Promises Kept 5

1991, a seminal year in my life. I was 57 years old and completing 25 years on the teaching Faculty of New York University School of Medicine in both Internal Medicine and Cardiology. My promotion to Associate Professor in both departments was the result of both my research and teaching activities. In addition, I had a private practice on Fifth Avenue and East 72nd Street and, perhaps more meaningful, an adored wife and three wonderful children, all of whom had finished University. My hours were long, the stress levels were high and, I had always promised myself, that after the children finished University, I would get off the treadmill, change the tempo of my life, and find a way to give back to Society for all I had received.

In 1990, my mother-in-law, Celia Weinberg, passed away. She was a single mother, having escaped from Germany in 1939, pregnant with my wife Ruth; getting through the war years in London and eventually, in 1949 finding her way to New York City. As a single mother in a foreign country, she managed to raise an incredible daughter! Despite Ruth's and my desires, we had deferred our fantasy of Aliyah as we could not see, once again, relocating Ruth's mom.

In 1990, Ruth and I decided to spend a year on Sabbatical in Israel. We scheduled an exploratory trip to examine different potential professional opportunities for me with interviews scheduled in several different Israeli hospitals. Our departure for the preliminary exploration coincided with the first day of the Gulf war. Upon our arrival we were issued gas masks and advised to find shelter before nightfall. And thus began our Aliyah.

I was offered a temporary appointment for the Sabbatical at several Israeli Medical Centers, but intuited that my services would be most significant at Meir Hospital in Kfar Saba. Though not the most prestigious institution, I felt my contributions would carry the most significance in what was a very busy community hospital, and not a major Medical Center. After prodigious efforts in finding coverage for my private New York Clinic, finding temporary furnished housing in Raanana, and obtaining a temporary medical license, Ruth and I arrived in Israel July 1991 to commence a year that would be life changing.

Meir Hospital is owned by the Clalit Health Care Fund and, in contrast to Government and privately funded hospitals, has relatively limited resources to supplement the monies they are paid for providing care. In addition, as a community-based hospital, it maintains a very active emergency service including ambulance coverage for an extensive area in the Sharon Region of Israel. They admit a large number of emergency cardiac cases many of whom are getting inadequate maintenance care for their conditions. With limited resources and limitless demands, there was a need to decide which patients could receive cardiology procedures and in which cases they would have to be deferred. My job during the Sabbatical year was to screen requests for Echocardiograms, catheterizations, stress tests, scans and pacemakers to determine which procedures had to be done immediately during hospitalization as opposed to being deferred to the outpatient services. This was my assignment day in and day out.

After six months of being responsible for screening, I was struck by the number of patients who had received our most sophisticated evaluations and treatments, whose conditions were most tenuous, and who returned via the emergency for repeat hospitalizations within weeks to months. Clearly, something was not working well.

Historically in Israel, the effective connection between hospital-based and community-based health care is weak. Upon discharge from the hospital the patient receives a discharge letter, usually generated by the most inexperienced member of the hospital team. This missive to the community-based family doctor was the sole access the family doctor had to the patients' experiences in the hospital. In some cases, the patient received a parallel reference to the hospital's specialty-based cardiology clinic. Once again, sharing of follow up information was via hastily written questions, requests and summaries between the hospital-based department and the doctor responsible for the patients' health care.

In the 1990s I became convinced that vigorous aerobic exercise was an effective tool in the prevention of the origin and the progression of cardio-vascular disease. At the time, when angioplasties and stents were taking credit for remarkable reductions in cardiac deaths, little attention was being focused on prevention, other than the routine prescription of Statins and Aspirin. Professor Daniel David, the Cardiology Department head and my boss during the sabbatical year, felt as I did, that the incorporation of an outstanding Cardiac Rehabilitation program would both improve patient care and reduce the frequency of readmissions to the hospital. The more we talked about it, the stronger was our conviction. On parting at the closure of my Sabbatical year, Professor David committed to finding space within the hospital and I committed to return with sufficient funds to equip a first-class facility.

In November of 1996 Ruth and I returned to Raanana as Olim. I had founded The Israel Heart Fund with commitments from friends and patients in New York for sufficient funding to both equip the Rehabilitation Center and to also commit to computer-based record keeping. This would allow effective monitoring and studying of our clinical outcomes. The first clients started flowing through the center in November 1997. In 2004 we were able to report in the Journal of Preventive Cardiology that we had recruited 32% of eligible patients into the program. Dropout rates over the initial 3 months were low (25%). We documented Improvement in low-density lipoprotein cholesterol level (-4.5%), high-density lipoprotein cholesterol level (+7%), body mass index (-2%), systolic blood pressure (-3%), and maximum metabolic equivalents, a measure of physical capacity, (+25%). This improvement in exercise capacity was comparable to levels achieved in studies showing angiographic stabilization and/or regression of disease. We had demonstrated the effectiveness of a community hospital-based risk management exercise program.

It continues to this day and has been duplicated in other Israeli Centers. The promise was kept.