Dr. Abraham Verghese
Interviews Dr. Jerome Kassirer
on New Book

August 2, 2017

In a career that spans more than five decades, Jerome P. Kassirer, M.D. has been an acclaimed kidney specialist, clinical researcher, administrator, author, creator of new medical disciplines and, during the decade of the 1990s, editor-in-chief of the prestigious New England Journal of Medicine. He has been a visiting professor at Stanford, for over a decade, coming once a month to teach students, to consult with faculty. I have looked forward to these visits and have marveled at Dr. Kassirer’s generosity in reading so many of our manuscripts and giving us advice on editorial matters, as well as personal advice.

This interview took place during his last visit, over lunch, to discuss his new bookUnanticipated Outcomes: A Medical Memoirwhich The Lancet reviews here.

AV: Jerry, I've been after you for a long time to write a memoir. I have loved the stories that you tell our students and that you tell me.  How many books have you written? This book is number  . . .what?

JK: The new one is number six. I wrote two books about electrolytes and acid-base equilibrium a long time ago with colleagues, another called On The Take about financial conflict of interest in medicine, and one entitled Learning Clinical Reasoning about the diagnostic process. Unanticipated Outcomes is a collection of stories … many of which you have heard… stories of my experience in medicine going back from medical school all the way through my career as a nephrologist, as an administrator, as a member of various medical organizations such as the American College of Physicians and the American Board of Internal Medicine, my involvement with research in cognitive science and decision analysis up to the point where I became the editor of the New England Journal of Medicine and beyond when I began to spend my time here at Stanford.

AV: Tell us a bit about the challenges in the structure of this book. I ask because I am always wrestling with that issue—the architecture of a book.  Did you know or think you knew its structure, and how did it evolve as you wrote it?

JK: Well, it evolved over a period of four or five years. I wrote four different books. The first book was simply a collection of stories, and it didn't hold together all that well. The next book I wrote was exclusively about my experience at the New England Journal of Medicine and the--

AV: Somewhat controversial experience.

JK: Yes, my controversial experience at the New England Journal . The feedback I got from that narrative was that it sounded a bit like an excuse. I gave that version up and turned to writing something that included stories of interest to people about medicine but also included my experience at the New England Journal. The focus this time was more on the decisions and judgments that I made in the course of a long career. Decisions at a given point where the choices are very different.  Where one has to make a decision whether to embark in a new field, for example, or to continue in a fairly traditional way.  I tried to show how I made those decisions and what the outcome was of these difficult choices. In some cases the outcome was very positive; in other cases my decisions were not so positive. So the evolution was into a book that the title really explains: the unexpected outcomes that result from opportunities that come along in the course of careers. I try to elaborate on these choices, arguing that when one is faced with all these choices you have to look at what the positive possibilities are and what the negative outcomes might be, make a choice and then live with your choices.

AV: It's interesting because you're…you're clinically famous for your work on decision making. But here you are turning the lens to you, and it is sort of a macro life-decisions or life hack that you're talking about. I think readers will really appreciate the similarity and the contrast there.

JK: Well the choice of whether or not to dive into a new field such as clinical decision making when there was no such field was one of these examples. As I describe in the book, I stumbled into a discipline that had not been applied in medicine. The choice was continue to work in the field, which was completely unknown at the time, or to continue to be a nephrologist. I chose to take the chance on the unknown because I saw the potential.

AV: There's one story in the book, which is my absolute favorite story. I keep bugging you every month when you come here to be sure to tell it to the students on the medicine clerkship. It was about your time as a new intern in Buffalo. You made a very astute diagnosis and it was your claim to fame. Can you talk about that?

JK: It happened the first week of my internship. I was called one evening to see a middle aged woman who had been seen by several distinguished Buffalo physicians who had been unable to make a diagnosis. She had a large liver and they were planning to do a laparotomy to identify what was in her liver. Remember that at that time, more than 60 years ago, no scans of any kind were available. The nurse had called me to see her for diarrhea and a drop in blood pressure. By the time I arrived her blood pressure had come back up. But I looked at her chart, and examined her. Indeed she had a huge liver, but I also found that her legs were bright red, flushed. In my naiveté, I put together the flushing and hypotension and a big liver and decided she had carcinoid syndrome. At that time, the syndrome had been described only one year earlier, and I had been reading the medical journal that first reported the syndrome, namely the American Journal of Medicine, the so-called green journal. I had written in her chart that she had carcinoid syndrome but no one believed me and they continued to schedule her for surgery. So I took her urine to the toxicology lab and gave them the method for measuring 5-hydroxyindoleacetic acid; they ran the test and the result was elevated. They couldn't quantify it but they knew it was abnormal. So I went back to the chart and I wrote that she does have carcinoid syndrome and that she didn't need to be operated on because that's what she had – carcinoid in her liver. I guess they still didn't believe me because they operated on her. She did have a liver full of a carcinoid tumor. And I became an instant celebrity because of that diagnosis. I presented her case at Grand Rounds and the chief of oncology from the Roswell Park Memorial Institute discussed the case. Later when I applied for an electrolyte fellowship in Boston, he wrote me a strong letter which actually got me the job.

AV: It was a moment of brilliance!

JK: In fact when you think about the diagnosis that I made, I should have been wrong because statistically carcinoid syndrome was extremely rare and even though the patient had all the characteristics of carcinoid, the probability is high that it was a different, more common diagnosis. Just because carcinoid syndrome is so rare.

AV: But . . .

JK: But i was right…[laughter]

AV: [laughter] Sometimes you need luck, right?

JK: A bit of luck. . . . But that was…that was a kind of a branch point too. A lucky diagnosis led to my fellowship in Boston, which then led to the rest of my career.

AV: When you were at the New England Journal of Medicine, you were responsible for a new section that I very much loved. In fact, very early on I had a submission to you. One of your six books, was a collection of all those images. Tell us about the evolution of that section.

JK: When I became editor, I was eager to add new formats to enhance the clinical relevance of the Journal and the very first new item was a monthly section called Clinical Problem Solving. Clinical Problem Solving explored how to solve difficult diagnostic problems. It was meant to expound on the kind of analytic thinking that people use when they are thinking about achieving a diagnosis. But I also realized that diagnosis involved much more than analytic reasoning, namely pattern recognition. So I decided that in addition to this one section – clinical problem solving – I would invent another weekly installment that I called Images in Clinical Medicine. The idea was to present any kind of image – a picture of a lyme tick or a face of a patient with acromegaly or an x-ray that showed the calcified kidneys in type 1 renal tubular acidosis, as examples. The idea was to use this kind of pattern recognition to help people immediately appreciate a possible diagnosis. As it turned out, the Images section of the journal became very popular. I'm told from the current editor that it continues to be one of the most popular sections…

AV: That’s wonderful.

JK: As I recall, you and I had an interesting interaction way back then, long before we had become colleagues.

AV: [laughs] Yes, you accepted my image of a nicotine stained nail. A man who had suddenly quit smoking, so that half the nail was nicotine stained and the proximal part was virgin white. By knowing the nail grows at the rate of 1mm per week, one could actually say when the seminal event had happened. I called the submission, THE HARLEQUIN nail, secretly hoping one day it might be called the Verghese Nail! When I got the galleys, it was changed to the QUITTER’S NAIL. I couldn’t believe it!  I called the offices of the NEJM to speak to a copy editor. I was incensed that my beautiful colorful title had been changed to something so prosaic! To my surprise, instead of getting a copy-editor, they put you on the line. I did not know you, and was in awe of you. Here I was an academic at Texas Tech El Paso talking to THE editor of the NEJM. You were and are a legend. Still, I made my case with you, said how much I preferred the other title and you listened carefully, and then you said, “No, I think we should go with QUITTER’S Nail. I said, “Okay.”  Turns out you were right, because now, if you google search, the “harlequin nail” what comes up is a choice for acrylic nail patters in women’s hair salons. I had the great honor of telling this story at the Jerome Kassirer Lectureship in Tufts a few years ago. My life had come full circle!

Quitter's Nail. See link to learn more.

What is found online today when searching "harlequin nail".

So, Jerry,  if there's one physical sign that as a nephrologist or an internist you love to teach because you often thought it was done poorly and technique was important, what would that be?

JK: A careful examination of skin turgor, is sometimes extremely useful when you're trying to determine the volume status of a patient with acute renal decline. The exam is often done poorly and often misinterpreted, especially in older people whose skin is thin to begin with.

AV: How exactly should we do it or how do we…?

JK: So we need to not just pick up a superficial amount of the skin. We should grasp a deep chunk of skin, pinch it carefully, and watch as it recovers. If it doesn't recover quickly, then you can infer that there may be substantial volume contraction.

AV: Wonderful. Thank you very much for this interview Jerry.

JK: That was fun!

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