REINHARD E. ZACHRAU, M.D. Treats his Second-Year Medical Students with Tough Love
"I am not congenial and teaching is not a popularity contest," insists the director of the Pathology/Pathophysiology course. Then why do students revere him and consistently rate his grueling program tops on surveys?
By Marjorie Roberts
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This familiar pose is the trademark of Reinhard E. Zachrau, M.D., professor of pathology and educator extraordinaire. There are more than 360 hours of teaching pathology/pathophysiology that he must coordinate for 190 students in the second-year class. |
It took faith
In 1986 there were naysayers aplenty when Dr. Zachrau initially revamped the course in Pathology that was overdue for an overhaul. "We designed it without any model," he says. "It was a struggle at first, but when you know it has to be done, the labor pains are worth it." The "we" were Richard Levere, M.D., former chairman of the Department of Medicine, and Yutaka Kikkiwa, M.D., then chairman of the Department of Pathology. "They okayed the integration of the courses of Pathology and Introduction to Clinical Medicine and left me to implement it," he says. "Pathology is a course in disease processes, and pathophysiology investigates the clinical correlates that deviate from the normal," Dr. Zachrau begins. "The beauty of what we did was to bring it all together - what are the abnormalities, how they are diagnosed and what we do about it? We integrated the clinical aspects from the beginning. For example, in cardiology we taught abnormalities of the structures, then of function and finally, how these abnormalities manifest themselves in patients." And to give the clinical side more clout, Dr. Zachrau implemented the use of two "Harveys," $80,000 (each) computerized mannequins that can simulate a variety of symptoms and conditions to help students hone their skills in diagnosing cardiovascular ailments. The buy recommendation came from Susan A. Kline, M.D., vice provost, university student affairs and executive vice dean, academic affairs. She had this to say about Dr. Zachrau: "He teaches a lot more than pathology. He teaches professionalism and duty and being meticulous in everything you do. The high standards he sets makes his course the tie that binds everything together... He is a role model because he never asks more of them than he does of himself."
An autopsy
Another program enhancement was Dr. Zachrau's insistence that every student witness an autopsy, followed by a writ- ten report and an oral examination. Ironically this may be the last year for the exercise due to the dearth of procedures being done at affiliated hospitals. "There are not enough to go around and it will be a loss," he fears, "because the autopsy assignment forces students to apply all their newly acquired knowledge in an integrated fashion. Beyond providing the ultimate verification of the cause of death, it may also show unexpected side effects of whatever drugs were being used, and may turn up abnormalities in the patient that weren't even suspected... "Some clinicians say you don't need autopsies because the modern diagnostic procedures are so accurate. Well, I wouldn't be for it if I didn't see the value in it," he says. "You know there are benefits to society beyond those of the individual." His voice loses intensity though his face shows anger when Dr. Zachrau touches on a childhood that coincided with the rise of the German war machine in 1939. "I was a refugee twice," he declares. "The Russians invaded East Prussia and we ended up in the outskirts of Dresden. I was five or six and we went through the heavy bombings. After the war that area was turned over by the allies to Russia and I became a refugee a second time... I seldom go back to Germany - the last time was to bury my mother." His pride is restored when he mentions having graduated medical school at the University of Heidelberg, "founded in 1386 and the oldest in Germany, and one of the oldest in Europe. You get only a physician's degree," he advises. "If you want to call yourself doctor you must write a doctoral thesis and defend it." Dr. Zachrau's dissertation explored the bio- logical behavior of ovarian tumors.
Fond remembrance
Although he admits to having had no thoughts of teaching while he was a student, "I knew I would have to pay back eventually," he says. "My God, I had such a great time in medical school, with no responsibility other than for my own growth." His citation in the 1995 Annual Report dedicated to the best teachers contained the following reply to the question, Why do I teach?
"I feel fortunate having had some of the most magnificent teachers imaginable, and the more time has passed the more I have come to realize how much they have given me and how much I am indebted to them. With my own commitment to teaching, I hope to pay back some of this debt, while enjoying the privilege of assisting in the births of new colleagues."
During the mandatory two-year rotating internship at the 2,400 bed medical center in Karlsruhe, Germany, Dr. Zachrau spent many sleepless nights devouring the essentials of surgery, internal medicine, obstetrics and gynecology and pathology. The latter would serve him well when, after only a couple of years, he decided to put practicing internal medicine and family practice on hold. Then it happened - a surprise turn of events in 1969 that altered his life. "During my internship I did research trying to isolate oxytocinase from the placenta, an enzyme that one Janis Klavins was also researching at Duke. I was on the verge of accepting his offer to come and work with him in North Carolina when he stopped writing - for eight months. Then one day he turned up in the pathology department at Downstate Medical Center in Brooklyn and he still wanted to work with me," Dr. Zachrau says.
"I wanted to find out if the placenta was actually the source of oxytocinase, which inactivates pituitary oxytocin, to keep the pregnant uterus from contracting. I went to see him, but when I arrived his laboratory was not even set up and his electron microscope was sitting in a crate in the basement of the hospital. For six months I struggled with the situation, performing the duties of a pathology resident. I'd really had enough after another six months went by and finally made the decision to return to Germany."
No going back
Fate intervened again in the person of Whitney Branwood, M.D., a pathology professor he had known at Downstate who went to work at what was then called New York Medical College, Flower and Fifth Avenue Hospitals in New York City. Dr. Branwood offered Dr. Zachrau a research position and a residency in pathology in lieu of going home disappointed. And that's how he met Maurice Black, M.D. '43, professor of pathology and a College grad. "I decided to work with him for two years and it turned into forever," Dr. Zachrau smiles.
His eyes widen and he becomes more animated when speaking reverentially of the renowned breast cancer researcher. (The editor of the journal Cancer asked Dr. Zachrau to write a tribute to Dr. Black upon his death in 1996.) Like so many innovators, Dr. Black held revolutionary ideas. Dr. Zachrau explains, "Forty years before it was accepted by the medical community, he declared that the mastectomy surgical procedure was inconsistent with the biology of breast cancer. He was right. I said to myself then, this is a fascinating man and that was the end of going back to Germany."
It also ended his expectation of becoming an internist. While doing research he completed his pathology residency and was chief resident for most of the 1970-1973 term. In 1972 he earned his first faculty appointment as an assistant instructor. A full professor since 1988, with tenure added three years later, Dr. Zachrau would again embark on a radical change for the pathology/patho- physiology course as the millennium approached.
"... I really wanted to create a different state of mind for the student. Rather than being passive listeners in a dark auditorium, I made them responsible for what they learn."
Other fare
Second-years do not live by pathology alone, and whether it is microbiology or pharmacology, it becomes the province of Dr. Zachrau, who schedules all courses taken in the second year. "There are 190 people with problems, and some who need mentoring, and there are recommendation letters that must be done in anticipation of students applying for residencies," he says. "Oh, the logistics of this enormous course! There are more than 360 hours of teaching [pathology/ patho physiology] to be coordinated for 190 students." They are further divided into 18 groups for problem solving and 9 groups of 20 for clinical pathological correlation exercises - all due to the radical makeover he designed. "We made a critical conversion in the lecture-based course to a self-study oriented format," Dr. Zachrau explains, "the most daunting task I ever faced." He emphatically acknowledges the supportive roles of Dr. Kline and Karl Adler, M.D., then dean of the School of Medicine. "He was very apprehensive about the sea change that would occur in the curriculum. "We eliminated 70 percent of conventional lectures, leaving time for guided self-study and for more interactive exercises in lab [modules] with a 20 to 1 ratio of students to instructor. Also for problem- solving exercises, with 10 to 12 students prepared to solve or at least learn to recognize what information is required to solve the problem... I really wanted to create a different state of mind for the student. Rather than being passive listeners in a dark auditorium, we made them responsible for what they learn. Now they can do it their way, knowing they can do it however it's best for them. Then we will verify if they achieved what was meant to be achieved!" The students already know that answer. By any measure, internal or external, the results of the USMLE Step I boards show since 1995 that the New York Medical College class scores consistently exceeded the national averages.
His research
"The placenta faded away once breast cancer got a hold of me. It never let go," admits Dr. Zachrau as he outlines his concept of cancer: "In a nutshell, cancer is a disease that reflects dynamic inter- action between the cancer as the aggressor, and the defense mechanisms of the patient - just like in infectious diseases. I'm focusing on characterizing the specific features of a cancer to determine its aggressiveness, and I measure the cell-mediated immunity of patients that is directed specifically against their own cancer cells through skin testing. It is analogous to skin testing for TB and this is how it's done. "We prepare test material from a patient's own cancer and attach it to a glass coverslip that is applied to a small skin abrasion. After 30 to 36 hours the coverslip is removed and then examined for evidence of lymphoid cellular reactivity. Our volunteers are referred by surgeons. What we are after is the documentation that the clinical behavior of cancer is not just determined by the properties of the cancer cells, but also by the effective- ness of the patients' immunological defense against them. I am trying to determine how best to assist a patient in maintaining an active defense directed against a cancer to prevent it from recurring. And, we try to stimulate anti-cancer, cell-mediated immunity in patients who don't have it."
There are nearly 100 breast cancer patients currently being followed by Dr. Zachrau, who at one time had many more in his study. He has no help, but is counting on getting a full-time technician to work in his lab. Incidentally the lab is one of a kind, with matching furniture arranged for maximum efficiency, posing in a state of cleanliness that may never be equaled anywhere at any time. It is the way Dr. Zachrau conducts his affairs, personal and professional, though he admits to having two, no three other passions in his life.
"My greatest love is sailing, but it will have to wait until I retire," he says. "I love to read, and recently finished Dante's Inferno. This is the third time I have read it, and this time the edition provided a juxtaposed version in Italian. I don't speak Italian but knowing Latin helped a lot." And then there is his dog, a black miniature dachshund named Lord Nelson the Second. "I call him Lordy," he confides. "He is all muscle and there is not a gram of fat on him... I've never had him fixed. The idea had such a finality to it I couldn't bring myself to do it."