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Nicholas M. Greene: Visionary Educator, Clinician, Editor, and Humanitarian

McGoldrick, Kathryn E. MD

doi: 10.1213/ANE.0b013e31826b46de
General Articles: Special Article

Published ahead of print September 13, 2012 Supplemental Digital Content is available in the text.

From the Department of Anesthesiology, New York Medical College, Valhalla, NY.

Accepted for publication July 13, 2012.

Published ahead of print September 13, 2012

Funding: None.

The author declares no conflict of interest.

Reprint will not be available from the author.

Address correspondence to Kathryn E. McGoldrick, MD, Department of Anesthesiology, New York Medical College, 100 Woods Road, Valhalla, NY 10595. Address e-mail to Kathryn_McGoldrick@nymc.edu

We are not here to get all we can out of life for ourselves, but to try to make the lives of others happier. It is not possible for anyone to have better opportunities to live this lesson than you will enjoy. The practice of medicine is an art, not a trade; a calling, not a business; a calling in which your heart will be exercised equally with your head.

Sir William Osler, The Master Word in Medicine

Nicholas Misplee Greene, MD (1922–2004), personified the Oslerian ideal.1 His was a distinguished and selfless life of service that advanced anesthesiology with many contributions that improved the lives of millions of people in our global community. Dr. Greene (Fig. 1) was the only anesthesiologist in history to serve as Editor-in-Chief of both Anesthesiology and Anesthesia & Analgesia. During his long and impressive career, he influenced the vocational interests and professional values of numerous trainees for whom he was an exemplary role model. According to Yale folklore, one perceptive resident wrote in his evaluation of Dr. Greene, “Learning anesthesiology from Nick Greene was like learning astronomy from Galileo.”2 Yet, by those of us who had the great fortune to be his colleagues and friends, Nick was perhaps admired more for his humanistic character than for his formidable academic prowess.

Figure 1

Figure 1

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THE EARLY YEARS

A descendant of the Revolutionary War hero Nathanael [sic] Greene, Nick was born on July 11, 1922, just weeks before the appearance of the world’s first journal for physician anesthetists, Current Researches in Anesthesia and Analgesia (now Anesthesia & Analgesia). He had a peripatetic childhood, spending time in Connecticut, New York, Michigan, Massachusetts, California, and Alabama, to name but a few homes. His parents were divorced, and Nick spent considerable time shuttling among relatives. He was fond of the Gulf region and enjoyed spending holidays with family members in New Orleans and near Biloxi, Mississippi. Most of his formal education, however, occurred in the Northeast, where he entered boarding school at 8 years of age. He lived in 11 states before graduating from Phillips Academy in Andover, Massachusetts. Nick often spoke of the sobering shadow that the Great Depression cast on his childhood and later years. Although his family was financially comfortable, employing a maid and a cook in their household,a Nick realized that most Americans were considerably less fortunate; these economic disparities troubled him. In general, however, he was circumspect about providing details of his early life. Despite his peregrinations, at heart he seemed to be the consummate New Englander who was reserved, disciplined, decorous, and parsimonious. When he did not volunteer personal information, few would have the impertinence to pry. In fact, few of us knew that he had 3 siblings until we read his obituary.

It is tempting to speculate, however, that Nick’s heritage played an important role in shaping his personality and character. Recall that General Nathanael Greene, “the fighting Quaker,” entered the American Revolutionary War as a militia private, the lowest rank possible, and emerged from the war with a reputation as George Washington’s most gifted and dependable officer. Indeed, Nick’s grandfather, a 1878 graduate of West Point, was an Army officer, and Nick’s uncle, Douglass [sic] Taft Greene, was an eminent major general in World War II.b Perhaps this lineage contributed to Nick’s disciplined, self-reliant, no-nonsense approach to the challenges of life and to his outstanding strategic and tactical skills.

Nick had no dramatic epiphany triggering his interest in medicine. Rather, his fascination with medicine “grew like Topsy until it became a conviction that I must and would go to medical school, a conviction reinforced by serving as a volunteer in the summer at our local small but busy hospital, witnessing everything from E.R. treatments to a few autopsies.”3 Despite Bostonian ties, he was eager to pursue higher education “west of the Charles River.”4 He matriculated at Yale College in 1940, where he was determined to take the absolute minimum of courses in science necessary to be accepted into medical school, reasoning that once he was a medical student, he would be exposed to “nothing but courses in science.”3 Unfortunately, World War II thwarted Nick’s attempt to immerse himself in the humanities. He was forced instead to accelerate his education and obtain a Bachelor of Science, rather than a Bachelor of Arts, from Yale where his classmates included John Chaffee, a future Governor of Rhode Island, and John Lindsay, a future Mayor of New York.

In 1946, Nick graduated from Columbia University’s College of Physicians and Surgeons. Immediately after graduation, he married the beautiful, witty, and vivacious Elizabeth Miller, a Columbia–Presbyterian nursing graduate. “Betty” was the love of Nick’s life, and their mutual respect and devotion were apparent throughout their 58 years of marriage. Despite Nick’s penchant for privacy, he seemed to greatly enjoy receiving compliments about Betty. Shortly after meeting her, I remember telling Nick that I thought Betty was absolutely beautiful, and that I admired her independence in resisting the temptation to dye her stunning mane of white hair “conformist blonde.” Nick beamed when he heard this, and responded with a tribute to Betty’s strength, intellect, and sense of humor. A few years later, I provided anesthesia care to Betty when she came to Yale for a relatively minor surgical procedure. After inserting an IV cannula and administering a small amount of midazolam, I repeated this story to Betty. Greatly amused, Betty told me that several years earlier she decided to dye her prematurely white hair red. She returned home that evening, apprehensively awaiting Nick’s reaction. He said nothing, and his countenance displayed not even an arched eyebrow. Three days later, Nick looked up from his newspaper and asked, “Betty, what have you done to your hair?” Vintage Nick!

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NEOPHYTE PHYSICIAN

In 1946, Dr. Greene served a 14-month internship/residency in surgery at Columbia’s Presbyterian Hospital, where Dr. Virginia Apgar was head of the anesthesia department. He developed great admiration for how skillfully Dr. Apgar managed the department during the turbulent war years when almost all male anesthetists, both physicians and nurses, had been drafted into the military. In the summer of 1947, Dr. Greene began his “pay-back”: 2 years of active duty in the Navy assigned as a general-duty medical officer to the United States Naval Hospital in Annapolis, Maryland. In his characteristically succinct (21 pages) autobiography published in 2000, Nick wrote, “Being a G.P. for two years was a great professional opportunity, during which I learned more about the practice of medicine than I ever would have learned had I been for two years in an ivory tower in some medical center.”5 Indeed, the genesis of his decision to become an anesthesiologist traces back to his Annapolis experience. As a general practitioner, Nick delivered 2 or 3 babies weekly, and he was shocked by the anesthetic management of parturients, which he said “terrified” him.4 He observed that high-quality care was “underrepresented in anesthesia,”4 and he became convinced that anesthesiology was a specialty in which he could make a palpable contribution to patient welfare. He abandoned his plan to become “yet another surgeon”4 and followed a path that, ultimately, was to prove more meaningful.

Residency in anesthesiology from 1949 to 1951 at the Massachusetts General Hospital (MGH) under the tutelage of Dr. Henry Beecher was the next step in Nick’s professional life. In that era, Dr. Beecher was spearheading seminal research on pain, as well as on the metabolic responses to surgery and anesthesia. The environment was dynamic and intellectually stimulating. Fellow residents included William Brewster, John Bunker, Robert Dodd, and Arthur Keats.6 The attending staff included such accomplished clinicians as Bernard Briggs and Donald Todd. Nick treasured his time at MGH, although several years later, when we were colleagues at Yale, he shared a poignant reminiscence with me. After only 6 weeks of training in anesthesiology, Dr. Greene was summoned to the MGH Emergency Room to anesthetize a 5-year-old child who suffered massive aspiration of gastric contents upon induction of anesthesia and subsequently died. Nick felt personally responsible for the tragedy. However, the strength of his character was sufficiently remarkable that he was not incapacitated by the event, nor did he assign fault to his superiors for their appalling lack of supervision. Instead, he became committed to doing everything he possibly could to prevent others from becoming involved in similar devastating incidents. He was determined that this could best be accomplished “through teaching, teaching, teaching.” And teach he did for the remainder of his life.

In 1950, Nick and Betty journeyed to the University of Edinburgh and the Royal Infirmary of Edinburgh where the dynamic Dr. John Gillies instructed Nick in the technique of high spinal anesthesia to produce near-total or even total sympathetic blockade. Nick subsequently used this approach when he returned to MGH and worked with the distinguished Harvard surgeons Drs. Joseph Vincent Meigs and Robert Linton to reduce blood loss during radical surgeries. It was during his fellowship in Edinburgh that Nick began to systematically make notes on every journal article featuring spinal anesthesia that was published in English from 1910 onwards. This characteristically meticulous approach resulted in the eventual publication of his classic monograph, Physiology of Spinal Anesthesia, which flourished through multiple editions.

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ACADEMIC ASCENT

In 1952, Dr. Greene accepted the invitation to serve as Director of Anesthesia at Strong Memorial Hospital and as Associate Professor of Anesthesia and Assistant Professor of Pharmacology at the University of Rochester School of Medicine. In 1955, he returned “home” to New Haven and Yale as Director of Anesthesiology at the Yale New Haven Medical Center, and Professor of Anesthesiology and Lecturer in Pharmacology at the Yale University School of Medicine. Dr. Greene was Yale’s first Professor of Anesthesiology. When Nick relocated to New Haven, the state of affairs in anesthesiology was dismal. He lamented the fact that the physicians in leadership positions at the university did not possess “even the faintest concept of what an academic anesthesia program involved, or even whether such a program was an oxymoron.”7 Although there was a department of anesthesia within the hospital, there was no independent department of anesthesiology at the university level. With his unique combination of vision and determination, however, Dr. Greene systematically addressed and redressed the situation.

When he arrived, there was no research being conducted in the department, so research programs “had to be established starting from nothing.”7 A more immediate challenge, however, was the personnel situation that was suboptimal in both number and quality of faculty. Nick brought Dr. Alastair Gillies with him from Rochester, along with 2 residents. Over time, he was able to recruit Dr. Frederick Hehre from Columbia–Presbyterian, who later became Associate Director, Dr. Robert Willenkin, an accomplished educator, and Etsuro Motoyama, a gifted pediatric anesthesiologist and researcher. After the first 5 years of Nick’s tenure, the recruitment crunch began to abate as the department became more visible on a national level. This staffing easement allowed him to focus more intensely on developing academic research. This was initially accomplished by his being “absolutely shameless in contacting anyone and everyone who had real money to supplement the modest start-up account the medical school provided.”8 By the mid-1960s, sufficient money had been raised to publish enough research to warrant National Institutes of Health support.

Much of the research in these early years derived from Nick’s interest in spinal anesthesia, focusing on physiologic responses to increases and decreases in sympathetic activity. He soon realized, however, that he “had neither the training nor the time”9 to continue in basic research, and eagerly recruited experienced PhD persons to further develop research. The fruition of his dream to establish a truly academic department in an eminent medical school was made possible to a great extent through a generous grant from the Josiah Macy Foundation. This support allowed Dr. Greene to finance nonclinical faculty and support such nonclinical, but vital, activities as research.6 Dr. Donald Caton, a fully trained anesthesiologist, was appointed to the Macy fellowship and for 2 years worked full time in the laboratory of a senior physiologist investigating the physiology of placental and placental–fetal blood flows, an experience that established the foundation for his productive career in obstetric anesthesia.

In 1964, Luke Kitahata, MD, PhD, joined the faculty. Dr. Kitahata had been head of the Department of Surgery at Japan Baptist Hospital and had a PhD in neuropharmacology. He immigrated to the United States in 1960 to undertake a residency in anesthesiology under the tutelage of Dr. Joseph F. Artusio, Jr., at Cornell–New York Hospital Medical Center. At Yale, Dr. Kitahata made several notable contributions, discovering that seizure activity as a result of local anesthetic toxicity originated in the amygdala. Importantly, he advanced our clinical understanding of spinal nociception. In his own autobiography, Dr. Kitahata remarked, “I was indeed fortunate in that Dr. Nicholas M. Greene … was truly an expert editor, and I learned a great deal from him about how to write scientific papers.”10 Nick’s hiring of Luke Kitahata proved pivotal in advancing Yale’s contribution to understanding of the pathophysiology and treatment of pain. Shortly after he succeeded Nick as Chair of Anesthesiology, Luke established the Yale Center for Pain Management, a multidisciplinary pain resource. He engaged talented basic scientists, including Jerry Collins, Norman Gillis, Carol LaMotte, and Robert LaMotte, to study nociceptive anatomy, physiology, and pharmacology.

In 1971, anesthesiology finally emerged as an independent department in the medical school, with Nick as the founding chair. He served with distinction as Chair of the department until 1973, when he decided to step aside to pursue other challenges. He believed that after 18 years the department would benefit from “new blood, new ideas, new enthusiasm.”4 In choosing this course, Nick became the first Chair of an academic department of anesthesiology to voluntarily relinquish the position of chairman and remain in his department. This is in contradistinction to Dr. Stuart C. Cullen, who stepped aside at the University of California, San Francisco, to become Dean there in the 1960s, and to Dr. E.M. Papper, who left the chairmanship at Columbia to become Dean of the University of Miami School of Medicine in the late 1960s. Dr. Greene continued in the department as professor until 1987, when he assumed the role of Professor Emeritus. His more than 4 decades of devotion to anesthesiology at Yale were honored in 2002 by the establishment of the Nicholas M. Greene Professorship of Anesthesiology, an endowed chair. Contemporaneously, the Betty Greene Research Fund in Anesthesiology was established to pay tribute to the “woman behind the man.”2

During his illustrious career, Dr. Greene was awarded many well-deserved honors, including an honorary degree as Fellow of the Faculty of Anesthetists of the Royal College of Surgeons of England (FFARCS), progenitor of today’s Royal College of Anesthetists. He delivered several eponymous lectures, including the Seldon (Fig. 2), Griffith, and Rovenstine lectures. The recipient of several medals for his contributions to anesthesiology, he especially treasured the Columbia University College of Physicians and Surgeons’ Silver Medal presented to him on the occasion of its bicentennial. In 1989, the American Society of Anesthesiologists’ (ASA) highest honor, the Distinguished Service Award, was conferred upon Dr. Greene.

Figure 2

Figure 2

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EDITORIAL ACHIEVEMENTS

Although Nicholas M. Greene was a Renaissance man who excelled in many domains— which included clinical medicine, education, research, ornithology, cross-country skiing, and tennis—he was especially outstanding as an editor. He served initially on the Editorial Board of Anesthesiology from 1965 to 1972 and then as its Editor-in-Chief from 1973 to 1976. He became convinced, however, that the anesthesiology community in the United States needed more than one high-quality journal.4 This certainty led him to accept the challenge of developing a second journal of stature comparable to that of Anesthesiology. No doubt some of his contemporaries considered this a quixotic endeavor, but Nick was to prove them wrong. Appointed Editor-in-Chief of Anesthesia and Analgesia…Current Researches in 1977, Dr. Greene brought to the position impressive experience as an editor combined with superb academic credentials. Under his gentle, but firm and meticulous, guidance, the journal, the oldest active publication devoted specifically and exclusively to the specialty of anesthesiology, was directed to new levels of accomplishment that assured its future.11 Indeed, his tenure as Editor-in-Chief proved to be transformative.12

It is essential, however, to understand the context in which Dr. Greene assumed editorship of Anesthesia and Analgesia … Current Researches. Although the journal had enjoyed considerable esteem during its early years, with the death of Dr. Francis Hoeffer McMechan in 1939 and the outbreak of World War II, it lost much of its momentum and prestige. In addition, the journal faced increasing competition from Anesthesiology, a relatively recently launched publication that had a captive audience owing to its status as the official journal of the ASA. Apparently, when Dr. Thomas H. (Harry) Seldon volunteered in 1954 to become editor of Anesthesia and Analgesia … Current Researches, he resuscitated a dying publication. With enormous effort, Dr. Seldon infused new life into the journal and made it saleable. Although clinicians found the journal readable, academicians derided its lack of scientific stature. Recognizing that Dr. Greene had done an outstanding job with Anesthesiology, several members of the Board of the International Anesthesia Research Society (IARS), however, were apprehensive when Nick was selected as the successor to Harry Seldon. They were fearful that the publication might “become too cat–rat oriented”13 and become less clinically helpful to its readers. As IARS Trustee John T. Martin stated, “My fear was that the style of Anesthesiology would be transferred involuntarily, but inescapably, to our Journal because that had been Nick’s experience base…. But, as his tenure progressed and the growth of the Journal continued while its scientific quality improved, these fairly widespread misgivings and apprehensions proved groundless.”13

Imbued with a clear sense of independence and the need for proper boundaries, Dr. Greene broke with tradition and declined to become a member of the IARS Board of Trustees when he was appointed Editor-in-Chief. As a result, the journal became independent of, yet remained accountable to, the IARS Board. He restructured the editorial board to comprise editors who were qualified to proffer valid assessments of submitted manuscripts (Fig. 3). Under Dr. Greene’s stewardship, and with the strong support of the IARS Board,4 the journal underwent a total cover-to-cover redesign and was renamed Anesthesia & Analgesia in 1979. With its new moniker, revitalized appearance, and outstanding leadership, the journal by 1980 attracted an increasing number of excellent manuscripts that necessitated its appearing monthly rather than bimonthly.14 In 1983, Elsevier Science Publishing (New York, NY) assumed publication of Anesthesia & Analgesia, replacing the previous arrangement that geographically separated the production and distribution of the journal. Circulation grew and profitability increased. The added revenue from subscriptions and advertising facilitated expansion of IARS’s research support for the specialty, which by the early 1990s granted approximately $1,000,000 to fledgling investigators.12 Importantly, Dr. Greene was committed to the concept of anesthesiology as an international specialty. Toward that end, he appointed 4 editors who were not American physicians to the Editorial Board of Anesthesia & Analgesia.4 After 14 years as Editor-in-Chief, Dr. Greene turned over the helm to his successor, Dr. Ronald D. Miller, in 1991.

Figure 3

Figure 3

In 1992, the initially skeptical IARS trustee, Dr. John T. Martin, reflected, “As I have said, Harry Seldon brought the Journal out of the wastebasket to a position of usefulness and acceptability. The results of Nick Greene’s stewardship as Editor-in-Chief are that the Journal is now highly competitive with any other publication in its field. I find myself hard-pressed to adequately express my admiration for the superb job Nick did in fourteen years as our Editor-in-Chief…. The publication prospered and its stature in the eyes of the academic community rose while its clinical readership continued to be supportive.”13

During his 26 years of editorial involvement, Nick emphasized the importance of publishing original and important manuscripts that were well written and reflected a “felicity of expression.” A masterful writer, he was well equipped to hold authors to the highest of standards. Since my medical student days, I had admired the precision and clarity with which Dr. Greene wrote, imagining that he had a natural, effortless talent for finding felicitous phrases on the first attempt. One day in the 1990s I finally mustered the temerity to ask Nick his recipe for success with the written word. To my amazement, he informed me that he writes and “rewrites every manuscript at least ten times.” Perspiration, rather than inspiration, was the key to excellence!

Although he attracted many excellent scientific manuscripts to Anesthesia & Analgesia, he bemoaned the fact that the “inexorable” proliferation of scientific journals that occurred in the 1970s and 1980s had the undesirable effect of enabling a larger number of manuscripts to be published that were insignificant or irrelevant, that “merely filled in the inconsequential interstices of our knowledge.”15,16 He firmly believed that the intellectual and professional stature of any branch of human endeavor can be evaluated by the caliber of the written record that it produces.16 With that as his lodestar, he lamented the “continuing erosion in use of the English language” and the “vacuous if not fatuous space-occupying lesions that clutter the pages of our journals.”16

Believing that the triad of originality, importance, and validity constitutes the basis of quality in scientific writing, Dr. Greene deplored the profusion of low-quality articles that detract from the stature of our journals and, by extension, tarnish the standing of our specialty. He further decried the “current balkanization of anesthesia literature into smaller subspecialty journals with restricted circulation” because he thought this phenomenon ultimately becomes self-defeating. An important, original article, he argued, deserves widespread attention as a result of publication in a major journal with wide circulation. “Authors with something important to say will shy away from smaller subspecialty journals that will inevitably carry papers of ever decreasing quality.”17 Importantly, he asserted that patients do not come to us with only subspecialty disease. “We must care for the entire patient, not just part of him or her. We must stay abreast of what goes on in areas outside our area of special interest within anesthesiology if we are to be truly expert in a specialty as uniquely transdisciplinary as anesthesiology.”16

Dr. Greene recognized that specialty journals exist to transmit new information, to recruit people outside anesthesiology into the specialty, to support research, and to serve archival purposes. He even acknowledged that journals exist to support their sponsor, be it a professional organization, company, or commercial enterprise.18 He felt most passionately, however, about the educational mission of journals and was committed to fostering education both within and outside the specialty. Furthermore, he believed that auctorial education was a vital responsibility of an editor to authors, especially nascent authors. He was uniquely gifted in this area, having an extraordinarily gentle and encouraging touch when he took his red pen to a fledgling author’s submission. Alluding to this special talent of Nick’s, Ron Miller perspicaciously observed, “In fact he is often described as the only editor-in-chief who could make an author feel good about having a manuscript rejected.”12

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THE WOOD LIBRARY-MUSEUM OF ANESTHESIOLOGY

Given his reverence for the written word, it was perhaps inevitable that Nick gravitated toward the Wood Library-Museum of Anesthesiology (WLM). He became a trustee of the WLM in 1987 and worked indefatigably to develop its influence nationally and internationally. He was the founding chairman of the WLM’s Publications Committee, and arranged to have seminal books related to anesthesia translated into English. These included such gems as the Overton monograph on the theory of narcosis, as well as writings by Claude Bernard and other luminaries. No doubt, however, his favorite WLM project was the establishment of the WLM Laureate of the History of Anesthesia program, which he viewed as an opportunity to publicize and underscore the value of the rich heritage of anesthesiology. This international initiative consists of a Laureate Committee that, every 4 years, solicits nominations from throughout the world for the honor of being elected WLM Laureate from among individuals who have made outstanding contributions to the anesthetic historical literature over several decades. The program started in 1996 by recognizing the first WLM Laureate of the History of Anesthesia, Dr. Gwenifer Wilson from Sydney, Australia. Fortunately, Nick lived to see one of his most admired protégés, Dr. Donald Caton, invested as the 2004 Laureate. Dr. Greene died 2 months after that investiture, but his legacy to the WLM is enduring. Indeed, Nick recruited Dr. George Bause, the Honorary Curator of the WLM, to join the organization in the 1980s, and George continues to make remarkable contributions in terms of time, talent, and treasure to the WLM. Nick recruited me to the WLM Board in the 1990s, enriching my life by allowing me to be part of this special coterie of bibliophiles. The privileges of serving as President of the WLM from 2001 to 2004 and currently as Chair of the WLM Publications Committee have been two of the most rewarding experiences of my professional life, and I shall be forever grateful to Nick for making this possible.

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HUMANITARIAN OUTREACH

Ornithology was Nick’s avocation, if not addiction (Fig. 4). He had studied birds on every continent except Antarctica and was highly respected by the cognoscenti of ornithology. In the early 1970s, he taught anesthesiology at the newly opened University of Tunis in North Africa. It was, however, his ornithologic, rather than medical, interests that subsequently attracted him during the 1980s to East Africa, with its >700 species of birds and other exotic wildlife. Although beautiful, East Africa is economically destitute and tragically lacking in high-quality medical care. After 4 safaris to East Africa, Nick began to realize that the impoverished people of East Africa were more deserving of his attention than were his beloved birds. He reflected on the fact that in Tanzania, for example, only 3 physician anesthesiologists were available to serve the country’s population of 30 million. Merely 10% to 15% of the volume of surgery that should be done in East African countries could be performed because of the bottleneck created by the lack of anesthesia care. Dr. Greene believed this untenable situation developed when the East African nations, upon attaining their independence, passively accepted the prevailing view of European colonial powers and international health organizations that anesthesia played no role in the delivery of health care.19 The result was an overproduction of surgeons who, ironically, were unable to operate owing to the paucity of anesthesia providers. Most anesthesia in East Africa was provided by lay persons who, after 2 years of education as medical assistant trainees and another 2 years as practicing medical assistants, became eligible for a 1- or 2-year (depending on the country) course that made them anesthetic officers. And there were far too few anesthetic officers. Feeling compelled to do something constructive to improve the abysmal level of anesthesia care in that haunting part of the world, Nick obtained the requisite financial support jointly from the ASA and the Foundation for Anesthesia Education and Research (FAER) to initially fund the Overseas Teaching Program (OTP). In October of 1989, the ASA House of Delegates approved a 5-year OTP to be based in 2 countries in East Africa.20 The 2 locations where the first programs were established were Lusaka (University of Zambia Medical School with its 1500-bed teaching hospital) and 420-bed Kilimanjaro Christian Medical Center (KCMC) in Moshi, Tanzania. The University of Zambia’s Teaching Hospital (UTH) performed a wide range of surgical procedures exclusive of organ transplantation and open-heart surgery. Teaching included medical students, medical assistants, and a few physicians (mostly surgical house officers or general practitioners). At KCMC, however, teaching involved only anesthesia officers.21 The types of operations performed, the types and severity of concurrent diseases, and the ages of patients, though similar at UTH and KCMC, were vastly different from what is seen in Europe and North America. How often does an American clinician, for example, encounter a child whose arm was amputated by a crocodile while the child was swimming? Alternatively, although it is not uncommon in the United States to anesthetize a nonagenarian, the average life expectancy in Tanzania in the 1990s was 52 years. It was, therefore, unusual to care for a geriatric surgical patient.

Figure 4

Figure 4

Nick arranged for anesthesiologists from the United States and Canada to serve as volunteer teachers to educate anesthetic officers to provide safer patient care with the limited resources they had. He always took great pains to emphasize that OTP was unique.19 First, and of supreme importance to Nick, was the fact that the program was designed by Africans, not Americans or Europeans. Second, OTP concentrated on teaching, both clinical and didactic, rather than clinical service. It was designed to respond “to the Third World plea: don’t give me a fish; teach me how to fish.”21 Moreover, the teaching emphasis was based exclusively upon what is germane to the practice of anesthesia in the setting in which the trainees will be functioning, rather than upon circumstances extant in the United States. Drugs and equipment considered standard in the developed countries might not be available for decades, if ever, in these underprivileged areas. Third, OTP was affiliated only with anesthesia training programs that were already established. Fourth, the program recruited experienced anesthesiologists to teach, one at a time, providing year-round educational assistance rather than erratic, short-term help. Fifth, and finally, the teaching involved not only trainees but also persons at policy-making and decision-making levels both locally and nationally.

One of my fondest memories of Nick is of the lunch we shared at Mory’s, that last bastion of male chauvinism in New Haven, immediately before my departure in 1993 for East Africa to serve as an OTP volunteer. With an impish twinkle in his eyes, Nick leaned across his plate of mashed potatoes and uttered conspiratorially, “Now I will tell you what to really expect in Tanzania….” Dr. Greene felt passionately that OTP volunteers have a uniquely rewarding opportunity to expand their understanding of how 85% of the world lives when they experience the Third World not as a tourist but as a physician and teacher. He admonished the volunteers to be culturally sensitive and to restrict discussions and remarks to teaching anesthesia.20 Gratuitous comments about poverty, local politics, and class distinctions were, in his lexicon, totally inappropriate. He urged circumspection when taking photographs because impoverished people are reluctant to have their destitution documented.20

During our memorable lunch at Mory’s, Nick warned me that transportation in Tanzania was primitive. There was, he said, a large bicycle in the compound where the OTP volunteers lived. I thought this was encouraging and told Nick that I loved riding bicycles. He then underscored that the bicycle was “quite large and heavy,” and that there was “no way a 5-foot 7-inch, small-boned woman who weighed 90 pounds could possibly maneuver the bicycle.” I demurred, attempting to reassure him that I was an excellent bicyclist. Nick then gave me a skeptical look and wisely changed the subject, probably in an attempt to let the notion that I might encounter bicycle difficulties marinate. A few minutes later, I informed Nick that I would love to climb Mount Kilimanjaro while I was in Africa. At this point, the usually calm, stolid, and emotionally inscrutable Nick exploded in exasperation, “Kathy, there are damn better ways to die!” I then was given a fatherly lecture on Personal Safety 101. (Parenthetically, Nick was right about the bicycle.)

Living conditions were harsh in East Africa, and political, cultural, and economic realities even harsher. Reflecting upon the progress of the OTP during its first 4 years, Dr. Greene felt that it had achieved some measure of success in a domain where changes, both permanent and substantive, are notoriously elusive. He took quiet pride in the contribution of OTP to the approval of a 5-year, postdoctoral degree program in anesthesia at the University of Zambia.22 The awarding of a Master of Medicine (Anaesthesia) degree provided a means of certification of physicians trained in anesthesia exclusively in Africa. This certification obviated the expensive custom of traveling to Europe for specialized training, a practice that often contributed to self-defeating “brain drain.” Sadly, however, the program in Zambia was terminated in its sixth year; the authorities had demanded OTP to be responsible for all clinical anesthesia coverage and to manage their anesthesia department rather than concentrate exclusively on teaching. The Lusaka site was replaced by the establishment of the OTP in Accra, Ghana, on the West Coast of Africa. After 5 years, Nick stepped down as Director of the OTP. He was awarded a President’s Citation at the 1994 ASA Annual Meeting in San Francisco for his “tireless devotion” toward improving the availability and quality of anesthesia teaching in developing countries.

During the remaining years of Nick’s life, the viability of the OTP began to wane. Neither an optimist nor a pessimist, Nick was sufficiently realistic and philosophical to accept that he had made a valiant effort to improve an entrenched “system” of inadequate anesthesia care. Perhaps the gains were not as dramatic or enduring as he had hoped, but they were improvements nonetheless.

Today the only remaining teaching program consonant with the original mission of the OTP is the collaboration between the ASA and the Canadian Society of Anesthesiologists in Rwanda. The ASA sends approximately 6 members to Rwanda annually. The Rwanda program, however, is expected to end in 2015.

In 2011, the ASA established the Nicholas Greene, MD, Award for Outstanding Humanitarian Contribution as a lasting tribute to the vision and generosity of its namesake.

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SUMMING UP

Nicholas M. Greene, MD, was a beacon of wisdom and gentility to the many people who loved and admired him. In an age during which style often trumps substance, Dr. Greene epitomized the virtues of integrity, humility, dedication to hard work, and meticulous attention to detail. I will close by quoting from the eulogy I wrote soon after Nick’s death on December 28, 2004: He had zero toleration of pretentiousness, prevarication, laziness, or ineptitude. I believe that, for Nick, the highest expression of an educated mind was the informed compassion that people are strong enough to feel and to demonstrate toward one another.

Nicholas M. Greene’s example of dedication and integrity touched our hearts, enlivened our imaginations, expanded our horizons, and enriched our perspective and understanding of ourselves and others. I am convinced that, when he died, people half a world away, at the base of majestic Mount Kilimanjaro, could feel the light dim.1

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DISCLOSURES

Name: Kathryn E. McGoldrick, MD.

Contribution: This author researched the background material and wrote the manuscript.

Attestation: Kathryn E. McGoldrick approved the final manuscript and is the archival author.

This manuscript was handled by: Steven L. Shafer, MD.

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ACKNOWLEDGMENTS

The author thanks Honorary Curator Dr. George Bause, Karen Bieterman, Margie Jenkins, Teresa Jimenez, and Felicia Reilly of the Wood Library-Museum of Anesthesiology (WLM) for their valuable assistance in retrieving archival material for this manuscript. She also thanks Dr. Selma Calmes, a trustee of the WLM, for her helpful suggestions concerning primary reference material. Finally, gratitude is extended to Drs. Bause, Calmes, Donald Caton, Doris K. Cope, and Elliott V. Miller for their personal reminiscences.

a Available at: Ancestry.com.1930. United States Federal Census. Pelham Manor, Westchester, NY; Roll: 1664; page: 19A; Enumeration District: 316; Image: 853.0; FHL microfilm:2341398.
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b Available at: http://www.generals.dk/general/Greene/Douglass_Taft/USA.html. Accessed June 11, 2012.
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