Duke GI Oral History: Michael McLeod, MD


Dr. Julius Wilder: Well, my name is Dr. Wilder and I have the distinct pleasure of interviewing a person who's really important to me in my life. A person who's been an important mentor and an example, stellar example of a human being, a stellar example of a father and husband, and certainly a stellar example of a physician and one of the reasons why I became a gastroenterologist and that's Dr. Micheal McCloud. You are awesome person and you have been so important in my development as a medical student since I came here to Duke now 18 years ago. I'm really excited about the opportunity to interview you and to learn more about your experiences as we kind of reflect on the history of Duke GI.

Dr. Wilder: Of course, you were here many, many years ago, including going back to the times of Dr. Tyor when the division was going through such tremendous change. Can you tell us maybe a little bit about what that experience was like and what that tradition was at that point in time?

Dr. Michael McLeod: Well, the GI division at the time I entered it was quite small. Dr. Ruffin, Julian Ruffin, was the original gastroenterologist coming back dating back to the late 30s and he was approaching his retirement at that point. He still had two, sometimes three fellows that mainly were doing clinical work with him, learning the clinical aspect of gastroneurology, occasionally maybe doing some simple little drug study and Malcolm Tyor was originally over at the VA interested much more in research and he was moved over to Duke probably '63, somewhere right around that date with a focus on research and it was the budding years of the concept of a physician scientist.

Dr. McLeod: Research really had not been part of the GI division until he moved over. His interest was in bile salt enterohepatic circulation down through the ileum reabsorption of the liver etc. and so, Tyor was working with Leon Lack in the physiology department and they were interested in doing research studies on bile salts. That was kind of the setting and Tyor was interested in starting to recruit fellows with research interest, which had not really been a part of GI up until that time. That's when I started in GI, at that point.

Dr. Wilder: What were you before you came here to Duke and what brought you to Duke. What was it that kind of really drew you here?

Dr. McLeod: I attended the University of Florida. At that time, Miami was the only medical school. University of Florida was starting their first year but you had to have a four year degree and was at the time, you could occasionally get in after three. So, I applied to Duke. Came here as a freshman medical student. We're going back to 1956 and then finished in '60, took two years of residency in medicine. Went into the Navy for two years. At that point [inaudible 00:04:05] called me, Eugene Stead. He was chair of medicine and asked me if I would be chief resident when I came back. It was quite shocking for me to get that invitation because the usual pattern was after your second year of residency, go to NIH. NIH was increasingly important funding research at that time. Two years at NIH then you'd come back and you'd become a chief resident.

Dr. McLeod: I felt like the only reason, looking back was Ruffin was approaching retirement. The idea was I had already expressed an interest in Gastro neurology and so, maybe he thought he could kind of groom me to fill Ruffin's space. I don't know if that was the case but I did not feel like I particularly deserved that invitation but I took it. It was a great opportunity. When I finished chief residency, '64,'65, I then went into the lab for approximately a year, looking at acid transport and hamster guts but it was clear for me, although research was important in terms of helping me be a more critical bedside physician, it was not what got me up in the morning. It was not my passion and so, I took about six, eight months of some clinical GI and then, suddenly, 1967, January, I'm on the faculty and I'm in Gastro neurology. Again, very small GI department at the division at that time.

Dr. Wilder: Were there challenging things in the division at that time with all the growth and changes or were there challenging things for you at that time with all the changes that were occurring.

Dr. McLeod:  Well, I think my personal challenge was to accept that fact that I loved taking care of patients and I loved teaching and the emphasis in the late 60s, early 70s with NIH funding and research was about 80% of people going into the department or in the department was doing research of some kind. About 15 to 20% of us primarily saw patients. So, there was a more clear division. Later, the third path doing clinical research and patient care became more and more of an option but initially, when I was there it was like you either went left to research or right to clinical care and part of it personally was felling like was I really a second class citizen because I just [inaudible 00:06:53] take care of patient. This kind of pull toward doing research was there but it was clear that was not my mission in life, not to be a researcher. Yet, I value that time in the lab. Stead always said, he went around watching physicians practice was that they were learning the wrong things so often, because they would do a certain thing, there'd be a certain result and they would assume what they did caused the result, rather than saying, maybe, maybe not.

Dr. McLeod: The idea of bringing clinical thinking to the bedside and bringing scientific thinking to the bedside and also being strongly clinical base but you need that clinical thinking. So, it was a good experience and I felt it was an important part of fellowship training to spend some time in research.

Dr. Wilder: When you came through Duke, with all the [inaudible 00:07:52] changed, with the new emphasis on research and the changes in the structure of the division, there were also tremendous change within our society. We're talking about the 50s and 60s and Durham, North Carolina. What was that experience like, coming from Florida and how the hospital and the health system and the division adjust with all these major societal changes at that time as well? What was that like?

Dr. McLeod: Well, Durham was starting to recover from being a tobacco town. I mean, late 50s, early 60s, I mean, you literally, depending on what direction the wind was blowing, you could smell the tobacco coming out of Liggett and Meyers and American Tobacco Company. As simple as going out to eat, you had to brown bag. There was no mixed drinks served. You couldn't bring in ... You couldn't buy wine etc. So, you had to bring your little flask and they would provide you with gingerale. So, it was fairly primitive in many ways when you look back but again we're looking back 50 years. Even simple things like my wife, coming from New Jersey, used to talk about, there's no bread here. I said, "No, you've got bread, whole wheat, white bread, corn bread." "No, no, I mean pumpernickel, I mean a variety of breads," that you know, in the North East in a bakery would be just standard fare.

Dr. McLeod: So, a lot of that was what we had to live with at that point. I think the other part was, what I realized looking back with all the stress and tension of the Vietnam war and the racial issues, in fact, the students on campus were closing down the Allen Building at one point etc., all that ...

Dr. Wilder: Armstrong right.

Dr. McLeod:  Right. I think what I was involved in was trying to find my way onto the faculty and establish my credibility as a gastroenterologist, with what back then was not much more than six months of training. I was a good clinician and I still feel that internal medicine you need to know to be a good clinical gastroenterologist but anyway, that was a challenging time and I felt very cloistered in a way that a lot of these social issues going on, I was aware of them bu my energy was into getting established as a clinician etc. Plus, my third child coming along and later my fourth child coming along. So, my family was expanding. So, there was a lot of distractions for me. I didn't go out and protest the Vietnam war. I didn't have energy for that.

Dr. Wilder: What did you enjoy most about your time back then, when you reflect on what it was like and the people you worked with and what you were able to do?

Dr. McLeod: I think the exciting thing for me in the late 60s, 70s and even into the early 80s, there weren't gastroenterologists in the communities, very few. We were getting pristine virgin cases of any GI disease you want to think about. So, it was exciting to see these cases never diagnosed before, case of Whipple's disease from Southern Georgia, celiac sprue, etc., even simple cases of ulcerative colitis. Back then we were generalists. We weren't hepatologist. We were these different ...

Dr. Wilder:  IB versus [inaudible 00:11:41]. Yes, sir, yeah.

Dr. McLeod: Exactly. So, we were a generalist at that point in time but the exciting part was the fact that we were seeing all this new virgin GI never diagnosed or treated and so, it was a great teaching opportunity, learning opportunity and when I came out of training, after my residency years, I was convinced also that all I needed was data, facts. Give me the lab data, the facts, the x-rays, and again, a reminder that all we had at that time was contrast barium studies. We could do an upper GI. We could do a [inaudible 00:12:18] minima and that was the extent. We had a short proctoscope, 25 inches and we had an esophagus scope that could look at the esophagus. Very limited gastroscope. All that kind of limited what we could do but at the same time, it was like the patients, as I begin to follow them, what I realized was things were starting ... And these, for the first time, you're getting a longitudinal view of an illness.

Dr. Wilder:  Sure.

Dr. McLeod: As a resident, you're just seeing intermittently and you being to realize that things were happening to these patients that you couldn't measure. Some got better when they should have died. Some died when they should have gotten better and you're sitting there saying, "What is going on," and so, you start to recognize the kind of psycho social dimensions of the mind body connection and seeing people with atypical chest pain, irritable bowel etc. and so, you begin to recognize also that you had people with organic disease like I had mentioned to you in the email. The ulcerative colitis who's also got irritable bowel. He doesn't need 50 milligrams of Prednisone. Or, the reflux patient, who's refractory because he's also got panic disorder.

Dr. McLeod: So, you being to see this overlap kind of thing and then the thing I would also really preach to the fellows is because an IBS has had it for 20 years and they come in now with their colon cancer, you've got to be able to take a clear history and recognize, hey, somethings different here.

Dr. Wilder: Sure.

Dr. McLeod: This is not the usual IBS kind of thing going on. So, that's the part I loved too, is my waking up to the fact that it's not just all what we can measure. As exciting as all that is, there's this other whole human dimension that we have to bring in to kind of picture, kind of a holistic view.

Dr. Wilder: You know, it's very different, the way you trained versus the way I trained for instance and how the practice has changed over time as you alluded to. We have more specialties now and areas that we specialize in as opposed to being more generalist in GI as you described. Do you think that's an advantage or a disadvantage?

Dr. McLeod:  I think it's both and. One of the things I've learned in my life is that growing up you feel like there's a right answer and a wrong answer. It's just that simple but as you go along, you realize that, well, this is right most of the time but this is right sometimes. You know, the example I would use is, pride and humility. Well, pride can lead to arrogance. Pride can give you confidence to go out and take a risk and do something. Humility can create appropriate humility even when you've learned something, you know you've got more to learn or humility can create passivity. So, pride and humility each can have a role in your life, depending on where you are. I think the specializations, the advent and molecular biology as it was coming along, all that is incredible and look at what happened with Hepatitis C. Wonderful, wonderful example of that.

Dr. Wilder:  Yeah, absolutely.

Dr. McLeod:  But, at the same time, I think there is a risk of losing the holistic view that when you're working with a patient, they have much more going on than just their molecular events and biology, so to speak. They've got a mind and their emotional and spiritual life that's affecting the biology. I recently did a talk at Elon on the role of mindfulness in changing genes. You can turn genes on and off. The epigenetic mechanism and it's a beautiful example of starting with stress up here going through psycho neuro immunology, endocrinology, all the molecular part, down to your genes and how all that's interconnected. Now, you know that generally but the question is, can you bring it to your patient?

Dr. Wilder: Sure.

Dr. McLeod:  Somebody's not responding like you think, what else is going on in their life? That's the question. How is this affecting your life kind of thing.

Dr. Wilder:  That's so very thoughtful and actually, I'll tell you one of the things I've always admired about you and one of the things I've taken from you in my training was the idea to look at the whole patient and to consider mindfulness and all the various issues beyond just that one pathophysiological issue in terms of the care of the patients when I'm providing that care.

Dr. McLeod: Right.

Dr. Wilder: And was an inspiration for my PhD actually as well.

Dr. McLeod: Well, great. Great.

Dr. Wilder: You definitely have sort of spread that.

Dr. McLeod: I think there's a technological part of medicine that you know, the skills of using our instruments, endoscopy, etc. For me, that came a long after I entered GI. Something that John [inaudible 00:17:43] came on and he and I, we kind of had to learn that together and it became a tool to use but it wasn't our primary goal. It was where could it help us kind of thing, but then you had the scientist part, being critical in your thinking, and of course, that became increasingly, the whole feel and molecular biology etc, and then there was the art of medicine, of being able to see this whole person and recognize that when somethings not working like you think, maybe we need to back up and take a look at the whole situation kind of thing. What I call being an artist. The artist of the art of medicine kind of thing but also a scientist and also a technician.

Dr. McLeod: Several years ago, Paul [inaudible 00:18:34] and I went out and interviewed several of our graduates who are now in their 50's. We were going out on a fundraising adventure kind of thing for the [inaudible 00:18:45], McLeod fellowship and as we talked to them, they said, "You know we're recruiting GI fellows to come. We need you people in our practice but all they want to do is endoscopy."

Dr. Wilder: Right. Yeah.

Dr. McLeod: They don't want to follow patients. So, again, that to me is a potential downside if you get focused only on the kind of technological part of medicine. Again, it's why are we in medicine kind of thing. Medicine's a very seductive profession. It dangles all these little gold stars and trophies and things out there and I think it can leas us astray for what is that core truth we carry. What is my passion. What's my purpose and it may well be research and whatever. On the other hand, you can get off track, I think.

Dr. Wilder: So, reflecting on that, if you were to talk to our new GI fellows, our current GI fellows and thinking about what your experience has been like and the things that you have learned, what might be the advice, some of the things you might want to tell them to make sure they're aware of as they embark on this career in gastroenterology?

Dr. McLeod: Well, I think for myself, I remember, as I said earlier, coming out of my training and just being ... It was like the old Marine, you know. Work hard, persevere, know every single general article coming out etc., know the data and then realization as you see patients. Now, the problem is, if you go immediately into research etc., etc., you may not ever have that experience but if you start following patients longitudinally, you begin to see these other elements, the so called mind, body elements that are there in all of us.

Dr. Wilder: Yes sir.

Dr. McLeod: And so, the other part of this I think, is that this connection you being to form with a patient also feeds you. It feeds why you're in medicine, at least for most of us kind of thing. There's a mutual exchange. The patient feels cared about, valued, etc., and you feel valued for what you're able to bring kind of thing and I think a lot of the burn out that's happening in general medicine, not necessarily GI, is because of the increasing compression of time involved. There's less and less chance and the computer comes in, you've got to deal with that. There's less and less chance for that interaction to occur. It's the, I, though connection that if we're not careful, we make it I, it. This patient becomes an object that we've got to fix and it becomes a machine, so we can find the right part, tune it up, etc., but the patient walks out of there feeling like he's not really being seen or hear kind of thing.

Dr. McLeod: I think, I say that's important not only ... The problem is you wanting to et ahead, establish yourself, get that fellowship, whatever, write that paper, all that's important but the risk is, are you losing parts of yourself that you originally brought into medicine and the part that feeds you kind of thing. I think it feeds you in terms of that personally interconnecting part, the, I, though connection.

Dr. Wilder:  Absolutely. That's wonderful. Thank you so much for your time Dr. McLeod. Thank you for being an important person in my life as a mentor...

Dr. McLeod: Well, its been fun. When I think back to our first year in practice [crosstalk 00:22:37].

Dr. Wilder: That's right. Yeah, way back then.

Dr. McLeod: You were first year. I was actually, I think that was my first year in practice course after I had retired.

Dr. Wilder:  I didn't realize that.

Dr. McLeod: I retired in 2000. Then to see how you helped us in practice courts when you came and gave your talks.

Dr. Wilder: I appreciate that.

Dr. McLeod: It's been a wonderful experience for me to watch how you've grown, evolved, etc. Yeah, it's been wonderful.

Dr. Wilder: I appreciate that. Thank you for your time today.

Dr. McLeod: Absolutely, absolutely.