5. The interim period: Toronto and NewYork

At the end of June 1968 I parted from my friends in Mississippi and on July 1st started my new work in the Toronto General Hospital, the University of Toronto main teaching center. The activity of the new Division of Thoracic Surgery involved surgery of the lungs, trachea, esophagus, thymus, diaphragm  –all the chest contents, excluding heart and major blood vessels. These confines of work were very much to my liking. The service was temporarily situated in the hospital’s oldest building. It was erected in 1913 and situated at the corner of College Street and University Avenue. Four certified surgeons formed the team. Chief of the division was Dr. F.G. Pearson ¹⁰.  Another member of the team was Dr. Norman C. Delarue, an older generation thoracic surgeon, with extensive experience in pulmonary surgery. The third surgeon was Robert (Rob) Henderson, who concentrated his activity mostly around the esophagus – study of esophageal physiology and disease, and surgery of the esophagus. I was accepted as a senior fellow (the highest rank of training), although at that time I had been already certified in thoracic surgery. In addition, there were residents and interns on rotation.
My work included participation in operations, teaching students in seminars and clinical discussions, clinical research, and consultations in other Toronto hospitals, mainly the Princess Margaret Hospital. This was a hospital for oncology from which I brought many patients to be operated on our service. I shared a secretary with another physician, and had an office of my own, with a telephone. The office was only 2x2 meters (7x7 feet), but the privacy was of inestimable value – I never had such a luxury in New York or in Mississippi.

Dr. Pearson was among the world’s first surgeons to operate on the trachea ¹¹ (resections, plastic repairs) and by the time I worked on his service, had already been widely recognized as one of the leaders in this new and exciting field. My involvement in the clinical workup of his patients and participation as an assistant in his operations, provided me with much valued experience and enabled me to learn a lot about the problems associated with surgery of the trachea. In parallel, I studied records of all the patients with tumors of the trachea treated in the hospital in the past and prepared an article on this subject for publication  (Fig. 31). Similarly, I prepared and wrote up neoplasms of the thymus ¹² and another group of interesting tumors – the bronchial carcinoid. This material was presented at several congresses of the most prestigious surgical societies and was published in leading medical journals. Through Pearson I became acquainted with other pioneers of tracheal surgery, among them Hermes Grillo from Boston and Mikhail Perelman from Moscow. Griff Pearson was an excellent teacher and a charming person. He treated members of his team as equals, and never gave anyone the feeling of being his subordinate (Fig. 32).


 Every one of us, the senior staff members, as well as interns and nurses, visited his home in Toronto and his farm in the country, a 2-hour drive from the city. He had a house there with a creek behind it, widening to a fish pond, all surrounded by woods – part of his farmstead, with cows and other animals. Canada is a big country… (Figs. 33 and 34). I spent many weekends on that farm, befriended the Pearson family – Griff’s wife and their three little children, swam in the pond, skied and even tried to hunt – unsuccessfully. I spent Christmas Eve of 1968 there, and in 1969 watched on the television the first man landing on the moon. Griff Pearson and I remain lifelong friends.

 


Pearson knew that I wanted to return to Israel and that I was looking for a job. However, for the time being, my connections with the institutions in Israel were limited to the exchange of meaningless letters. There was no progress. In order to revive the subject, I had to go to Israel, meet people personally and remind them that I existed and was looking for an opportunity to return to Israel. It was embarrassing to ask for a vacation only three months after I started working, but there was no choice. Pearson did not object that I take my annual holiday in the beginning of the year rather than at the end. So, in October, three months after starting my new job, I went to Israel.

I had meetings with senior officials in the Ministry of Health, city hospitals, central offices of Kupat Holim (health services of the Labor Federation) and the deans of both medical schools – Tel Aviv University and Hadassah. The possibility to find a position in Kupat Holim seemed reasonable for a while. A meeting was arranged for me with Dr. Eger, chief of the Department of Surgery in the Kupat Holim Hospital in Be’er-Sheva (today the Soroka Medical Center). Dr. Eger described to me the situation on his service and stressed that he needed a good deputy. Also, he told me that the hospital was in desperate need of a thoracic surgeon, and that there were plans to open a thoracic surgery service. If I start working there as his deputy, I would be able, besides my work as a senior surgeon, to take care of all the thoracic patients. When the time comes to open the thoracic surgery service, it would be only natural that I would be its chief.

I was very much impressed with Dr. Eger. “This is an example of a department chief, not to be afraid of” I thought. “With a man like him, it would be possible for me to cooperate and, in parallel, built foundations for a unit of my own.” The day’s activity was over and I was in good mood. I went to visit an old friend who served as a senior physician in one of the hospital departments. I told him about my conversation with Dr. Eger and about my plans and dreams for the future. My friend was skeptical. He agreed that Dr. Eger was a nice person and an excellent surgeon, but was surprised at my naiveté. “Of course, you could work and get along well with Dr. Eger, but your hopes for a thoracic surgical service of your own will remain a dream”. He told me that during the Six-Day-War, a thoracic surgeon, Dr. Joseph Borman from Hadassah, was brought to the hospital in Be’er-Sheva to fill the void. He was my age, a senior surgeon on the thoracic surgery service headed by Professor Milwidsky. He worked well and had a good reputation. He was the candidate of Kupat Holim to become chief of the thoracic surgery service, once it will be established. My friend was greatly surprised that I did not know about this, as apparently everybody else did. Meanwhile Dr. Borman worked under the greenhouse conditions of Hadassah, and was not in a particular hurry to come to Be’er-Sheva and start organizing the new service from scratch. He preferred to wait for the department to open, and then come as its chief. He had been assured of this position by the hospital administration and by the Kupat Holim executives.

I had witnessed a similar scenario before. An exact reconstruction of the Jack Abouav affair in Rambam was now unfolding in Be’er-Sheva. By accepting the Kupat Holim’s offer, I would actually be building the foundations of thoracic surgery service for Joe Borman. Should I prefer to stay in thoracic surgery, I could possibly work on Dr. Borman’s service, perhaps as his deputy. In the Kupat Holim offices no one told me this, nor did Dr. Eger mentioned it to me, although it stands to reason that he must have known about it.

I returned to Kupat Holim with a counter-offer: I would start working in Dr. Eger’s department as his deputy, if the tender for the position of chief of thoracic surgery takes place now, and I win it. Once the thoracic surgery service opens, no matter when, there will be no need for another tender. “This is not logical” was the officials’ response. “The tender will be announced when the service is ready to open; at the moment it is not of immediate interest.” They added that if I start working now and organize the service from the foundations, there would be almost no doubt that I would succeed in the tender. However, they were not ready to commit themselves. During those conversations no one mentioned Joe Borman. The people who conversed with me did not suspect that I knew anything about him, and I preferred not to disclose all the information I had, bringing about an open confrontation. In the final outcome I did not accept the job offer in Be’er-Sheva, but the correspondence with the Kupat Holim and other institutions in Israel was rejuvenated and strengthened.

Although at this stage I did not obtain a desired job in Israel as I had hoped, my visit in Israel had one other important result. Until that visit, I have never seen the Western Wall in Jerusalem. Now, that Jerusalem was liberated and united, I went to see it. In the Old City I met an old medical school friend, Dr. Judith Grünwald-Rapaport, and right there she introduced me to her sister Milka. I will not elaborate on the details of courting that lasted two weeks, but at the end I proposed to Milka and brought her to Canada, where we married. Now we have four children and two grandsons. One could say that my trip was not wasted…

Dr. Joseph Borman did not come to Be’er-Seva to run the thoracic surgery service. On February 21st 1970, a Swissair aircraft exploded in the air, fifteen minutes after its takeoff from Zurich, on the way to Tel Aviv. “The Popular Front for the Liberation of Palestine” took proud responsibility for the explosion. Among the 47 victims of this heinous act of  “liberation” was Professor Hanoch Milwidsky, Chief of the Department of Thoracic Surgery in Hadassah. Joseph Borman was appointed as the new chief and was no longer interested to move to Be’er-Sheva.

In order to work in the Province of Ontario (Toronto is the capital of Ontario) I needed an Ontario medical license. I passed the necessary examinations in 1969 (Fig. 35). I also sought recognition of my title of Specialist (Board Diplomate) that I had obtained in the United States. However, during the late 1960s, the institution in charge of qualifying specialists in Canada (The Royal College of Physicians and Surgeons of Canada) was not yet ready to approve titles that were obtained “south of the border”. My Specialist Certificate, valid in the United States, was meaningless in Canada. I had to study for examinations once again. At that time, the Royal College examinations were conducted on two levels. The lower level was to obtain the title of a specialist (Fig. 36). The higher level was to become Fellow of that prestigious and highly respected College. All examinations were written and oral.



For physicians who read this book, I copied some of the questions from the written part of the fellowship examinations (Figs. 37 and 38). Those were the most difficult examinations in my entire life. But I passed them too, and in 1970, at three different ceremonies, I was accepted to three prestigious societies: the Royal College of Physicians and Surgeons of Canada (Fig. 39), the American College of Surgeons (Fig. 40) and the American College of Chest Physicians (Fig. 41). All paths of professional progress in North America were now open for me, on both sides of the border.
 


 
 

My daughter Dorit (named in the memory of my late mother) was born in March 1970 (Fig. 42), and in the summer I completed my second year of fellowship at the University of Toronto. I wanted to obtain a permanent position in Israel and to return home. The search for a job by correspondence reached a new peak, but there was no real progress. I reached a dead end, exactly as predicted by Dr. Prywes, when I had asked him for a recommendation letter before setting on my American adventure. Therefore, in parallel to the search in Israel, I started looking for work in the United States. The most attractive job offer came from the Montefiore Medical Center in New York. This hospital had been requested to upgrade the professional level of an old city hospital – the Morrisania City Hospital in the Bronx, a few city blocks from Montefiore. The administration of


the Montefiore Hospital was supposed to fill the vacancies in Morrisania with physicians who were on the Montefiore staff and served on the faculty of the Albert Einstein College of Medicine. The position offered to me was a full time appointment in the Department of Surgery at the Morrisania. I would instruct residents in general surgery and, as the only thoracic surgeon in the hospital, would be in charge of thoracic surgery. In parallel, I was offered the academic appointment as Assistant Professor of Surgery at the Albert Einstein College of Medicine. The salary, to be paid by Montefiore, was quite good. I accepted this offer, and in July 1970 my family and I moved to New York. During the four years of my absence, some changes had occurred at the Albert Einstein: Dr. State moved to Los Angeles and the new Chairman of the Department of Surgery was Dr. Marvin (Marv the Marvelous) Gliedman from the Montefiore.

The Morrisania Hospital was located in an area of poverty, riddled by crime. Most of the work in surgery was related to trauma. Until I came, no chest operations were performed there; all thoracic patients were transferred to the Montefiore Hospital. My initial work concentrated on organizing the groundwork for thoracic surgery. The necessary instruments were purchased and operations on lungs and esophagus were performed for the first time in Morrisania. The thoracic surgeons in Montefiore were relieved when the volume of chest trauma in their hospital dropped significantly. Groups of students from Albert Einstein – Montefiore came to the Morrisania for short periods of study. My relations with the surgical staff and with the department chairman – Dr. Gliedman, were excellent. I enjoyed my work and was happy.


I had been at the Morrisania for about two months, when a letter came from the Ministry of Health in Jerusalem: a position of chief of surgery became vacant at the Shmuel Harofe Hospital in Be’er-Yaakov, and a tender was announced. Forms were enclosed, to be filled, in case I was interested in applying for the position. Before receiving that letter I had never heard of the Shmuel Harofe Hospital and had not been aware of its existence. Its obscurity notwithstanding, Milka and I, both viewed this tender with great hope: an opportunity to return home. In case I won the tender, I would have an assured job and could return to Israel immediately. There was no room for hesitation. Without knowing a thing about the Shmuel Harofe Hospital, I filled the forms and mailed them to the Civil Service Commission in Jerusalem. The authorities in charge of the tender agreed to my unusual request to conduct the tender without my personal appearance and were satisfied with my documents, submitted by mail. From the day of application until the results of the contest became available, we lived under indescribable stress. I could barely function. The tender took place in November. At the end of that month I received a telegram (why not a phone call?) stating that I had won the contest (Fig. 43). Here I must point out an extremely important detail: the tender was for the position of Chief of the Department of Surgery (Thoracic and General). At the time I did not realize the importance of this particular phrasing. Its significance became clear only ten years later, when Shmuel Harofe was converted to a geriatric hospital and my department was transferred to the Wolfson Medical Center. I will return to this subject in a later chapter.

From that moment on, our lives had changed greatly. After ten years in America we became used to certain way of life. We had to liquidate our home, make purchases toward our return to Israel and organize the trip. But most important, I had to see the hospital  in  which  I expected  to  spend   the   following   years,
perhaps the remainder of my professional life. With this in mind, in December 1970 I went on a trip of acquaintanceship.
 


The hospital in Be’er Yaakov was built in the days of the British Mandate in Palestine as part of a big military camp. It consisted of barracks built of ”mud and rags”, according to the description of the hospital director, Dr. Walter Davidson. During World War II they started using this particular part of the camp as a British military hospital, and the barracks served as hospital wards. After the establishment of the State of Israel, the hospital was converted into a rehabilitation center for new immigrants with chronic disabilities (“MALBEN”). Most patients were hospitalized for long periods of time, sometimes for several years. Many had lung diseases, usually tuberculosis. After several years, the center was transferred to the government ownership and served as a hospital for tuberculosis. During the Six-Day-War it was temporarily converted to a hospital for wounded prisoners of war. Later it became a general hospital, with a heavy predominance of chest medicine: there were four pulmonary wards, but only one general medical service. The Department of Surgery consisted of one 50-bed surgical ward. It filled the function of a general surgical service, but again, there was great predominance of pulmonary surgery. The chief of the Department, Dr. Süsskind Herman, was a thoracic surgeon with extensive experience in surgery of the lungs. In 1970 he died after a prolonged illness and the position of department chief became vacant. Dr. Herman’s staff consisted of two surgeons, both in their fifties. The hospital was not affiliated with any medical school and had no teaching tradition. Patients were admitted to the surgical service for operations only. Dr. Herman performed all lung operations by himself. The two members of his team performed operations of hernia, hemorrhoids and the like. “Major” operations in the realm of general surgery were rare. The physicians in the department of medicine preferred to refer patients who needed surgery, to other hospitals. However, the four pulmonary services supplied Dr. Herman with sufficient volume of work.

When I came for my acquaintance visit in Be’er Yaakov, I met the hospital director, Dr. Davidson, who also served as chief of one of the pulmonary services. I was not given the opportunity to meet the staff of the Department of Surgery. In retrospect, I believe that this omission was intentional, planned ahead of time by Dr. Davidson, who had good reasons to hide my future team from me.
The hospital barracks were spread over a wide area (Fig. 44). Among the hospitals in Israel it was a peripheral institution, not widely known. Of course, there were no medical students. Only the Department of Medicine was approved for residency training and in 1970 it had only one medical resident. All the other services, including surgery, were not approved for training and had no residents. Thus I was condemned to work with two surgeons whom I had never met. I only knew that both were much older than I. That was it, at least for the immediate future.


I could not have been encouraged by this visit. But what was the alternative? To stay in the United States and wait for another opportunity? Others before me have done that. Their “temporary” stay in America lasted their lifetime. It was obvious that the chances for another “lucky strike” with a possibility of returning to Israel were close to nothing. This was my first and probably the only opportunity to become chief of a department of surgery in an Israeli hospital, miserable as it may be. I expected years of tough struggle, but also a challenge. In spite of the disheartening impact of my visit, I did not hesitate. My final conversation with Dr. Amos Arnan, the executive officer in charge of Hospitalization Services, concentrated only on the date of my arrival. Dr. Arnan tried to convince me to return to Israel and start working immediately. Without a chief, the surgical services in Shmuel Harofe were close to collapsing. However, my contract with the Montefiore Hospital obliged me to work for a whole year at the Morrisania, and I was not ready to violate it. In addition, after ten years in America, I needed time to get organized. I promised Dr. Arnan to try to shorten the “arrangements” as much as possible, but could not commit myself to return before July – six months ahead.

In New York I had a concluding conversation with Dr. Gliedman, Chairman of the Department of Surgery at the Albert Einstein-Montefiore – the surgical empire of the Bronx. Dr. Gliedman considered me an asset, important to the further progress and development of the Morrisania Hospital and did not want me to leave. He offered me a considerable raise in salary, tried to tempt me with promises of additional modern equipment, such as a flexible bronchoscope (a novelty in 1970), and more. But all this did not attract me. My decision was unshakable. I had spent ten years in America. It was now time to part from this wonderful country. Further postponement would turn into a permanent abandonment of Israel.

Milka supported my decision without hesitation. During the following six months we concentrated all our efforts on preparations for the return home and in July we set on a trip. We were happy.

On August 1st 1971 I entered my new position as chief of my own surgical department.

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10 For historic accuracy I wish to point out, that prior to the establishment of this service, no department or division of general thoracic surgery (separate from heart surgery) existed anywhere. The new division was the first of its kind in the world, and F.G. Pearson was the first person to ever head this kind of service.
11 Windpipe.
12 Thymus: a gland located in the mediastinum, important in immunologic processes.