, who admired my efforts to reform the NHCU. During a lunch break together, he asked me what influenced my decision to become a physician? I told him that I was inspired by reading Dr. Tom Dooley’s book “Deliver Us from Evils” about his epic mission as an American Naval Physician to assist, care for and relocate 1 million North Vietnamese refugees trying to flee the approaching Communist troops to reach the land of freedom in South Vietnam when I was in the 9th grade. Dr. Patterson’s eyes brightened up when he told me that he was a Navy medic serving under Dr. Dooley on one of those ships providing care to the refugees including cleaning the ship deck of their vomits daily from sea sickness and the strange taste of American naval ration. Dr. Dooley encouraged “Pete” to apply for Medical school when he gets out of the Navy and the rest is history. The world is a small place indeed.
Dr. Beard retired and Dr. David Lipschitz, a hematologist turned geriatrician, became Director of Geriatrics which is a Division of Department of Internal Medicine. Dr. Lipschitz had strong research interest in anemia and protein calorie malnutrition in elderly patients. He also helped setting up a Dementia/Alzheimer’s evaluation and treatment clinic at the medical school and began an elective rotation in Geriatrics for Senior Medical Students. Because of those expansions, I became more involved in teaching and clinical practice at UAMS.
During that time, Dr. Lipschitz and I were able to persuade Sue Griffin PhD, an accomplished researcher based at Arkansas Children Hospital who had done ground breaking discovery on brain beta-amyloid and inflammation in Down’s syndrome patients, to move over to Geriatrics and continue her works on Alzheimer’s, another brain beta-amyloid related disease commonly found in demented elderly. Griffin’s theory of brain inflammation in Alzheimer’s later was confirmed which put us on the national map. She is the pioneer of, and currently is still serving as editor of Neuro-Immunology journal, an online publication.
My works at the VA Nursing Home Care Unit and Dementia/Alzheimer’s Special Care Program encouraged UAMS College of Nursing Faculty to further study and implemented programs to improve care in community nursing homes with great success and Dr. Cornelia Beck (Nursing PhD) became one of the best funded nursing researchers in the country.
The Senior (M4) Geriatric elective rotation was popular with students as I won numerous Red Sash Teaching Awards voted by the graduating class of each year. Our clinical incomes and research grants continued to growth which allowed Dr. Lipschitz to recruit more full-time faculty. Dr. Cathey Power, a fellowship trained geriatrician became the Geriatric Education Coordinator at UAMS. The VA GRECC (Geriatric Research Education and Clinical Center) also grew with Dr. William J. Carter as Chief of Geriatrics, Dr. Dennis Sullivan as Associate Director for Research and Dr. Ronnie Chernoff as Associate Director for Education and Evaluation.
By 1988, ten years after Geriatric Fellowship training programs were established in the US, the first certification exam was jointly administered by the American Board of Internal Medicine and the Board of Family Practice to their respective eligible diplomats. The pass rate was 90% for fellowship trained candidates and around 40% for diplomats on “grand fathering” tract which indicate that expertise of Geriatric Medicine is best acquired through formal training program. Academic Geriatric Medicine, as you can see, was already active and robust at UAMS and the Little Rock VA hospital but it was about to be even bigger because in 1997 we applied for a big grant from the Donald W. Reynolds (DWR) Foundation to be a free standing Department of Geriatrics within UAMS College of Medicine.
Chairman of the Board of the DWR Foundation, Mr. Fred Smith (founder of FedEx), and its members hired Dr. Robert Butler, a former Director of the National Institute of Aging and Chairman of Geriatric Department at Mount Sinai, NY to review ours and other grant applications. We were ecstatic to be chosen for a grant of thirty four million dollars; twenty four millions for the construction of a ninety thousand square foot building with an auditorium, two classrooms, ample space for offices and research labs (for our need at that time), outpatient clinic space, physical and occupational treatment rooms and a therapeutic pool. Another ten million dollars were designated for programs start up expenses and building maintenance.
In 1998, the Donald W. Reynolds Department of Geriatrics and Institute on Aging (IOA) at UAMS were born then grew rapidly in all three missions of teaching, medical care and research. Beside the Geriatric Fellows, Medicine and Family Practice Residents, we also started a geriatric rotation for all Junior Medical Students as recommended by Dr. Robert Butler. Our well funded researchers and basic sciences faculty members also hosted doctoral and post doctoral students in their labs. I was appointed Vice Chairman for Clinical Affairs in 1999 to grow and manage all aspects of clinical geriatric care which I organized into three divisions: Acute Hospital Care with Geriatric unit and in-patient consultation service, Ambulatory Care and special out-patient programs including Wellness Program, Dementia Evaluation and Management clinic, Gero-psychiatric consultation service etc… and Long-term Care Division for home care and medical care in various nursing homes.
Around that time, I noticed that we also sorely needed a program to provide state of the arts care for the terminally ill. Fortunately, Dr. Reed Thompson, a faculty from Ear Nose and Throat service approach us with the desire to start a Hospice and Palliative Care program if funding is available. After many years of being a Head and Neck Cancer Surgeon, Reed became so dissatisfied with the system of caring for his disfigured patients (from surgery, radiation and chemotherapy) who suffered relapse then in pain without adequate pain control and died indignantly. Palliative and Hospice Care became a calling to Dr. Reed Thompson and a God send to our Department of Geriatrics. UAMS Geriatric clinical service got national notice and ranked in Best Hospital issue of US News and World Reports. Honors and accolades also came my way such as being listed in Best Doctors of America and America’s Top Doctors for Geriatrics and remained on those lists for many consecutive years. I was invited to serve as Member of the Review Board for evaluation and management of Alzheimer’s disease, State of California in 2001.
In 2003, I was promoted to Full Professor with tenure; the first fellowship trained geriatrician ever promoted to the rank of Professor at UAMS. In early 2004, I was encouraged by a recruiter to apply for a Chairman of Geriatric Department position in a Western state but my wife and my younger son who was still in high school asked me to stay put because they love being in Little Rock. Shortly after that, I was informed by the Chancellor office that I will be the inaugural recipient of the Jackson T. Stephens Endowed Chair in Geriatric Clinical Affairs at UAMS. I believe I was the first Vietnamese-American physician to ever become an Endowed Medical Professor in the USA.
Around the time of hurricane Katrina threatening the Gulf Coast in 2005, we had the opportunity to help Dr. Robert Wolfe moving his entire team of researchers and their world renowned labs on protein metabolism in aging to UAMS. This was a tremendous addition to our ongoing metabolic and nutrition research projects and, a few years later, to our Alzheimer’s research efforts as well. As mentioned earlier, Dr. Sue Griffin and her group are at the cutting edge of studying inflammatory lymphokines and other cytokines in the brain of patients with beta-amyloid deposits such as major head trauma, Down’s syndrome and Alzheimer’s; gradually with the insight into metabolic aspects of Alzheimer’s, we realized that inflammation and insulin resistance play a major role in all aspects of chronic diseases associated with frailty in aging, be it Alzheimer’s, Sarcopenia, Osteoporosis, Cardio-vascular disease or Type 2 Diabetes. Thanks to the discovery of Dr. Wolfe group, we know that certain essential amino-acids can facilitate or trigger protein synthesis and may have profound positive effects on prevention and treatment of frailty in old age. I consider that an important breakthrough in the fields of Biological Gerontology and Geriatrics.
The success of our educational programs, our research projects and our clinical services earned us national recognition in the US News ranking of Graduate Education issue. We ranked 9th in the Top Ten for Geriatric Medicine in the country and has ranked as high as 7th to no lower than 11th every year since. By all yardstick, the experience at the Donald W. Reynolds Department of Geriatrics at UAMS since its inception has been extremely positive.
We had a great 10 Year Anniversary Celebration in 2008 attended by members of the DWR Foundation Board and Dr. Butler himself. At the dinner celebration, I had the opportunity to let him know that his writing in “Why Survive? Being Old in America” inspired me to go into Geriatric Fellowship training and it has turned out to be a rewarding experience for me. Dr. Butler told me that our Geriatric Department has made a difference for the care of old people in Arkansas and around the country. Two years later, he passed away at the age of 83. I am forever grateful to have known and been influenced by the fathers of modern Geriatric Medicine in America: The late Drs. Robert Butler (NIA), Paul Haber (VA/UCLA) and Eugene Tobin (VA/UAMS).
Around that time, I returned to the VA at the invitation of Dr. Nicholas Lang, a Professor of Surgery, Chief of Staff and Acting Director of the Little Rock VA hospital, to be his Associate Chief of Staff for Geriatrics and Extended Care. Apparently, Geriatrics had grown so fast at UAMS which created negative impacts on the VA programs which served as our incubator in the recent past. It took me about one year to get the VA Geriatric service back on track but the severe Federal budget deficit hit us hard in 2009 and made life miserable for VA administrators at all level, including me. Furthermore, the decentralize reform initiated by the Under Secretary for Veterans Health, Dr. Ken Kizer, of the Clinton administration which helped improve quality and efficiency in the past, had been rolled back in recent years. The new Obama administration also instructed VA administrators to include employee union representatives in all policy, strategic and budget planning process before any decision is made; this really impaired the VA operation from my point of view.
Meanwhile, Dr. Jeanne Wei, a Professor and Director of Geriatric Medicine at Harvard Medical School, came to UAMS as Executive Vice Chair of the DWR Department of Geriatrics. Dr. Wei brought more prestige, accomplishments and research expertise in aging myocardium to our institution. We quickly ran out of room for more research labs and office space at the eleven year olds building and again, asked the DWR Foundation help for a building expansion plan.
Dr. Lipschitz stepped down as Chairman in 2010 and a national search was organized to find his replacement. A year later and after having interviewed some very qualified candidates, the Search Committee recommended Dr. Wei to be appointed as Chairman of the DWR Department of Geriatrics and Director of IOA at UAMS. The DWR Foundation rewarded us with another twenty million dollars gift to add another three floors to our building and constructing an enclosed air conditioned bridge connecting our structure to the rest of UAMS campus.
The compulsory Geriatric rotation had to be moved up to the fourth year because the new curriculum cited the need for students to learn Neurology in the third year. Dr. Reed Thompson expanded his Palliative Care and Hospice Program at both VA and UAMS hospitals and we were approved to accept fellows for Palliative Care Medicine, a brand new medical subspecialty along side with Geriatrics.
I began tying the loose ends of my various projects and resigned my position at the VA hospital in early 2012 then completely retired from academic medicine at UAMS a year later after having fulfilled all my commitments to my beloved institution.
Since my retirement, I have been invited to serve on the Board of Directors of Progressive Eldercare Inc., a nonprofit multistate corporation dedicated to Cultural Transformation of nursing home care using Eden Alternative with home like atmosphere, respect for privacy and home oriented activities including planting gardens etc…. I also have learned to write articles on practical medical/geriatric topics in Vietnamese for online publications to help my expatriate community.
Since the tragedy and trauma of losing my former country of South Vietnam forty years ago to the marauding North Vietnamese Communist troops, I have followed my destiny and calling here in America. I was so lucky to be out of the country on that Black April of 1975. It was destiny that took me to the ECFMG Review Course at OU to meet my wife. Dr. Tom Dooley’s book inspired me to be a physician when I was a schoolboy then Dr. Robert Butler prize winning book pointed me to Geriatric Medicine as a true calling of my professional life when I was a Resident. It was destiny for me to be at UAMS in Little Rock, one of the first four Geriatric Fellowship training sites in the USA. Much still need to be done for older Americans but compare to how it was as described in “Why survive? Being old in America”, we have made lots of progress. There are now FDA approved medications to treat symptoms of Alzheimer’s, incontinence, osteoporosis etc…. We also know how to effectively prevent cardiovascular disease, type 2 diabetes, sarcopenia and other conditions of frailty in old age. There is now a website showing quality of care index of all nursing homes in the USA to help patients and families making better choice. I’m glad that I have contributed a small part to that progress from my research, teaching and patient care activities at UAMS over the years.
I have many people to thank for all they had done for me in the past to get me here: My parents, my wife, the Faculty of the University of Saigon Medical School, my mentors and co-workers at UAMS and the Little Rock VA Hospital. Most of all, I’m deeply grateful for all ARVN and American soldiers who made the sacrifice to protect my freedom while I was pursuing my medical education; without their noble deeds, I would not have time to complete my medical degree during the Vietnam war.
Many South Vietnamese physicians came to the US as refugees forty years ago. Most, like me, were able to resume their medical practice after meeting strict licensing requirements and many have been providing good services to their patients. A few have made great impacts to their American communities; I went to the funeral of one over a week ago: His name was Dr. Duong Ngoc Ly, he graduated from the same Medical School seven years ahead of me in Saigon but thirteen years older in age. He served with distinction in the ARVN Medical Corps then came to Fort Chaffee, Arkansas as a refugee in 1975. We met at UAMS when I was a Resident and he was doing a Rotating Internship in 1978.
After that, Dr. Duong resettled in Marianna, Lee County, the most impoverished area in the Mississippi delta of Arkansas where he provided good primary medical care to the previously grossly underserved population. Dr. Duong and his family set roots in Marianna; he loves the community and its people and the feeling is mutual. Most of all, as he once told the local newspaper, Dr. Duong Ngoc Ly is proud to be an American. One of his son was my former student at UAMS who is now practicing in Jonesboro, Arkansas. Dr. Duong passed away 2 weeks ago at the age of 81. Many local people came to his funeral and one of them shared his though with me: “In my opinion, Dr. Ly (Ngoc Duong) was a patriot as a South Vietnamese Medical Officer and as an American physician”.
Hear hear!!! I hope my forty years of experience in the USA also holds up to that standard.
Pham Hieu Liem, MD
Former Jackson T. Stephens Professor and Vice Chairman of the Donald W. Reynolds Department of Geriatrics, UAMS
From Chapter 6 of the recently published book “Four Decades of Medical Training, Research and Practice (1975-2015)” Nghia M.Vo, MD editor.
During my student years at the University of Saigon Medical School, I developed a love for the study of Internal Medicine and its subspecialty in Cardiology but for my new life in the USA, I felt committed to serve the medically underserved people in the inner city or rural areas. I had applied to take the ECFMG exam in Vietnam in 1973 but did not take it which helped simplify my reapplication process because my credentials are already available at the ECFMG office.
I took the exam in Houston in late 1975 thinking that I may pass the English test because I was already fluent in every day conversation and had scored 92 out of 100 on the Armed Forces ESL test prior to my journey to America, but may not pass the Medical part because I did not have time to fully prepare for it. A strange twist of fate happened, a few months later the results indicated I passed the Medical test but flunked the English part; it was the first time in my life that I have failed an exam of any kind.
Subsequently I got an invitation to participate in an ECFMG Review Course offered at the University of Oklahoma Medical School for Vietnamese refugee physicians; for my part, I will just have to take the English class then take and pass the TOEFL to meet all the ECFMG requirements. In early 1976, I came to Oklahoma City to attend the program where I met old friends and classmates still traumatized by the collapse of our old country. Participants in the review class were all busy studying hard because many had graduated from Medical School several years to decades earlier or had not learned English prior to arriving in the US.
I had plenty of spare time with just going to an English class, which I found easy, in late afternoon so I used that time to help my older classmates with chores and provide tutoring service for some who may not have understood all the medical items explained to them in English earlier during the day. The biggest reward for me to have participated in that ECFMG review course was to have met my wife, who was one of the English teachers in the program, fell in love and married her a few months later. Told you, I was already “very” fluent in English.
We moved to Fridley, Minnesota where I found work as a house officer (intern) in a private hospital while looking for a residency training program in Family Practice so I can fulfill my wish to serve the medically underserved in the USA. It was hard for a foreign medical graduate to get into a residency program but in June 1977, we moved again to warmer climate in Little Rock, AR where I began my residency training in Family Practice.
Life was hectic for a first year Resident but I did well in ambulatory care at the Family Medical Center and on Pediatric ward; as expected, I excelled on Internal Medicine rotation and did well enough at the ER and on Surgical Service. I did not enjoy my OB-Gyn rotation and realized that I just didn’t have the aptitude for it. Toward the end of my second year, I did an elective two month rural practice rotation in Calico Rock, a very small town nestling across the White River and on the Ozark mountain in North Central Arkansas with population of roughly two thousands and a distance of three hour driving from Little Rock, over half of that is on curvy mountain roads.
My mentor was Dr. Meryl Grasse, a graduate of Hahnemann Medical College who came to Calico Rock in late 1940s and set up a General Practice to serve a community of isolated Mennonites who settled there in the old days. For many years, Dr. Grass was the only physician serving Calico Rock and mountainous vicinity; traveling was treacherous and the nearest hospital was thirty miles away without good road to get there. Dr. Grass started treating patients in his house but ended up opening a small twenty bed hospital with ER, 2 bed CCU, 2 bed ICU, X-Ray, Operating Room and of course a clinic.
By the time I got there, the hospital had three physicians doing Family Practice while taking turns to answer calls from the ER. Dr. Grass would do emergency surgical procedures and another doctor served as the anesthetist. Local people were extremely nice and friendly; many are deeply religious, no one ever locks their houses or their cars during that time. My wife stayed in Little Rock because of her job but we managed to see each other during weekends by taking turns to travel every other Friday or Saturday. We both fell in love with the people, their peaceful life style and the natural beauty Calico Rock. At the end of the rotation and during a farewell party, Dr. Grasse said I will be welcome back to join the hospital and clinic practice with him if I so choose after my residency training.
At the beginning of the third year, I was chosen by Dr. Ken Goss, Chairman of Family Practice Department at UAMS to be one of the three Chief Residents, of the other two, one was a graduate of UAMS, the other graduated from Harvard Medical School. During that year, I got to read Dr. Robert Butler’s 1976 Pulitzer prize winner “Why survive? Being old in America” which made me realize that old people are also the medically very underserved in the US. My feeling was reinforced with the case of an elderly man admitted to my service who was restless and wandered on the ward the night before; the psychiatric consultant gave the diagnosis of Organic Brain Syndrome aka Chronic Brain Syndrome and recommended 2mg of Haldol every six hours as needed. The Attending Physician also ordered soft restraint which was changed to four point leather restrain in bed by the On Call Resident the next night.
When I came in to see my patient in the morning, he had received a total of 10 mg of Haldol in past 36 hours, restrained flat in bed with his head moving up and down while saliva and mucus were drooling out of his mouth; his trunk was stiff with muscle twitching on his restrained arms and legs. Fortunately, UAMS and its affiliated VA hospital had opened a Geriatric Medicine Fellowship training program two years earlier (it was one of the only four programs in the US at that time, the other three were at UCLA, Duke and Portland, Oregon), and during lunch break that day,
I ran into a Geriatric Fellow (there are two of them) and talked to him about my elderly patient. He told me my elderly patient most likely suffered from a delirum on top of a dementia; we should avoid the term Chronic Brain Syndrome because it’s insulting to say someone has the syndrome of having a brain in his head for too long. He also advised me to reduce the dosage of Haldol to 0.5mg up to 1mg every six hours as needed and ask the Attending Physician to order a sitter to look out for patient safety instead of restraining him all the time while we treated his medical problem. The change of approach saved my patient and cemented my interest in learning more about Geriatric Medicine to hopefully improve the horrible conditions suffered by elderly patients in American nursing homes as described by Dr. Butler in his book.
My application for a two year Geriatric Fellowship training at UAMS was approved by Dr. Eugene Tobin who, together with Dr. Paul Haber at UCLA were considered to be fathers of modern Geriatric Medicine in the USA. I was assigned to be mentored by Dr. Owen Beard, a cardiologist turned geriatrician who had a special interest in congestive heart failure in old age.
The VA hospital hosted the fellowship program because it has a 15 bed Geriatric Evaluation Unit at the acute care hospital in Little Rock and a 45 bed Geriatric Rehabilitation Unit at the Psychiatric and Extended Care hospital across the Arkansas River in North Little Rock. I spent 90% of my fellowship time at the VA working at those Geriatric units and 10% at UAMS doing Geriatric consultation on the hospital wards. During my first year, Dr. Beard and another Cardiologist on the faculty, Dr. James Doherty, organized an International Conference on the topic of the Aging Heart with the participation of the most revered geriatrician in the world at that time: Professor Sir William Ferguson Anderson, the Scottish geriatrician who was Knighted by the Queen of England for having done so much to modernize medical care for the elderly in the UK.
The second year of fellowship gave me opportunity to pursuit my own fields of interest in Geriatrics for research. I was already collecting outcome data of patients treated at our Geriatric Rehabilitation Unit as a project in Health Service Research and Development (HSR&D) area, but clinically, that old patient with delirium and dementia during my time as Resident physician who was mistreated because of ignorance from the medical team still burned in my memory so I chose to learn more and search for better way to understand and treat patients with Senile Dementia with its most common disorder being Alzheimer’s disease. By the end of my Geriatric training, the approach using cholinergic drugs to treat symptoms of Alzheimer’s was showing promising results at various sites in the US.
While I had a hard time finding a Residency Training position in 1976, at the end of my Fellowship in 1982, I had several offers to be Geriatrician in Arizona and Florida. However, both Dr. Beard (my mentor in Geriatrics) and Dr. Goss (Chairman of Family Practice) asked me to join the faculty at UAMS and with my in-laws still living in Oklahoma City, my wife asked me to stay in Little Rock to be within driving distance to her aging parents . I chose to stay with Geriatrics in order to continue my academic works in HSR&D and Dementia/Alzheimer’s disease. It later turned out to be a very rewarding choice for my career.
In 1984, Dr. Joe Bates, Professor and Chief of Medicine Service at the Little Rock VA hospital, asked me to assume the Medical Directorship of the 200 bed VA Nursing Home Care Units (NHCU) at the North Little Rock Division after a Systematic External Review Program (SERP) survey uncovered some potentially serious deficiencies in patient care. A new Associate Director of Nursing was also appointed to collaborate with the new Medical Director to fix the defects and improve the quality of care. It was a dream comes through for me to have a chance to make a difference by addressing some of the horrific problems mentioned in Dr. Butler’s book that got me interested in Geriatrics. Together with my nursing administrator Mary Ann Parsley we implemented some radical changes in the approach to care of our veteran patients in Nursing Home Care Units.
The goals are set for rehabilitation and optimization of functional status of each patient instead of custodial care by warehousing the chronically ill and disabled elderly. Patients are evaluated periodically to see if care goals are achieved; adjustment in care plans will be made with new goals set as appropriate. Using good data previously published on the adverse consequences of restraint on nursing home patients while restraint free approach resulted in fewer serious injuries from falls, we declared our VA nursing home “restraint free”. I hired four Nurse Practitioners (later became Advance Practice Nurses) to provide primary medical care using clear guidelines and protocols for our 200 nursing home patients with special care programs for sub-acute/intermediary post hospitalization care, dementia/Alzheimer’s special care unit, pressure sore prevention and wound care program.
The interdisciplinary team approach with medical, nursing, physical/occupational/recreational therapists, dietetic, pharmacist, social worker and occasionally psychologist/psychiatrist (when necessary) collaborate on setting and carrying out care plans was universally applied with good results. We passed the next SERP survey and 3 years later got a perfect 100 grid score from the JCAH (now the Joint Commission) survey team. I was invited to help Dr. Phillip Weiler from UC Davis to develop frame works for Adult Day Care Program legislation as alternative for nursing home care for eligible veterans; when it became official, I also served as the Medical Director for our local program.
The Associate Chief of Staff in charge of the North Little Rock VA hospital at that time was Dr. Rodney “Pete” Paterson, an Associate Professor of Medicine and nephrologist, who admired my efforts to reform the NHCU. During a lunch break together, he asked me what influenced my decision to become a physician? I told him that I was inspired by reading Dr. Tom Dooley’s book “Deliver Us from Evils” about his epic mission as an American Naval Physician to assist, care for and relocate 1 million North Vietnamese refugees trying to flee the approaching Communist troops to reach the land of freedom in South Vietnam when I was in the 9th grade. Dr. Patterson’s eyes brightened up when he told me that he was a Navy medic serving under Dr. Dooley on one of those ships providing care to the refugees including cleaning the ship deck of their vomits daily from sea sickness and the strange taste of American naval ration. Dr. Dooley encouraged “Pete” to apply for Medical school when he gets out of the Navy and the rest is history. The world is a small place indeed.
Dr. Beard retired and Dr. David Lipschitz, a hematologist turned geriatrician, became Director of Geriatrics which is a Division of Department of Internal Medicine. Dr. Lipschitz had strong research interest in anemia and protein calorie malnutrition in elderly patients. He also helped setting up a Dementia/Alzheimer’s evaluation and treatment clinic at the medical school and began an elective rotation in Geriatrics for Senior Medical Students. Because of those expansions, I became more involved in teaching and clinical practice at UAMS.
During that time, Dr. Lipschitz and I were able to persuade Sue Griffin PhD, an accomplished researcher based at Arkansas Children Hospital who had done ground breaking discovery on brain beta-amyloid and inflammation in Down’s syndrome patients, to move over to Geriatrics and continue her works on Alzheimer’s, another brain beta-amyloid related disease commonly found in demented elderly. Griffin’s theory of brain inflammation in Alzheimer’s later was confirmed which put us on the national map. She is the pioneer of, and currently is still serving as editor of Neuro-Immunology journal, an online publication.
My works at the VA Nursing Home Care Unit and Dementia/Alzheimer’s Special Care Program encouraged UAMS College of Nursing Faculty to further study and implemented programs to improve care in community nursing homes with great success and Dr. Cornelia Beck (Nursing PhD) became one of the best funded nursing researchers in the country.
The Senior (M4) Geriatric elective rotation was popular with students as I won numerous Red Sash Teaching Awards voted by the graduating class of each year. Our clinical incomes and research grants continued to growth which allowed Dr. Lipschitz to recruit more full-time faculty. Dr. Cathey Power, a fellowship trained geriatrician became the Geriatric Education Coordinator at UAMS. The VA GRECC (Geriatric Research Education and Clinical Center) also grew with Dr. William J. Carter as Chief of Geriatrics, Dr. Dennis Sullivan as Associate Director for Research and Dr. Ronnie Chernoff as Associate Director for Education and Evaluation.
By 1988, ten years after Geriatric Fellowship training programs were established in the US, the first certification exam was jointly administered by the American Board of Internal Medicine and the Board of Family Practice to their respective eligible diplomats. The pass rate was 90% for fellowship trained candidates and around 40% for diplomats on “grand fathering” tract which indicate that expertise of Geriatric Medicine is best acquired through formal training program. Academic Geriatric Medicine, as you can see, was already active and robust at UAMS and the Little Rock VA hospital but it was about to be even bigger because in 1997 we applied for a big grant from the Donald W. Reynolds (DWR) Foundation to be a free standing Department of Geriatrics within UAMS College of Medicine.
Chairman of the Board of the DWR Foundation, Mr. Fred Smith (founder of FedEx), and its members hired Dr. Robert Butler, a former Director of the National Institute of Aging and Chairman of Geriatric Department at Mount Sinai, NY to review ours and other grant applications. We were ecstatic to be chosen for a grant of thirty four million dollars; twenty four millions for the construction of a ninety thousand square foot building with an auditorium, two classrooms, ample space for offices and research labs (for our need at that time), outpatient clinic space, physical and occupational treatment rooms and a therapeutic pool. Another ten million dollars were designated for programs start up expenses and building maintenance.
In 1998, the Donald W. Reynolds Department of Geriatrics and Institute on Aging (IOA) at UAMS were born then grew rapidly in all three missions of teaching, medical care and research. Beside the Geriatric Fellows, Medicine and Family Practice Residents, we also started a geriatric rotation for all Junior Medical Students as recommended by Dr. Robert Butler. Our well funded researchers and basic sciences faculty members also hosted doctoral and post doctoral students in their labs. I was appointed Vice Chairman for Clinical Affairs in 1999 to grow and manage all aspects of clinical geriatric care which I organized into three divisions: Acute Hospital Care with Geriatric unit and in-patient consultation service, Ambulatory Care and special out-patient programs including Wellness Program, Dementia Evaluation and Management clinic, Gero-psychiatric consultation service etc… and Long-term Care Division for home care and medical care in various nursing homes.
Around that time, I noticed that we also sorely needed a program to provide state of the arts care for the terminally ill. Fortunately, Dr. Reed Thompson, a faculty from Ear Nose and Throat service approach us with the desire to start a Hospice and Palliative Care program if funding is available. After many years of being a Head and Neck Cancer Surgeon, Reed became so dissatisfied with the system of caring for his disfigured patients (from surgery, radiation and chemotherapy) who suffered relapse then in pain without adequate pain control and died indignantly. Palliative and Hospice Care became a calling to Dr. Reed Thompson and a God send to our Department of Geriatrics. UAMS Geriatric clinical service got national notice and ranked in Best Hospital issue of US News and World Reports. Honors and accolades also came my way such as being listed in Best Doctors of America and America’s Top Doctors for Geriatrics and remained on those lists for many consecutive years. I was invited to serve as Member of the Review Board for evaluation and management of Alzheimer’s disease, State of California in 2001.
In 2003, I was promoted to Full Professor with tenure; the first fellowship trained geriatrician ever promoted to the rank of Professor at UAMS. In early 2004, I was encouraged by a recruiter to apply for a Chairman of Geriatric Department position in a Western state but my wife and my younger son who was still in high school asked me to stay put because they love being in Little Rock. Shortly after that, I was informed by the Chancellor office that I will be the inaugural recipient of the Jackson T. Stephens Endowed Chair in Geriatric Clinical Affairs at UAMS. I believe I was the first Vietnamese-American physician to ever become an Endowed Medical Professor in the USA.
Around the time of hurricane Katrina threatening the Gulf Coast in 2005, we had the opportunity to help Dr. Robert Wolfe moving his entire team of researchers and their world renowned labs on protein metabolism in aging to UAMS. This was a tremendous addition to our ongoing metabolic and nutrition research projects and, a few years later, to our Alzheimer’s research efforts as well. As mentioned earlier, Dr. Sue Griffin and her group are at the cutting edge of studying inflammatory lymphokines and other cytokines in the brain of patients with beta-amyloid deposits such as major head trauma, Down’s syndrome and Alzheimer’s; gradually with the insight into metabolic aspects of Alzheimer’s, we realized that inflammation and insulin resistance play a major role in all aspects of chronic diseases associated with frailty in aging, be it Alzheimer’s, Sarcopenia, Osteoporosis, Cardio-vascular disease or Type 2 Diabetes. Thanks to the discovery of Dr. Wolfe group, we know that certain essential amino-acids can facilitate or trigger protein synthesis and may have profound positive effects on prevention and treatment of frailty in old age. I consider that an important breakthrough in the fields of Biological Gerontology and Geriatrics.
The success of our educational programs, our research projects and our clinical services earned us national recognition in the US News ranking of Graduate Education issue. We ranked 9th in the Top Ten for Geriatric Medicine in the country and has ranked as high as 7th to no lower than 11th every year since. By all yardstick, the experience at the Donald W. Reynolds Department of Geriatrics at UAMS since its inception has been extremely positive.
We had a great 10 Year Anniversary Celebration in 2008 attended by members of the DWR Foundation Board and Dr. Butler himself. At the dinner celebration, I had the opportunity to let him know that his writing in “Why Survive? Being Old in America” inspired me to go into Geriatric Fellowship training and it has turned out to be a rewarding experience for me. Dr. Butler told me that our Geriatric Department has made a difference for the care of old people in Arkansas and around the country. Two years later, he passed away at the age of 83. I am forever grateful to have known and been influenced by the fathers of modern Geriatric Medicine in America: The late Drs. Robert Butler (NIA), Paul Haber (VA/UCLA) and Eugene Tobin (VA/UAMS).
Around that time, I returned to the VA at the invitation of Dr. Nicholas Lang, a Professor of Surgery, Chief of Staff and Acting Director of the Little Rock VA hospital, to be his Associate Chief of Staff for Geriatrics and Extended Care. Apparently, Geriatrics had grown so fast at UAMS which created negative impacts on the VA programs which served as our incubator in the recent past. It took me about one year to get the VA Geriatric service back on track but the severe Federal budget deficit hit us hard in 2009 and made life miserable for VA administrators at all level, including me. Furthermore, the decentralize reform initiated by the Under Secretary for Veterans Health, Dr. Ken Kizer, of the Clinton administration which helped improve quality and efficiency in the past, had been rolled back in recent years. The new Obama administration also instructed VA administrators to include employee union representatives in all policy, strategic and budget planning process before any decision is made; this really impaired the VA operation from my point of view.
Meanwhile, Dr. Jeanne Wei, a Professor and Director of Geriatric Medicine at Harvard Medical School, came to UAMS as Executive Vice Chair of the DWR Department of Geriatrics. Dr. Wei brought more prestige, accomplishments and research expertise in aging myocardium to our institution. We quickly ran out of room for more research labs and office space at the eleven year olds building and again, asked the DWR Foundation help for a building expansion plan.
Dr. Lipschitz stepped down as Chairman in 2010 and a national search was organized to find his replacement. A year later and after having interviewed some very qualified candidates, the Search Committee recommended Dr. Wei to be appointed as Chairman of the DWR Department of Geriatrics and Director of IOA at UAMS. The DWR Foundation rewarded us with another twenty million dollars gift to add another three floors to our building and constructing an enclosed air conditioned bridge connecting our structure to the rest of UAMS campus.
The compulsory Geriatric rotation had to be moved up to the fourth year because the new curriculum cited the need for students to learn Neurology in the third year. Dr. Reed Thompson expanded his Palliative Care and Hospice Program at both VA and UAMS hospitals and we were approved to accept fellows for Palliative Care Medicine, a brand new medical subspecialty along side with Geriatrics.
I began tying the loose ends of my various projects and resigned my position at the VA hospital in early 2012 then completely retired from academic medicine at UAMS a year later after having fulfilled all my commitments to my beloved institution.
Since my retirement, I have been invited to serve on the Board of Directors of Progressive Eldercare Inc., a nonprofit multistate corporation dedicated to Cultural Transformation of nursing home care using Eden Alternative with home like atmosphere, respect for privacy and home oriented activities including planting gardens etc…. I also have learned to write articles on practical medical/geriatric topics in Vietnamese for online publications to help my expatriate community.
Since the tragedy and trauma of losing my former country of South Vietnam forty years ago to the marauding North Vietnamese Communist troops, I have followed my destiny and calling here in America. I was so lucky to be out of the country on that Black April of 1975. It was destiny that took me to the ECFMG Review Course at OU to meet my wife. Dr. Tom Dooley’s book inspired me to be a physician when I was a schoolboy then Dr. Robert Butler prize winning book pointed me to Geriatric Medicine as a true calling of my professional life when I was a Resident. It was destiny for me to be at UAMS in Little Rock, one of the first four Geriatric Fellowship training sites in the USA. Much still need to be done for older Americans but compare to how it was as described in “Why survive? Being old in America”, we have made lots of progress. There are now FDA approved medications to treat symptoms of Alzheimer’s, incontinence, osteoporosis etc…. We also know how to effectively prevent cardiovascular disease, type 2 diabetes, sarcopenia and other conditions of frailty in old age. There is now a website showing quality of care index of all nursing homes in the USA to help patients and families making better choice. I’m glad that I have contributed a small part to that progress from my research, teaching and patient care activities at UAMS over the years.
I have many people to thank for all they had done for me in the past to get me here: My parents, my wife, the Faculty of the University of Saigon Medical School, my mentors and co-workers at UAMS and the Little Rock VA Hospital. Most of all, I’m deeply grateful for all ARVN and American soldiers who made the sacrifice to protect my freedom while I was pursuing my medical education; without their noble deeds, I would not have time to complete my medical degree during the Vietnam war.
Many South Vietnamese physicians came to the US as refugees forty years ago. Most, like me, were able to resume their medical practice after meeting strict licensing requirements and many have been providing good services to their patients. A few have made great impacts to their American communities; I went to the funeral of one over a week ago: His name was Dr. Duong Ngoc Ly, he graduated from the same Medical School seven years ahead of me in Saigon but thirteen years older in age. He served with distinction in the ARVN Medical Corps then came to Fort Chaffee, Arkansas as a refugee in 1975. We met at UAMS when I was a Resident and he was doing a Rotating Internship in 1978.
After that, Dr. Duong resettled in Marianna, Lee County, the most impoverished area in the Mississippi delta of Arkansas where he provided good primary medical care to the previously grossly underserved population. Dr. Duong and his family set roots in Marianna; he loves the community and its people and the feeling is mutual. Most of all, as he once told the local newspaper, Dr. Duong Ngoc Ly is proud to be an American. One of his son was my former student at UAMS who is now practicing in Jonesboro, Arkansas. Dr. Duong passed away 2 weeks ago at the age of 81. Many local people came to his funeral and one of them shared his though with me: “In my opinion, Dr. Ly (Ngoc Duong) was a patriot as a South Vietnamese Medical Officer and as an American physician”.
Hear hear!!! I hope my forty years of experience in the USA also holds up to that standard.
Pham Hieu Liem, MD
Former Jackson T. Stephens Professor and Vice Chairman of the Donald W. Reynolds Department of Geriatrics, UAMS
From Chapter 6 of the recently published book “Four Decades of Medical Training, Research and Practice (1975-2015)” Nghia M.Vo, MD editor.
Loading