NIP was a tertiary level centre with the ability to perform renal transplants and cardiac surgery and stuff. But also we had a very large caseload of run-of-the-mill infections, and the pathology of poverty – malnutrition, tremendously advanced cancers, all kinds of things. It’s a hospital that covers the full spectrum of human pathology, from zero to 18 years of age, so I was exposed to a massive amount of paediatric human pathology in the four years that I spent there.
How did you manage the two things – your career and bringing up a family?
Well, my ex-wife had some psychological problems. We decided to split and I kept my three children. I was in the second year of my residency training when the divorce happened, so it was tough. Usually I would take the children to school in the morning, and I would take an hour off to eat with them around 2 p.m. At 3.15 p.m. I would run back to the hospital and continue my activities, and then in the evening I would go back to the university to teach. So it was crazy: I didn’t have much time to be with my children, so I had to spend what is now called ‘quality time’ with them. And eating is an opportunity to exchange a lot of things; it’s a very important time of the day, and an educational experience for children.
And did you remain close to them?
Oh yes; they lived with me until they all left home. They are married now, and I have one granddaughter.
When I divorced I met my second wife, who was a medical student. It was tough, because she came from a very conservative family that wanted her to marry someone without a lot of baggage, and I had three children, but she finally married me. After four years together in Mexico we decided to try to come for one year to the United States.
I went to speak with Dr Pérez-Tamayo and he mentioned González-Crussí, who was a huge figure for me. He was a fantastic paediatric pathologist, a famous Mexican, and he had written Notes of an Anatomist. So it couldn’t get better. Dr Pérez-Tamayo wrote a letter and a week later I got a phone call from Dr González-Crussí inviting me to visit Chicago. He said, ‘If Dr Pérez-Tamayo recommends you, you’re accepted’!
Your intention was to come and do some learning here and then go back home?
Absolutely. I never even took the United States Medical Licensing Examinations [USMLE], so I wasn’t officially allowed to take part in any medical procedure because I had no credentials. I was a research associate doing projects, and I was just learning pathology on the side with Dr González-Crussí and his team. But then things got complicated with my ex-wife and it was very difficult. I sent my children on vacation to Mexico and they were kept there against their will. Finally I recovered my children in a complicated transaction that took all my little savings. My wife was pregnant at that time, and we decided to stay in the United States and cut our ties with Mexico at that moment.
Dr González-Crussí told me, ‘If you can take the USMLE, get your credentials in time to be appointed fellow, I will keep the position for you.’ I got my licence just a week before the deadline and I stayed on in Chicago as his fellow in paediatric pathology.
This was already my fourth year in Chicago, and then I saw that Yale University was looking for a paediatric pathologist. That was in 1994, and I was there for fourteen years.
Tell me about your time with González-Crussí. You had started reading his essays before you met him, had you?
I have read every book he has published to date. Dr González-Crussí is a vastly cultured man. He speaks many languages. But my first impression was that he was a fantastic pathologist. Pathology is a difficult trade; you need to be special in certain ways. It’s like, to do basketball you need to be tall. Well, to be a good pathologist there has to be something in your brain that allows you to orient yourself in the visual, spatial field, and he had a particular talent with that. But also massive medical information – he knew everything, and I was very impressed with that. Then I started reading his contributions to medical literature, and saw that he was able to jump from one topic to another in paediatric pathology, always as if he was an expert in that particular topic.
In his writings Dr González-Crussí has considered death a great deal. What are your own thoughts about death and dying?
I’m not a religious person, so I have tried to look at the process of death from the most scientific angle. But even so I recognise there are certain things completely beyond our scientific understanding. And I have had my own personal experiences – I don’t make too much of them, but others perhaps could.
I was called to do an autopsy on a baby who had a disease that required very rapid intervention in order to make the diagnosis, and to provide genetic counselling to the family. The only option was to go immediately after her death into her heart and take some parts for examination. The clinician called me before the baby died, asking, ‘Would you be available if she dies in the night?’ He called me later and said, ‘We’re going to interrupt artificial life support in half an hour, okay?’ So I drove over in the night, and they came with the baby a few minutes after she died.
When you die, cells are still viable in many organs, and when you stimulate certain tissues that are contractile they can develop mechanical activity. And what happened was that I was doing the autopsy with the head of the paediatric intensive care unit at my side, and when we got to the heart it started moving. The baby was dead, but the heart was sort of beating … Not really, but in a disorganised fashion there was a beat. I felt at that moment like an Aztec prince taking out the heart of a human sacrifice, if you will. And I wondered at that moment, ‘What am I doing here, opening the heart of this little baby?’ Of course, that was just for a flash second, and I understood that what I was doing was very important. The diagnosis was made, and the family now knows what type of disease they might carry, and understands what to do. It was a very valuable autopsy. But the experience was very chilling.
Is it something that has lived with you?
It has. It has. You wonder … In many autopsy rooms there is a statement in Latin that says something like, ‘This is a morgue, the place where death helps those that are still alive.’ And that’s exactly what came to my mind – the contribution this baby was making to her family and to humankind was huge. So I see autopsy as the most exhaustive, and final, medical exam that a doctor can provide for a patient. I don’t see autopsy as something horrendous and macabre.
But it was just too close to the event of death – was that what got through your professional defences?
It was too different. When you do an autopsy, usually the body has been in the refrigerator for several hours, it’s cold, it has changed colour and there are many familiar things. But with this little kid I saw something different. She was dressed as a baby. She was pink and warm. It is very difficult to open a body like that – and just very different.
People can lose track of what life is all about. Frequently I see a case where the clinicians have spent weeks, or sometimes months, treating a patient. They know all the parameters – respiratory, cardiac, etc. – and they follow those and watch the curve of progress up, or down. Then finally, when the patient dies, they come to me and say, ‘What happened? We don’t understand how this patient died.’ And my answer on several occasions has been, ‘Well, I can’t understand how this patient lived.’
Our practice of medicine nowadays is so fragmented into different specialities and little tasks that we as doctors lose track of the patient. So they come and say to me, ‘But this patient was doing fine. The blood pressure was this and that, the urine was so …’ But when I just show them the heart, the lungs, the whole thing … I mean, you can no longer recognise the human body. The baby weighs two or three times the normal weight because it has been inundated with fluids. It has seven or eight catheters in different places. It has been operated on three times… What I’m trying to say is that medicine is now a practice in which lots of specialists lose track of the big picture, and frequently it is only the pathologist that can try to bring all the loose ends together.
There are situations in which specialists put too much trust in their