ISN VIDEO LEGACY PROJECT

DR.  EVERT J. DORHOUT MEES
 

 


---Why medicine?

In high school I was interested in philosophy and psychology, but I also experimented at home with chemicals. That fascinated me.  So I decided to study chemistry. However, the universities had just been closed by the Germans (!944). Because a psychotechnical test had advised medical study, I took the opportunity to start (secret) unofficial medical study with the help of staff members of the Utrecht University.. Thus by the time Holland was liberated, I had become so much interested that I continued that study. Looking back, I cannot imagine myself in  any other profession. To be a doctor gives both intellectual and human satisfaction.

Once in the medical field, every aspect becomes interesting, but finally I decided to specialize in internal medicine.

---Why nephrology?  

During my internship I discovered that the idea, that my professors knew everything was quite mistaken. Two subjects seemed particularly neglected, kidney disease and hypertension. Cardiologists in particular did not have any interest in hypertension. They  considered attempts to treat it useless if not harmful. So I started a hypertension outpatient clinic, and became more and more convinced that hypertension is a kidney disease.

As for nephrology, that term did not exist, and I preferred to call myself, following Sir Robert Platt, a nephrophile.  I still sincerely believe that a nephrologist should first of all be an internist, even a generalist..

---The Dutch connection.

I said that my professors in Utrecht did not have much interest in the kidney, but there was an outstanding pioneer in the field of  kidney,  circulation and hypertension in Amsterdam, whose name is Jan Borst. He and his coworkers used meticulous clinical observation and balance studies, which showed that hypertension resulted from salt and volume retention by the kidney, and could be cured with salt free diet and the at that time only available mercury diuretics. Unfortunately, his extreme self-criticism and modesty prevented extensive publication in international journals. His ideas were later re-discovered and systematized by Arthur Guyton.

Borst was and wanted to be a general internist, at best a nephrophile (he did not use that expression). It was only many years later that nephrology was recognized as an entity, in which neither his department nor any of his pupils played an active role.

Among the prominent Dutch nephrologues of that time I must commemorate Jaap de Graeff, who in collaboration with the immunologist Jon van Rood pioneered in the transplantation field, and Flip Hoedemakers who was an internationally known pathologist.

I also want to pay tribute to William Drucker. He was an extremely enthusiastic dialysis doctor, founded the EDTA together with Parsons and edited the first dialysis textbook.

He was removed from the EDTA council in a very shameful way by some intrigues of which I never understood the details.

---The English connection.

Studying the international literature I was struck by an article of  Sir Robert Platt from Manchester,  who argued that many of the functional disturbances of the diseased kidney are due to adaptations of a reduced number of relatively normal nephrons to the increased demands of the body. I had the pleasure to visit this perfect gentleman, who practiced high ethical standards. When he investigated 'normal volunteers', he was himself always one of them. It is interesting that both Platt and Borst were very conservative and reluctant to do biopsies.

Other colleagues I visited on that very helpful trip were my ex-compatriot Mark Joekes, Graham Bull, Hugh de Wardener and a young promising lady Priscilla Kincaid Smith. These contacts were be continued for many years.

---The French connection

In order to broaden my horizons I had the opportunity to stay a few months at Hamburger's service in Paris.  I am a bit francophilic by heritage. Among the things I learned from Hamburger was not to discuss a patient's problems at the bed-side. This was a bad habit among Dutch professors during their grand-rounds at that time, which I abolished as soon as I became myself head of a department.

It is strange that doctors often are not aware of the effect of their behavior on the patient. Once a head-nurse told me that she had to run along the patients to comfort them after the professor had made rounds. Yet I admired that man for his very humane approach.

Clinical nephrology was flourishing there at that time, and I had many educating  discussions with, among others, Marcel Legrain, Renee Habib and particularly with Gabriel Richet, whose critical, provoking and inspiring mind impressed me very much.

-- The American connection.

In 1962, I spent a happy year with my family as an assistant professor in St Louis. I was invited there by Neal Bricker because of two articles I had written inspired by Platt's hypothesis, which Neal had extended to his 'intact nephron hypothesis'. I learned that an investigator should at least master and preferably perform himself the techniques used.        This notion was completely unfamiliar to European minds, and still is in many countries.

I had the pleasure to get to know Donald Seldin in Dallas, who, like Richet, combines an extremely inquisitive and critical mind with good doctorship and a broad intellectual interest.

During several trips to the USA in later years I made acquaintance with Arthur Guyton, whom I consider the greatest physiologist since Claude Bernard.  With my collaborator and future successor Hein Koomans we had very useful discussions with him and his co-workers.

His approach appealed to us and was particularly well suited to the problems we were working at.   I do not quite understand why Guyton was not appreciated in the world of nephrology. I never saw him at congresses. It may be that his very strong personality and keen systematic mind did not encourage other investigators to discuss with him, but I also feel that the focus of attention was already shifting from pathophysiology to molecular problems and the 'evidence based' approach.

-- Own focus of interest.

I was fortunate to witness the birth of nephrology, which for me was first of all (patho)physiology. Understanding how a normal kidney works and then try to help it in disease conditions. I had a personal subscription on the New England Journal of Medicine and the Journal of Clinical Investigation, and remember how thrilled I was reading each new issue. That were the times of such brilliant investigators like Alexander Leaff, William Schwartz and Donald Seldin.

My interests were along two lines:

First, how the kidney works on the nephron level. This can be investigated with clearance methods and also by micropuncture. We first limited our research to the first, later using the Lithium clearance. The micropuncture and -perfusion techniques needed so much investment in time and money that I considered them impracticable for Dutch conditions. Yet, my successor Hein Koomans was able to set up a micropuncture lab around 1990, but it was rather late and international attention was shifting in other directions.

The other aspect was regulation of fluid volumes, circulation and blood pressure.

Against much opposition of the hospital management I was able to buy a 'volemetron', an apparatus which enabled us to measure blood and extracellular volumes on a routine basis.  This opened the road to two main research lines: Nephrotic syndrome and chronic renal failure.

In both conditions, we expected low volumes, but instead we found the opposite. I am always triggered when I find an unexpected result. I think many investigators abhor facts that do not fit into generally accepted concepts and prefer to ignore them. We investigated this issue from all sides and were able to put many pieces of the puzzle together, but the nephrological community was slow to accept them

The other subject, volume and blood pressure, could be pursued up to the present day.

--Hemodialysis

Although this treatment was developed in the Netherlands, it had to be exported first before being accepted here, in particular at the university level. This is not the place to explain why. But the whole nephrology world initially did not immediately boil with enthusiasm. I vividly remember the skepticism encountered by Belding Scribner when he presented the results of his maintenance dialysis at the first congress in Evian..

By the time I started this treatment in Utrecht, some of my Dutch colleagues feared that it would consume all the energy and money of their department. I also had to fight the hospital bureaucracy. They did not realize how profitable it would turn out to be. Because we had no room to treat all the patients, I founded a non- profit organization, the Home Dialysis Foundation. Because it got a very good administrator, he could provide this treatment at a much lower price. That caused an outcry among many dialysis doctors.

We worked hard to bring the elevated blood pressure of our patients down by applying   the principles of volume control as outlined by Scribner.  It was hard to convince some doctors and nurses that certain patients were volume expanded, despite the fact that they looked so thin.  Thus I had to sit next to the patient and carefully turn the ultrafiltration button until success was finally apparent.

I found dialysis treatment very rewarding in those years. Hugh deWardener remarked: 'For the first time in my career I feel that I am keeping patients alive' , while George Schreiner once said  that 'chronic dialysis was the last piece of general practice'.

This is gradually changing nowadays.  Dialysis centers are becoming rinsing factories, and the appalling high percentage (at least in the USA) of patients who voluntarily discontinue dialysis suggests that there is something rotten in the dialysis world.

The Turkish connection

I have always intensely enjoyed the work at the University, where you combine patient care, teaching and clinical investigation. Yet I was not sorry when I was forced to leave at   my 65th year of age, because the atmosphere was gradually changing. The 'Managerial revolution', once prophesied by Burnham, had finally reached the universities.  

Overconsumption of medical care threatened and I felt that I could apply my experience     in a better way elsewhere.  Thus I applied to the Ege University in Izmir, Turkey, where I  was immediately accepted in a similar position which I had in Utrecht, except administration.

It is no exaggeration to say that the 8 years I spent there  were the happiest and most rewarding years of my life. My wife Mia and I enjoyed this Turkish 'culture', the friendship and hospitality and warm human interest at all levels of the society, most of all of the 'lower' classes. Of course, abuses galore, more impudent and less sophisticated than in Holland. But the amazing thing was that, in contrast to Holland, my criticisms were accepted in Turkey, be-it not without some problems. It became apparent to me that I had to 'seed the seeds of doubt', and that a criticism in science was closely related to a critical attitude at the social and political level. So I also became interested in politics and human rights, which continues to the present day. But that is another matter.

Cardiovascular problems.

Soon after starting in Izmir I realized that doing some kind of research yourself is needed to develop the self-criticism which is so vital to be a good doctor. For practical reasons this had to be clinical research. This had always been my favorite,  but was just about to be abandoned in the nephrology world.

Nephrology had become more and more identical with dialysis, but our patients were not dying from the kidney, they died  from heart and artery disease. Yet, the idea that this had something to do with salt, fluid balance and blood pressure was not in the doctors mind. Thiazide diuretics were not available any more. Most of the patients, in the wards as well as in the dialysis department were severely overhydrated. So I told my colleagues that they should become 'circulatory physiologists', and make the heart the focus of our research.

Because gray hair and experience is respected in Turkey (in contrast to Holland), I got almost a free hand, in particular use echocardiography at lib. We made very interesting observations, but now we had to publish them in international journals, in which my friends had no experience at all. There were two obstacles: First a completely unjustified lack of self-confidence of my colleagues, and than resistance of the nephrological editors, who were blinded by the 'evidence based' fashion. I am still angry at Kidney International, who refused a series (the first in world literature) of  21  patients with Doppler-echo proven severe valvular regurgitation that disappeared or improved after ultrafiltration, because of  'lack of controls'!

We got, however, the support of Eberhard Ritz, editor of NDT, and finally published about 20 papers, also in the American journals.

As a result of the efforts of my friends, there are now many dialysis centers in  Izmir and further away, whose patients are nearly all normotensive without drugs and excellent survival  rates. However, we have not and will not deprive a 'control group' of the treatment we showed to be so beneficial, until their mortality reaches the statistically required level.

The rise and decline of nephrology

The kidney is a wonderful organ. Starling once remarked that it seems to be 'endowed with intelligence'. It not just makes urine, but according to Homer Smith, the stuff of philosophy itself. But fact that we can get that product easily facilitated study of the kidney very much. The differentiated  anatomical structure enables physiologists as well as pathologists to investigate more details than of most other organs. But now many problems have been solved.  I don't say that there is no interesting stuff left, but medicine as a whole is shifting towards molecular biology. Very interesting, but you need not be a doctor for that.

The patient is getting out of focus, although he is not only our goal, but also the main source our  inspiration.

On the other hand,  attention has been directed towards  nephrology's big success stories: dialysis and transplantation. The first has nothing to do with the kidney any more, as I just explained, and the second has more to do with immunology. Dialysis has the additional drawback that it is too well paid. This does not attract the most interested type of doctors, if I may say so. In short, nephrology is not any more what it used to be.

Evidence based conformism.

This is another subject of concern. In the past unjustified, ridiculous and even harmful concepts have been accepted because a professor said so and is sounded plausible. Thus to the demand for rigid statistical proof was a necessary correction. It is a method, not a religious dogma. It is not applicable to all problems. If you apply it that way, it becomes the death of originality. Take the discoveries of Borst which I mentioned. In the field of dialysis, it worked out definitely harmful, as I also indicated. Big numbers is not everything, they may also obscure  important insights. Let me give you one more example: The Parfrey and co-workers followed up a large group of dialysis patients and calculated risk factors and all kind of correlations in multiple regression analysis. They were able to get more than 20 papers on this subject in high quality journals. But the main conclusion I draw from all this is: If you treat your patients badly, the results will also be bad.

Finally, this type of research is loved by the pharmaceutical industry, which often does not generate the most interesting questions,  but absorbs a lot of energy.

The social connection.

After my second retirement from Izmir in 1998 I continued the scientific contacts with my Turkish friends and wrote a book: 'Cardiovascular Aspects of Dialysis Treatment'. 

But I also directed my interest to social and economic aspects of medicine and also human right problems. While in Turkey I was confronted with such issues, but coming back in the Netherlands found that, far from being limited to that country, they were 'global'.

The first was the overwhelming influence of the pharmaceutical industry on medical research, teaching and treatment. 'The Lancet' called them 'Uneasy bedfellows', but many doctors appear to be quite comfortable in that position. In the past, we had fruitful collaboration with the industry, but on a mutual basis, we could bargain. But now there is but one active partner in that relationship

The other matter of concern is the tendency to privatization and commercialization of hospitals and the whole medical field, which is accompanied by a change in the physicians mentality. Look at the advertisements! But now we are leaving the field of nephrology.     

I have no illusions to turn the tide, but it gives me comfort to raise my voice now and then.

Evert J. Dorhout Mees,          March    2004