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Dan DeMarco (Figure (Figure11) was born in Natick, Massachusetts, on 28 September 1956 and grew up in that area. At age 13, his family moved to Dallas, Texas, where he has lived ever since. He was accepted at the University of Texas Southwestern Medical School after 3 years at the University of Notre Dame. His training in internal medicine and gastroenterology was all at Baylor University Medical Center at Dallas (BUMC). He finished his fellowship in gastroenterology in June 1985 and has been at BUMC ever since. In addition to his extremely busy practice, he participates actively in BUMC's teaching activities and has been twice elected Teacher of the Year. Not only does he teach the medical residents, but he daily tutors the gastroenterology fellows. He has served as chairman or member of the Institutional Animal Use and Care Committee since 1995, the Liver Transplant Selection Committee since 1987, the Emergency Services Committee since 1992, and the Medical Advisory Committee of BUMC since 1999. He has published 16 articles in peer-reviewed medical journals or chapters in prominent books. Dr. DeMarco is married to Dr. Cara East, a cardiologist at BUMC, and they have one son. He is a major player on the BUMC scene and a good guy, and it was a pleasure to talk with him.
William Clifford Roberts, MD (hereafter, Roberts): Dr. DeMarco, I appreciate your willingness to talk to me and therefore to the readers of BUMC Proceedings. To begin, could you talk about your early memories, your family, and what it was like growing up in Massachusetts?
Daniel Carl DeMarco, MD (hereafter, DeMarco): Although born in Natick, I grew up in Wayland, Massachusetts, a town of 10,000, with one high school and 2 ZIP codes. My father was a civil servant who worked for the army. He was a research chemist specializing in textile chemistry, specifically water repellents. This was as the Vietnam War was gearing up. My mother was a typical housewife. I had 3 sisters, 1 older, 2 younger. We lived in Massachusetts until I was 13. Then my family moved to Dallas. My father left his job with the army and became a quality control expert for the Haggar Company. He ultimately became their vice president in charge of quality control and product development.
It was quite a shock moving from just outside Boston to Dallas, especially when everyone knew what had happened in Dallas in 1963. People in Massachusetts at that time did not have a good opinion of Dallas. Dallas was a real culture shock for our family, who had always lived in the Northeast. We had no idea what Dallas would be like. The biggest shock was school. I had been in a middle school in Massachusetts, but the seventh grade in Dallas was in elementary school and accordingly I was “moved backwards.” I still remember being dropped off and seeing the jungle gym and the playground and wondering what in the world had happened to me. I found the Dallas public schools to be unsatisfactory, and at my own instigation enrolled in Jesuit College Preparatory School, which was close to where we lived.
Roberts: What was Wayland like? How far was it from downtown Boston?
DeMarco: It was 20 miles west of Boston, very suburban. During my 13 years there, I went to Boston only a few times. My father worked in Natick. He occasionally traveled to Boston. I've been to Boston more since moving to Dallas than when living in Wayland! We lived close to a lake, but I saw the ocean only once before we left Massachusetts. I don't know if my parents ever went to the ocean. About a year ago, my 3 siblings and I took our parents back up to visit our old stomping grounds (Figure (Figure22). It was an education.
Roberts: What do you mean by that?
DeMarco: I hadn't seen the place for 40 years, and our house was no longer there. It had been replaced by a much bigger house. The whole area seemed much smaller than I had remembered.
Roberts: What was your house like in Massachusetts?
DeMarco: It was a slab house. My father and I actually constructed additions to the house. He hired contractors to do a lot of the big work, such as pouring the slab, but then he and I finished out the house, putting up walls, wiring, etc. He was a do-it-yourselfer. I still remember joining pipes and installing bathroom toilets. The house originally had 3 bedrooms, 2 bathrooms, and a single-car garage. By the time we were done with it, it had 4 or 5 bedrooms, 4 bathrooms, and a 2-car garage. It was on a fairly large lot.
Roberts: Are your parents still living?
DeMarco: Yes. They still live in the same house that we moved into 40 years ago in North Dallas.
Roberts: What is your father's name?
DeMarco: Carlo George DeMarco (1927–). When he moved from the Northeast to Dallas, Texas, everybody started calling him Carlos. He would always correct them.
Roberts: What is your mother's name?
DeMarco: Jane Louise Smith (1926–).
Roberts: She is a year older than your father.
DeMarco: Yes. They were both from the same small Pennsylvania coal-mining town, Hazelton. They didn't meet, however, until they were in college at Penn State. Hazelton is a melting pot but predominantly Catholic-Italian and German-Lutheran. Fifty-something years ago, it was quite controversial for an Italian Catholic to marry a German Lutheran. My dad was never deeply religious and wasn't a practicing Catholic when he married my mother in a Lutheran church. Their marriage wasn't recognized by the Catholic Church and was so controversial that many of my father's relatives, including his mother, did not attend the wedding. They have been married for 58 years!
Roberts: When did they marry?
DeMarco: In 1952. My oldest sister, Nancy Jane, was born in 1954; I was born in 1956; Janice Marie, in 1958; and Lynda Jane, in 1965. Lynda was spelled the same as President Lyndon Johnson. My parents weren't huge political people in any sense, but the name struck their fancy.
Roberts: What is your father like? Did you have a lot of contact growing up?
DeMarco: We played golf together and still do. I still see both my parents once a week when I'm in town. We usually go there for dinner on Sunday. It's after church, usually around noon or 1:00 pm. It's always spaghetti and something. My father and I still work together on a lot of projects and play golf every week or two. He plays a couple of times a week. We get along fine.
Roberts: What is your golf handicap?
DeMarco: It is 17. I don't play enough. I'm doing good to play once every 2 weeks.
Roberts: What are some of your father's characteristics?
DeMarco: He was not always the most social person or the easiest person to get along with, even after moving to Dallas. He could be argumentative at times. He is a really good person.
Roberts: What is your mother like?
DeMarco: My mother was very supportive. Although mainly a housewife, she did some teaching on the side. For a couple of years she was headmaster of a kindergarten here in Dallas.
All of my great-grandparents came through Ellis Island. My paternal grandfather's parents were Italian, and they immigrated in the late 1800s. My paternal great-grandfather actually had a wife in the USA and another wife in Italy. We said he commuted back and forth. How he managed to do that I never understood. My father indicated that the wife in Italy didn't want to come to America, and that was grounds for as close to divorce as you could get but entitled him to have a wife in America. My maternal great-grandparents are of German extraction and came to the US around the same time. They all settled in northeastern Pennsylvania. My mother's side was more in coal mining and farming, and my father's side was in the import business. They imported olive oil, had a macaroni company, and made spaghetti sauce. All their customers have since died off and the business is gone, but my father still makes spaghetti sauce. In my refrigerator there is a jar of spaghetti sauce that my father has made. We usually pick it up on Sundays when we go for dinner.
Roberts: Do your parents go to church now?
DeMarco: Yes. My father attends church only on special occasions—weddings, funerals, and holidays. My mother still goes to church regularly. One of the kids will take her and then hang around the house for dinner afterwards. I went to Jesuit High School and then to the University of Notre Dame, but I'm not Catholic.
Roberts: Where in Italy did your father's family come from?
DeMarco: I'm not sure. I have never been to Italy myself. I think it was south of Rome; the city Salerno rings a bell, but I'm not sure.
Roberts: What about your mother?
DeMarco: No idea at all. I'm not even sure my mother knows. My father speaks no Italian, and my mother speaks no German. When everyone immigrated, they wanted Americanization and were not raised speaking foreign languages. Most of their heritage was left behind.
Roberts: Your parents went to Penn State? Did they both graduate?
DeMarco: Yes. My father graduated later because he got drafted in World War II. He spent some time at Fort Sam Houston in San Antonio. He received his induction notice on VE Day. He always says that when they heard he was coming they quit.
Roberts: How long did it take your mother and father to adjust to Texas and Dallas?
DeMarco: It is still going on in some respects. It took all of us a couple of years. Although they still don't sound like they are from Texas, they enjoy living in Dallas. Our whole family has remained in the Dallas area (Figure (Figure33).
Roberts: What do they do? Do they work?
DeMarco: Yes. My older sister, Nancy, lives in Trumble (halfway between Dallas and Ennis) and has taught bilingual education for 35 years. She teaches in an elementary school near Samuel Grand Park, located in an underprivileged area of Dallas. She majored in Spanish in college. Nancy never had children and has always been very helpful in raising my son. She is his favorite aunt. My younger 2 sisters, Janice and Lynda, live in Grapevine. They work for National ChemSearch in the information technology department. They each have 2 kids. Cara's siblings are in the Dallas area also.
Roberts: Where did your sisters go to college?
DeMarco: Nancy went to Texas Tech in Lubbock; Janice to Stephen F. Austin in Nacogdoches; and Lynda to Baylor University in Waco.
Roberts: Are they practicing Lutherans?
Roberts: Did studies in school always come easy for you, or did you have to work hard at it?
DeMarco: Studies do come easy, but I always worked hard. I enjoy working hard. In junior high school in Massachusetts, I loved science. My father was a chemist back then, and I had my own chemistry lab on the back porch of our house. My father would bring home chemicals, including hydrochloric acid, and I did electrolysis and things like that at the age of 10 or 11. It was great. When we moved to Dallas, I was disappointed with the lack of technology in our school and felt that I had been held back a year. I always loved science and math and was always much better in those subjects than in the verbal skills. That was reflected on my SAT, where my score was 200 points higher in science and math than in the verbal section.
Roberts: It sounds like you've always been a gadgeteer?
DeMarco: I like technology but it's always ahead of me. In computers, I'm probably the generation that got left behind. It seems that the older generation in many respects, people in their 60s and up, has time to catch up with their computer technology, the younger people were brought up with it, and I'm there in the middle, sort of like BUMC's BCON [a clinical software program now being replaced].
Roberts: Were you an athlete in high school?
DeMarco: I lettered in soccer in high school. I got 2 concussions and joke that I could have been a cardiologist if I had played soccer longer. One more concussion and I would have had to go into politics! At Notre Dame, I played intramural sports. In my first year at Notre Dame, I was able to “place out” of chemistry and a couple of other courses.
Roberts: That means you didn't have to take the course?
DeMarco: I was one of the few freshmen to skip freshman chemistry, which was the sink-or-swim class for premed students. I always wanted to be a physician. My freshman advisor told me that if I did very well I might only have to go to college for 3 years. That's what I did. I didn't actually graduate at that time. When I got into Southwestern Medical School, my Notre Dame instructors couldn't believe I would give up a year at Notre Dame to go to a Texas medical school. They tried to convince me to stay and they would help me get into a “good” medical school, like George Washington or Georgetown or the University of Chicago. I told them that I thought Southwestern was a pretty good medical school.
Roberts: How did you decide to go to Notre Dame since no one in your family had gone there?
DeMarco: My parents had gone to Penn State and were not big Notre Dame fans. I had done very well at Jesuit High School, and Jesuit, being a good Catholic school, fed into Notre Dame.
Roberts: Was Jesuit all male?
DeMarco: Yes. But Jesuit has a sister school, Ursuline Academy, so we would go to functions together with them.
Roberts: What year did you begin as a freshman at Notre Dame?
Roberts: How many were in your freshman class?
DeMarco: About 2000.
Roberts: So the whole university was about 8000? I understand it has a beautiful campus.
DeMarco: Yes, it is a beautiful campus for about the first and last 2 weeks of the school year, and then the cold weather takes over. I joked that I only lasted 3 years because of the weather and the lack of women.
Roberts: How many women were there?
DeMarco: Notre Dame graduated its first class with women around 1975. Prior to that it was all male. About 20% of the students in my class were women. But, St. Mary's College, which was all women, was on the other side of the lake.
Roberts: Was St. Mary's equivalent to Notre Dame academically?
DeMarco: It was a college rather than a university. It just happened to be near Notre Dame. I actually took 1 or 2 courses over there just to meet some girls.
Roberts: How did you get back and forth between Dallas and South Bend?
DeMarco: It was a long drive, about 18 hours. Once I did it in 13 hours. Back then the fuel crunch lowered the speed limit to 55 miles per hour.
Roberts: You had a car when you went off to school?
DeMarco: No. I rode with 3 or 4 other students, one of whom owned the car. We split the cost of gas. We would do it nonstop except for stopping for gas. I got a car my last year of college. Students didn't leave campus very much, and those with cars didn't park very close to the dorm. It was a closed campus. Often, I would leave the car in the parking lot, take the battery out of the car, and keep it in my dorm room so it wouldn't die. The car would get snowed in anyway.
Roberts: What was your major in college?
DeMarco: There was a major there called preprofessional sciences, which was in the College of Science and basically was premed. It wasn't chemistry or biochemistry. Lots of people would major in chemistry or biology if they wanted to go into medicine, and they would get out with a degree in case they didn't make it into medical school. The preprofessional sciences were designed solely for the premedical school students.
Roberts: I have heard that Notre Dame gets a high percentage of its students into medical school.
DeMarco: Maybe. If you got a C in organic chemistry, they didn't let you even apply to medical school. My roommate didn't do well in organic chemistry and he went into hospital administration.
Roberts: Did you make an A in organic chemistry?
Roberts: Did you apply to medical schools other than Southwestern?
DeMarco: I applied to Georgetown, George Washington, Northwestern, and all the Texas schools. The minute I got into Southwestern I withdrew all my applications to the others.
Roberts: You left college at what age?
DeMarco: Age 20. The joke back then was that the drinking age was 18 in Texas, 21 in Indiana, and 18 in Michigan. We used to hitchhike the 8 miles to Michigan, but it was a very long walk home. When I returned to Texas, the drinking age had been reversed to 21. I was in medical school and still was too young to drink alcohol until September of that first year.
Roberts: When you were growing up was there alcohol in your house?
DeMarco: Yes, but not much. My father used to drink beer, then wine, and then quit drinking when I was in college. My grandfather always had wine. My father drank a lot of beer in college. I don't think he's had anything to drink in 20 or 30 years.
Roberts: Did either of your parents smoke cigarettes?
DeMarco: Yes. Everybody did back then. My father quit around the time I was born and is very critical of those who do smoke. My mother quit when I was about 6 years old. I still remember seeing her smoke.
Roberts: You never smoked?
Roberts: You mentioned that you always knew you wanted to be a physician. Where did that come from? Are there any physicians in your family?
DeMarco: None in my immediate family. According to my paternal grandmother, there were 13 doctors in the family, but I didn't know them. I'm not sure they all went to medical school. My grandmother believed that doctors were something special. My biggest mistake was thinking that I wanted to be a doctor because I was an independent person. I didn't like being told what to do. I had the illusion that doctors weren't told what to do. Well, nothing could be further from the truth. If it's not your patients, it's the administrators, or the politicians, or the payers. So everyone is telling you what to do.
Roberts: Did you read a lot growing up?
DeMarco: I read more now than I did in college—because I travel a lot now and have lots of time waiting around for planes. I didn't read for enjoyment back then.
Roberts: Do you read fast?
DeMarco: No. Cara does. I've given up trying to read fast. I get my money's worth out of a novel.
Roberts: When you were at Southwestern Medical School, did you live at home?
DeMarco: No. I lived in an apartment off of Lemmon Avenue for the first year with one classmate from Notre Dame who also got into Southwestern after 3 years of college. (Kevin Kline is an anesthesiologist at Zale Lipshy.) The second year I lived at home, and the third and fourth year I lived in apartments.
Roberts: Were there any surprises for you at medical school?
DeMarco: Yes. Two surprising things about Southwestern were its diverse group of very bright people, including some frankly weird students, and its very competitive atmosphere. We didn't have letter grades or pass-fail grades but number grades, and all students knew exactly where they stood in the class. A passing grade was 75. We had some casualties because of that competitiveness. Some students just didn't adapt well and therefore didn't do well. In college, especially at Notre Dame, in contrast to medical school there was such a homogenous group of individuals. Most students came from Catholic schools, were brought up Catholic, and came from the Midwest. All 3 of my roommates were from Ohio—2 from the same high school in Cleveland and the other from Cincinnati.
About 100 of the 200 students in my class were from the University of Texas at Austin. When I was a freshman, Notre Dame beat the University of Texas in the Cotton Bowl to win the national championship. Bryan Williams, dean of students back then, a great but also very satiric type of person, walked into the first class in January after the Cotton Bowl and wrote my name and 2 other names on the board. Above the names, he wrote: “These students attended the University of Notre Dame.” Then he wrote the names of students from the University of Texas, provided upon request, and walked out.
Roberts: Someone mentioned to me once that Notre Dame was a little “blue collar.”
DeMarco: It's in a blue-collar area. South Bend, Indiana, doesn't have much to offer. Notre Dame was the second largest employer in the area. Rick Boland went to Notre Dame; Jeff Crippin, 1 year behind me, went there and was the second string center at the time that Joe Montana was the quarterback; and Greg Pearl was a year ahead of me, but we didn't know each other then.
Roberts: How would you compare classes at Notre Dame to Southwestern? Were you very glad of your decision to become a physician when in medical school? Did you ever have any doubts?
DeMarco: I never had any doubts. I was thrilled with the idea of getting into medical school early. I was probably one of the youngest people in the class, and it was a struggle and hard work in that regard. In high school and college I was always at the top of the class. In medical school, everyone had been at the top of their class earlier. In medical school I was in the middle and very happy to be there.
Roberts: During your different years of schooling, were there any teachers who had a particular influence on you?
DeMarco: At Jesuit, the teachers were excellent and most took a real interest in the students and wanted them to do well.
Roberts: How many were in your classes at Jesuit?
DeMarco: About 200 in the total class; each class had 25 to 30.
Roberts: What about in college?
DeMarco: In college it was variable. One reason I chose Notre Dame was because I didn't want to go to a place where the classes were huge. There were 200 to 500 in organic chemistry at Notre Dame; the liberal arts classes, in contrast, had 20 to 30. Notre Dame required theology or some type of philosophy.
Roberts: Did any particular teacher influence you at Notre Dame?
Roberts: In medical school was it easy to decide on internal medicine, or did you have a problem choosing a specialty? Did you have any particular faculty influences in medical school?
DeMarco: There were things I didn't like. I found psychiatry frustrating because I think we don't have a good way of handling psychiatric illness. I found neurology difficult too. I always liked pulmonology and gastroenterology. John Fordtran was at the medical school when I was a student there and shortly thereafter moved to BUMC. He influenced me a lot. He had a lot to do with my love for gastroenterology and also in choosing to come to BUMC and staying here. The people who influenced me a lot were John Fordtran, Dan Polter, Kent Hamilton, Lloyd Kitchens, Walter Berman, and Ralph Tompsett. I have been around Dan Polter my entire professional life. I jokingly have said that when Dan does retire it is going to be such a shock for me not to have him looking over my shoulder, and it's going to be a shock for him too. I did my fellowship under Dan Polter and Kent Hamilton, two excellent gastroenterologists. Walter Berman had a tremendous effect on me. Lloyd Kitchens was one of the most talented physicians I ever met. I took care of both him and Walter before they died.
Roberts: What do you mean by “most talented physician”?
DeMarco: Lloyd was a pianist and singer; he had a tremendous amount of talent. Walter Berman had such an ability to communicate with people and sense their needs. Walter taught me that when you select consultants for your patients, you have to match up the personalities more than anything else. You might like to use Dr. A all the time, but you have to realize that this little lady probably needs someone different from Dr. A. He was a brilliant but down-to-earth person.
Roberts: Who was the other person in gastroenterology?
DeMarco: John Kent Hamilton. He was our interventionalist. He was the first guy to do endoscopic retrograde cholangiopancreatographies at BUMC. He was an excellent teacher and is still in practice.
Roberts: The reason you decided to come to BUMC for your houseofficer training was because Dr. Fordtran had come to BUMC?
DeMarco: That was a big part of it. By that time I had already met Cara East, and we were more or less engaged. We went through on the couples match. She had decided to stay at Parkland. I didn't enjoy medicine at Parkland but I did at BUMC. I was fortunate enough to win the lottery and be able to do medicine as a third-year medical student at BUMC.
Roberts: Is there a lottery to come to BUMC?
DeMarco: Back then there was. If you lost the lottery you went to the Veterans Administration Hospital. Cara did her medicine rotation there. You did 8 or 10 weeks at Parkland and 8 or 10 weeks somewhere else—either at BUMC or the VA Hospital. We did our medicine rotation together at Parkland.
Roberts: How did you and Cara meet?
DeMarco: In the second year of medical school, we were in the same class. I asked her out one day. She is 1½ years older than me like everyone else in our class.
Roberts: What attracted you to her?
DeMarco: Cara went to Rice University along with 12 others from our class. She was sharp, smart, and eloquent.
Roberts: When did you marry?
DeMarco: On May 7, 1983, Mother's Day weekend.
Roberts: You started medical school when?
DeMarco: I started in 1977 and graduated in June 1981. I met Cara in 1978 and we dated until we married. We did not have time to get married, and we weren't sure how our careers were going to go. It wasn't until we were doing electives in our second year of residency that we were able to make time to get married. We were both very dedicated.
Roberts: Where is Cara from?
DeMarco: Marshall, Texas.
Roberts: How big is her family?
DeMarco: Her mother died a couple of years ago. Her father is retired and lives in Florida. She has 2 younger brothers. Her mother was a schoolteacher but later became disabled. Cara really had a lot to do with raising that family.
Roberts: What does her father do?
DeMarco: Her father left the house when Cara was 6 and her parents divorced. He subsequently married several other times.
Roberts: So Cara was a “mother” early on. When you rotated through obstetrics-gynecology or surgery, did you give those specialties a hard look?
DeMarco: Very little. From the first few months of my residency at BUMC I liked gastroenterology. I liked the various combinations of things: the intellectual part, the working with your hands part, seeing all genders and ages, and the ability to really help people. I didn't like gynecology because only one gender was seen. Cara and I did obstetrics together at Parkland; we delivered lots of babies, and it was fun. But it also seemed very regimented: stitches out on day 2, home on day 3, etc. Now a lot of medicine is regimented by protocol, but I still like to think about the individual patient and not manage entirely by protocol.
I tell people that gastroenterology is the best subspecialty because it affects older and younger, men and women from all walks of life. Most people are more concerned about their gastrointestinal (GI) tract than they are about their heart, lungs, or anything else, especially people who plan vacations. More vacations are ruined because of GI problems than anything else. More work days are lost because of GI problems than are lost from problems related to other specialties. Also, in gastroenterology you get to play with the newest and coolest technology. As director of endoscopy, part of my job is to be on the forefront of technology, so I spend many hours in and out of town working with new technology.
Small-bowel enteroscopy is an amazing field that is blasting off. I never would have dreamed that I would be watching television monitors as part of my work. When I started, we were doing fiber optics, and one of Dan Polter's famous quotes was that he didn't think that video endoscopy would take off. Now, no one does fiber optics any more. The other thing is capsule endoscopy, which took off about 10 years ago. I never would have dreamed I would spend my nights at home sitting with my laptop computer watching 50,000 pictures of the small bowel go by. But that's what I do now. When I travel, I have my laptop with me and I read capsule studies then too. One of the newest things we are looking at is a retrograde camera that goes through the colonoscope and turns around and looks backwards as you are doing the colonoscopy so you can see polyps on both sides of the folds. We did a big study at BUMC using that technology and are finding about 10% to 25% more polyps than previously. I've been all over the country and in Europe presenting our findings on that technology. Gastroenterology is a great specialty.
Roberts: You like all these gadgets? You are oriented that way?
DeMarco: Yes. Mike Brown once said that gastroenterology was hurt by endoscopy and screening colonoscopy, implying that the procedure detracted from the intellectual aspects. These procedures have done a lot for the average gastroenterologists, like putting their kids through school. But, I didn't do all this work just to do screening colonoscopies on 50-year-old healthy people. Part of my passion for the new technology is to be on the forefront of our field's development. Also, as director, it's part of my job to bring this new technology to BUMC, which has a strong GI division. We've always been very proud of it. We've got one of the largest GI labs anywhere.
Roberts: How did you enjoy your houseofficership at BUMC?
DeMarco: I really enjoyed it. I still spend a lot of time teaching the housestaff. I still interview first-year medicine applicants, and a lot of our interview process is actually a recruitment process. I think the BUMC medicine residency is a very good experience. It's not oppressive—but none of them are now, with a 60-hour work week. But even back then it wasn't oppressive. Our on-call averaged about every fourth night, as opposed to every third night elsewhere. It was a very supportive and nurturing environment rather than a critical one. The housestaff supported each other, and the attendings put patients on the teaching service because they wanted to teach. I came out of that residency program fully equipped to be a practicing physician. Many graduates of the “academic” programs back then did not come out of the residency prepared to practice medicine and work with consults in a cooperative fashion for the benefit of patients. BUMC is a great place. Unfortunately, I've never trained or practiced anywhere else.
Roberts: But you travel around quite a bit? You see other places.
DeMarco: Yes, and I work with physicians outside BUMC.
Roberts: What is your life like now? What time do you get up in the morning? What time do you get to the hospital?
DeMarco: I get up at 5:30 am and get to the hospital in time for a 7:00 am case or meeting. I try to be home by 6:00 pm. When I am home, I'm usually doing some office work. I used to do dictation at home but I do less of that now. Usually at home, I'm either working on some new technology or reading capsule studies. I don't go out to a lot of movies. If I want to watch a movie I wait until it comes out on DVD. We eat out a considerable amount. I travel, especially the first half of the year, about every other weekend.
Roberts: Are you seeing patients every day?
DeMarco: I see patients all day on Mondays, on Tuesday and Thursday mornings, and on Wednesday afternoons. I have time blocked off for procedures, which I do on Tuesday afternoon, Wednesday morning, and Thursday afternoon (usually at an outside center) and all day Friday.
Roberts: What time do you get to bed?
DeMarco: 10:30 or 11:00.
Roberts: So you get about 6 hours of sleep? That's enough for you?
Roberts: What do your travels entail?
DeMarco: It varies. I work on behalf of the American College of Gastroenterology as a current procedural terminology (CPT) advisor to the CPT editorial panel. This work requires a lot of phone conferences and travel about 6 times a year. Any new technology has to be assigned a CPT code. Then eventually it goes to the Relative Value Update Committee, where a value is assigned to the procedure that ultimately translates into reimbursement. There are 3 GI societies, and each has a CPT advisor. We are trying to get all 3 societies to work cooperatively. I am a member of all 3: the American Gastroenterology Association, the American College of Gastroenterology, which I represent, and the American Society for Gastrointestinal Endoscopy. At the next CPT meeting in Orlando, we are discussing coding of 3 new procedures: colonic motility, high-resolution esophageal pressure topography (a sophisticated esophageal manometry), and a “smart pill” that measures the pH, pressure, and temperature throughout the GI tract over 5 days. These new technologies have been put forth by the GI Motility Society, and we are working with that society to get the CPT codes for these procedures. Ultimately, hopefully, they will end up getting reimbursed. The whole process is technology driven but is also very political. It's almost like a give and take. There is only a fixed pie of dollars, and gastroenterologists compete with neurosurgeons and cardiologists, among others, for their piece of the pie. It's very challenging.
The other part of my travel is to attend national meetings for presentations and courses. I do a lot of teaching at courses. In fact, this afternoon I go to Las Vegas to speak at 7:00 pm.
Roberts: You are “part-time” at BUMC, which means that you receive some income directly from BUMC. How does that work?
DeMarco: I am director of endoscopy, and BUMC provides an office for me. We used to have our offices on the third floor of the Truett building and we had patient rooms. It was the John Fordtran Diagnostic Center for Digestive Diseases. Then about 5 years ago we were able to move the GI lab from the third floor to the first floor of the Jonsson building, which was much more patient accessible, and we expanded it by 2 procedure rooms. I am very proud of that facility. I helped design it. It has 10 procedure rooms and 20 recovery beds. The recovery beds are in the middle and the procedure rooms are on the periphery, so you don't have to go very far from the procedure room to the recovery area. Before we designed it we went to the Cleveland Clinic and looked at its facility. I looked at the architectural plans several times a day—even dreamed about them—before we finalized things. I worked with the hospital architects in designing it. We forgot a laundry chute. But, when we had the nurses review the plans, they were quick to point it out. Dr. Irving Prengler's office used to be in the basement and we had to move his office so the laundry could go down there.
We were a hospital-based private practice, and we had already formed Digestive Health Associates of Texas (DHAT), which is our private practice. I was director of endoscopy even back then when we had our office in the hospital. Having a private practice on not-for-profit property didn't look good to the BUMC compliance people, so we moved to 712 N. Washington (Figure (Figure44), which was probably the oldest building near the BUMC campus. We did not move there willingly, and we had a lot of negotiations about who owned our charts that were at BUMC for 25 years. We finally reached a compromise on some issues. It has been a good move for us because we were actually paying a lot more to BUMC, being on BUMC property, than we are now. Because of my position as director of endoscopy, and similarly for Larry Schiller, director of the fellowship program, we have offices within BUMC that are alongside the fellows' office and a conference room, but we cannot see patients there. I use that office purely for administration issues and for teaching.
Roberts: How many fellows do you have?
DeMarco: We have 6 fellows, 2 fellows per year for 3 years.
Roberts: Who pays those fellows?
DeMarco: The fellows are BUMC fellows. One of my goals is to endow the fellowship program, one spot at a time. The Baylor Foundation tells me if I can raise $1.5 million I can endow a fellowship spot. I am moving towards it. I am working with the Foundation and trying to get a few good people to contribute 6 figures apiece and we'll get the $1.5 million.
Roberts: How many endoscopy procedures are done at BUMC per week?
DeMarco: About 70 to 100 per day.
Roberts: How many do you do?
DeMarco: It varies with the day. The maximum I do in a day is 17 or 18. I'd rather do just 10.
Roberts: You have to be pretty tired when that's over?
DeMarco: Yes, especially for the past few months when we were doing a tandem colonoscopy study. Each patient received 2 colonoscopies with 1 sedation. It was randomized. I wouldn't know until the patient was sedated if it was going to be the regular colonoscopy first or special colonoscopy using the new technology first. We were comparing our polyp find rates. We did 90 patients in the study, but that was really 180 colonoscopies. I was doing 2 procedures instead of one for each colonoscopy, and it was a lot of work. It was a multicenter study. A lot of it was done in Belgium and Germany. We did more than anyone else in the world. That study is being written up now, hopefully for publication in the New England Journal of Medicine. This was the first tandem study done at BUMC.
Roberts: How many gastroenterologists at BUMC do endoscopies?
DeMarco: Sixteen of the 18. That is the way gastroenterologists make a living. The colon and rectal surgeons also do colonoscopies in the GI lab. Most gastroenterologists do endos-copies at more than one place. Our group, until 2010, had 5 outpatient endoscopy centers that we owned in different locations. Now, I do less than one case a week outside BUMC.
Roberts: Are all these 18 gastroenterologists utilizing BUMC in the same group?
Roberts: How many are in your group?
DeMarco: Seventy. It's the biggest GI group in the country. When I decided to stay at BUMC, Dan Polter, Kent Hamilton, and I were the group. John Fordtran's name was on our business card but he really wasn't practicing with the group. There was one other gastroenterologist at BUMC then, Mike Allen, and Charlie Walker left the group at the same time they brought me in. About 12 years ago, when we saw things changing in medicine and in private practice, Dan Polter, Tom Rogoff (a gastroenterologist at Medical City), and I decided that with Dan's reputation and knowledge of the GI community and with our strong GI division at BUMC, we would start a large GI group so that we could do our own contracting. It was a merger of several small groups. Back then we called it “a group without walls.” We brought about 20 gastroenterologists from Presbyterian, Medical City, and the Mid-Cities together and created Digestive Health Associates of Texas. My experience as chairman of the board of Southwest Physician Associates, a big independent practice association originally started by John Bagwell and Barry Uhr, had been helpful in bringing about the merger.
Roberts: That was created when?
DeMarco: Around 1998. It has subsequently grown to 70 physicians, about 63 of whom are full partners. We had 5 endoscopy centers and infusion centers. We do our own pathology, which is associated with some of the endoscopy centers. We hire out anesthesiology services. The group has been very successful. Dan Polter was president of the group for several years. Then about 8 years ago it became clear that we needed more of a business approach than a medical approach because they are different. The leadership was changed, but the group has done very well.
I'm a full partner in DHAT and I'm head of endoscopy at BUMC. Rick Boland is chief of gastroenterology at BUMC. Rick has been great to work with. He pretty much lets me take care of the endoscopy service and he takes care of the GI research and administration.
Roberts: Gastroenterology at BUMC ranks in the top 40 in the country every year!
DeMarco: A couple of years ago we were even better than that. I only did 1 year of gastroenterology fellowship. (It was supposed to be 2 years.) I finished medical school in 1981, the residency in 1984, and the fellowship in 1985. In 1985 I joined Polter and Hamilton and also worked under John Fordtran. The position was called an “instructorship,” not a fellowship. Because I was a fellow with admitting privileges, they needed me to be an attending and do a lot of the work. My instructorship was under John Fordtran that year, and it allowed me to sit for the boards after doing only 1 year of true fellowship. The second year under John Fordtran counted, and we cleared that with the board at that time. Thus, I was able to be an attending in gastroenterology at a very young age.
It was a tough year working for those 3 guys. I was the director of the Diagnostic Center for Digestive Diseases (DCDD), which was down in the basement back then. Then, I stayed on with Polter and Hamilton, and we were a big referral service for John Fordtran's patients with chronic GI problems. I got somewhat disenchanted with the idea of being head of the DCDD. We were trying to make an outpatient facility, and I was busy taking care of critically ill inpatients. We had no hepatology service at that time, and liver transplants were just starting. (Goran Klintmalm had just come to BUMC.) Dan, Kent, and I were handling all the liver patients as well. We brought in Kaky Little. She and my wife did their residency together at Parkland, so I knew her quite well. I figured that if she could grow up under her father, who was the chief of surgery and a brilliant guy at the University of Mississippi in Jackson, then she could work under John Fordtran. I like to think I was instrumental in bringing her to BUMC. She became the director of the DCDD and did a great job. That outpatient facility flourished over the next 15 years.
At the same time I was starting my practice, I had Tuesday afternoon off according to the schedule. My colleague, Larry Jinks, who had done his internal medicine residency with me at BUMC, went to Ennis to practice. Baylor Health Care System owned the hospital there. He called and said he needed someone to do GI at his place. “Just come down one afternoon a week,” he requested. Cara was in the middle of her endocrinology fellowship, and I felt funny having an afternoon off. The other thing was that I had always been at BUMC and had always been under Fordtran, Polter, and Hamilton. Some people thought I was still a fellow. Others thought I was still a student. Here was a chance for me to go out and do something on my own. Thus, on Tuesday afternoons I went to Baylor Ennis carrying the endoscopy equipment in the trunk of my car. I did endoscopies in the emergency room. I had to stop a procedure when an emergency patient came in, but that was not very often. I taught the nurses how to assist and take care of patients during the procedure. One of the first things I had the hospital buy was a teaching head so that nurses could look too. This was back in the days of fiber optics. That practice grew to almost a full day in a very short time. Another one of my colleagues, Glen Ledbetter, was in practice in Waxahachie, and he also requested that I do GI work there. There was a whole untapped cohort of patients who weren't interested in leaving Ellis County for a procedure but would be more than willing to have it done there. It was amazing how much cancer I found there because it hadn't been looked for earlier. It was a neat place to work. I would see my in-house patients at BUMC in the early morning and then drive to Waxahachie and see patients from 9:00 am to 1:00 pm, doing both inpatient consults and outpatient GI procedures. Then I would travel to Ennis and spend the rest of the afternoon seeing patients and doing procedures, and then return to BUMC to check on patients there. That practice continued to flourish. It got so busy that we ended up hiring a gastroenterologist to work full-time in those locations.
It was about that time when Cara got sick, 13 years ago (1997). She was sick for a year, and Michael, our son, was 4 then. How good it was to have our families in town during this time! I realized that I couldn't take call at BUMC for a couple of reasons: having a spouse who everyone knows at BUMC and is quite ill meant that I could not go anywhere at BUMC without someone asking about Cara. It was very hard to be on call at night when I had to take care of her. I took myself off call and worked in Ellis County 4 days a week and at BUMC only 1 day a week. My partners, Hamilton, Polter, Sarles, and Crippen, were very cooperative and helpful in taking care of on-call issues.
I inadvertently built the practice up in Ellis County, and after about a year when Cara recovered and started back to work, it was too much for me to be 2 places at once. About that time I assumed the directorship of endoscopy at BUMC, and we decided to give the Ellis County practice to another physician. He didn't do well with that practice. Also in 2000, Baylor gave up ownership of the Ennis hospital and moved all of its activities to Waxahachie. Baylor Health Care System gave the Ennis hospital back to the city. At this same time I withdrew from going to Ellis County. They don't have a full-time gastroenterologist down there anymore.
Roberts: How did you handle Cara's illness?
DeMarco: The year she was sick was a life-changing experience. That's a lot for anybody to go through. She was on home total parental nutrition (TPN). I called a surgeon to put a Hickman catheter in my wife. Back then, whenever you put a Hickman in somebody, it was usually for high-dose chemotherapy and you never took it out because the patient died. Her gut shut down with all the chemotherapy. I didn't have to worry about cooking for her because she wasn't eating, and even when we would go out she would take the TPN with her in a backpack. For the record, she is 13 years posttreatment and cancer free.
Roberts: This was breast cancer?
DeMarco: Yes. Steve Jones was her physician. She had multiple positive lymph nodes. She had an autologous bone marrow transplant, where they took her stem cells, kept them outside her body, and then gave her lethal doses of chemotherapy, and when that cleared out they reintroduced her stem cells. She was in the bone marrow unit for about 4 weeks.
Roberts: When was Michael born, and what is his full name?
DeMarco: Michael Austin DeMarco was born in 1992. We gave him the name “Austin” because we love going to the Hill Country around Austin and try to go there as often as possible (Figure (Figure55).
Roberts: Do you have a place down there?
DeMarco: Yes, in Horseshoe Bay, which conveniently has an airstrip too. It used to be a 4-hour drive and the traffic gets worse every time we go, so about 6 years ago I started flying and now we fly down there and that takes 1½ hours. We have lots of friends in Horseshoe Bay. Chuck Gottlich has a place there; Buddy Hurst lives there now at least half the time. We'll go down for just a day.
Roberts: What do you do there?
DeMarco: Usually nothing, just relax. Occasionally we play golf, and we have a jet ski. It's like a small boat and goes up to 70 mph. A group of us get on jet skis about 6:00 am, when the water is smooth as glass, and go all over the lake.
Roberts: Where do you like to go other than the Texas Hill Country?
DeMarco: We have a house in the middle of Mexico (Figure (Figure66). That is Cara's baby. It's in a colonial town called San Miguel de Allende. It's a great place to go and relax. We go there about once or twice a year for a week at a time. The house is rented out most of the time.
Roberts: When did you buy it?
DeMarco: About 7 years ago.
Roberts: What do you do when you get there?
DeMarco: A lot of nothing. It's not too touristy. The town is full of Texans. Most of the people on our street there are from Texas. A lot of Texans and Californians have migrated there for retirement. The town has a lot of restaurants, cultural activities, and shopping.
Roberts: Do you fly there now?
DeMarco: Not in my plane. I don't want to take my plane across the border; the paperwork and inspections are a hassle.
Roberts: Where do you fly to?
DeMarco: We fly into Leon. It's a 1½-hour drive to the city. Once we're at the house, we don't need a car. In fact you don't want a car because it's more of a hassle than anything else. It's like having a car in New York City.
Roberts: Does your son prefer the Hill Country or Mexico?
DeMarco: I think he likes the Hill Country better. But he is a teenager and doesn't like to do much with his parents. He likes to stay home when we go out of town. He's not a big golfer.
Roberts: How did you start flying?
DeMarco: I've always dreamed about it but never had the money or the time. It takes a lot of both. About 6 years ago I went up for a 1-hour Discovery Flight, a promotional deal in Addison that costs $50. After the Discovery Flight I enrolled in the school, which provides a self-paced course. I have taken Friday mornings off for a long time because I never get home early on Friday. If I took Friday mornings off I couldn't complain about being there late on that day. So I took flying lessons on Friday mornings, returning to the hospital to do procedures at noon. (I started taking Friday mornings off about 16 years ago, when my dad had complications from prostate surgery and I began playing golf with him then. That was my rehab therapy for him.)
Despite the fact that I am an instrument-rated pilot, I still have a terrible problem with motion sickness. I cannot ride on a merry-go-round without getting sick. Several mornings after flying, I would come to work and be as white as a sheet from motion sickness. I stayed with it and got my pilot's license. After another year, I started training to get instrument rated because that would make me a better and safer pilot and give me more travel flexibility. I've had the instrument rating for about 4 years and am now working on my commercial (multiengine) rating. We now go on lots of trips; my son and I go skiing in Taos, NM, every year because it's easy to get there by plane. We joke that we go to Taos by our plane, then rent a car from Enterprise, and then we stay at the Quality Inn hotel for $65 a night. I try to fly once a week for an hour.
Roberts: What kind of plane do you have?
DeMarco: We have a Cessna 206, a single-engine 6-seater (Figure (Figure77).
Roberts: Tell me about learning to fly. How many hours did it take before you got your license?
DeMarco: It takes 50 hours in the air, 30 hours with an instructor, and a lot of solo flights. A kid half my age taught me how to fly and sometimes it was difficult, especially when he yelled at me!
Roberts: Are there some pilots who have a knack? Did you learn it quickly?
DeMarco: I think I was probably about average. My son has a better knack than I do. I have a lot of friends who are pilots, including a brother-in-law. A high school friend, best man at our wedding, flies Boeing 777s for American Airlines. He takes a special interest in making sure that I am a good pilot because, if anything were to happen to me, he'd have to face Cara. I couldn't have a more concerned flight instructor! His father was a pilot for Braniff, and he was flying before he was driving.
Roberts: How much do flying lessons cost?
DeMarco: The instructor fee is $35 to $40 an hour. That's the least expensive part. Flight instructors are just building time so they can go to work for an airline somewhere. I've been through 3 or 4 flight instructors because they graduate. They get their time and get a job with an airline or become a corporate pilot. The plane itself costs between $180 an hour (single engine) to $400 an hour (twin engine). It's expensive.
Roberts: Flying has been a nice thing in your life?
DeMarco: Yes. It's something I can do with my son. He is still taking flight lessons. I enjoy flying with him because he is a very good pilot.
Roberts: How much does a Cessna single-engine plane cost?
DeMarco: They start around $250,000.
Roberts: Do you own it? When did you buy it?
DeMarco: Yes, I bought it in 2005.
Roberts: How much does it cost to store a plane?
DeMarco: I store it at Dallas Executive Airport, which is the cheapest place around town. The hanger rent is $250 a month.
Roberts: How much time do you take off a year for these trips?
DeMarco: I don't count. I take as much as possible. We don't have rules in our group about time off. It's a productivity model—“You eat what you kill.” If you don't work, you don't eat. I figured out a long time ago that the guy who dies with the most time off wins (Figure (Figure88). I try to take as much time off as possible, probably 4 to 6 weeks a year. Then, if you throw in my business-related trips, which the office thinks is all for fun, that is another 6 weeks a year.
Roberts: You fly commercial when you go on business trips?
DeMarco: Yes, because I have to be there and I don't want the extra pressure on board to make me make a wrong decision regarding weather. Also, the associations have trouble reimbursing appropriately if you take your own plane as opposed to buying a ticket. The few times that I have used my plane for business trips I usually take another pilot with me so that helps me make the “go/no-go” decision.
Roberts: You must have thought John F. Kennedy Jr. was very foolish?
DeMarco: He wasn't instrument rated, and he was flying a twin-engine plane. He probably was flying too much plane at night. Not being able to fly by instruments is a challenge. Flying a twin-engine plane at night over water where there is not really a horizon is asking a lot.
Roberts: How long did it take you to get instrument rated?
DeMarco: About 1 year.
Roberts: That means how many hours?
DeMarco: In the air, 40 hours. Currently, I have 660 flying hours.
Roberts: Cara and Michael have no problem flying with you?
DeMarco: Cara gets anxious sometimes, but that's her nature. Michael enjoys it and he is a good pilot.
Roberts: Tell me about Michael. How old is he?
DeMarco: Michael is now 17½ years old, a senior at Highland Park High School and at the top of his class. We decided to have children after 10 years of marriage. It took a couple of years to get pregnant. He was born in July 1992.
Roberts: Cara was how old at that time?
DeMarco: She was 37, and I was 36. She quit work on June 30, and the baby was due July 12, but on July 1 she called me to say that her water had broken. I told her I had a full day. I then ran into Dan Polter, who gave me 2 more cases. I told Cara, “July 1, can't do it. All the new interns and residents start on July 1.” Bob Gunby delivered the baby later that day. I would check on her and then go see patients, back and forth. She was in labor all day long. I was on call that weekend. On July 4, I took Cara and Michael home and went back to work. I don't think I've been forgiven since, but fortunately we had a lot of family around for support, and, let's face it, there is nothing more useless than a new father. The dog seemed more important. Six weeks after Michael was born, we hired a Hispanic nanny because Cara had to go back to work at 12 weeks and we wanted Michael to be raised speaking Spanish fluently as well as English, and he does. He had the same nanny for 13 years. We still keep in touch with her. She did a great job in raising Michael. He is a very bright kid.
One of my dreams was for him to go to Jesuit because I went there. And we have been very supportive of Jesuit. There is an East-DeMarco Scholarship there. He applied and got right in. (Legacy didn't have much to do with it because he had excellent scores.) I told him that if he went to Jesuit he would be at the top of his class and there were no women to compete with. The minute he started going there as a freshman, he didn't like it. It was perhaps a little bit regimented for him and they made him cut his hair. When I was there they didn't have rules like that. I spent more time in the vice principal's office in his 6 weeks there than I ever did in my 3 years there. After 6 weeks it was quite clear it wasn't working out, so he left Jesuit and transferred to Highland Park. He is ranked about 10 out of 500 in his graduating class. He will be going to Rice. He didn't apply to Notre Dame.
Roberts: Does he want to be a physician?
DeMarco: No. He has a keen interest in music, which I don't exactly identify with, so he wants to major in music and physics. Having 2 type-A strong-willed physician parents does not make one want to be a physician!
Roberts: Do you or Cara play a musical instrument?
DeMarco: I do not. Cara played the flute in high school.
Roberts: Do you attend the symphony?
DeMarco: Yes. We have season tickets.
Roberts: What about the opera or musicals?
DeMarco: We used to go to the SMU lecture series on Tuesday nights at 7:30. For both of us to get free of work by 7:00 on Tuesday night was near impossible. We were season ticket holders for about 10 years but gave up after that.
Roberts: You work about 12 hours a day?
Roberts: How often are you on call?
DeMarco: Call has been an evolving thing. When I was with Polter and Hamilton, it was every third weekend and one night off during the week. I had Tuesday nights off. The way it was set up, Kent had Wednesday nights off and Dan had Thursdays, but Dan played tennis on Wednesday and Kent went to the symphony on Thursday night, so I was getting hit every night. I brought that up to them to change their nights off to match their activities, but they didn't see why they had to do that. That was 20 years ago.
Our call changed when BUMC wanted to bring on another gastroenterologist. BUMC asked if I would cover with him. At about the same time Polter went off all night and weekend call. I covered for Dan and for the new gastroenterologist so it was every other night for a while. After a year of that, we decided that was too tough on the other guy because he was covering my service, which is hefty, and would be better off on his own. I went back with the rest of my DHAT associates. We have about 7 people who take call now. It's about every seventh night but some new colleagues work every third or fourth. I'm only on every 6th or 7th weekend.
Roberts: When you are on call, what is that like?
DeMarco: Terrible. Don't make any other plans at all because it's just frustrating to do so.
Roberts: Weekend call starts Friday night?
DeMarco: Yes. Weekend call starts Friday night and ends Monday morning. Call is not insulated by the fellows at all. In fact, it's kind of backwards. Our GI fellows can't cover the whole service. The GI fellows take less call than the attendings do. They are on call every sixth day. It's attractive that way and conducive to learning and complies with the 60-hour workweek. When you are on call, you get all the patient calls for everything from indigestion to life-threatening hemorrhage. It's difficult in that regard because both weeknight and weekend calls demand a lot of your time and attention. The only time I can call a fellow in is if it's an interesting consult or procedure. I end up calling them for such things as foreign bodies in the esophagus, but the fellows don't get the first call, I do. I assess the patient and decide whether it's a good case or not and then I will call the fellow. We've worked to change that a little bit, but Larry Schiller thinks that the present system is a real asset to the program. He is probably right.
Roberts: Cara's new position has no call anymore?
DeMarco: Right. She no longer sees private patients. Her efforts now involve clinical research only. She works about 60 hours a week.
Roberts: She still puts in the hours but she is more in control of those hours. That must have made it nicer for both of you.
DeMarco: Yes. Trying to get 2 on-call schedules to mesh has been a challenge ever since we met each other.
Roberts: What is your house on Abbott like?
DeMarco: When we first got married we lived in an apartment on Central and Fitzhugh. Those have since been torn down. It was the same apartment house where Jack Ruby lived. If you look at the Warren Commission Report, there are pictures of Jack Ruby's apartment, and it looks just like the inside of ours. We then moved to Bryan Place, close to BUMC. Ralph Tompsett lived there also. We lived there for about 5 years and then in 1989 we bought the house on Abbott. It had been foreclosed on, abandoned, and ransacked because the owner came back and took all the amenities out of the house due to the foreclosure. When we stumbled on the house it was coming up for auction, and we walked through the house and couldn't figure out if it had even been lived in. There were no appliances, no alarm systems or garage door opener, just a bunch of holes where everything had been torn out. We went to the auction and bought it for about half price. The first thing we did was call the original builder and have him rebuild it. That cost about $100,000. Nevertheless, we still got a great price on it, much nicer than we would have been able to afford otherwise. We've been there for 20 years. I have gotten to BUMC from home at night in 3 minutes. I joke about the time that I had a patient who was crashing and I told them to get a blood gas. I got there before the blood gas had been drawn.
Roberts: Daniel, how old are you now?
Roberts: Do you plan to work forever?
DeMarco: Dan Polter and I joke about who is going to retire first. Nearly all physicians say as they are approaching 65 that they will quit at 65. John Fordtran said that years ago and I still see him every day. Although I'm working hard and enjoying the work, I don't see myself continuing to do this forever.
Roberts: So when you get into bed at night, it doesn't take you long to fall sleep?
DeMarco: Not at all.
Roberts: What's happened with that gadget that you were the first to use that rolls through the intestinal tract? What do you call it?
DeMarco: Right now we call it the Power Spiral. There is a video of it on YouTube. We started with spiral endoscopy, which was an overtube with a spiral on it (Figure (Figure99). The idea was to position it into the proximal jejunum, which can be done fairly easily, and then rotate it. Instead of pushing the scope through the small bowel, the bowel gathers itself on the scope or on the overtube. It's like rolling up your sleeve. The bowel is surprisingly amenable to that. It is atraumatic, and a huge portion of the bowel can be viewed. A lot of this work is done outside of the US because of regulations. We took a pediatric colonoscopy device and put a spiral on the end of the scope and then put a motor in the handle with a drive shaft going down that would turn the spiral. What we used to use as an overtube with the spiral on it with the scope through the overtube now is just a scope with a spiral on it. It was amazing how it could fly through the small bowel. We were the first in the world to use it. Our results have been submitted to the national organizations. We are still perfecting its technology. We have another trial that started in March 2010.
Roberts: Is colonoscopy going to continue the way it is now?
DeMarco: Yes, screening colonoscopy will continue because screening colonoscopy applies to everyone over the age of 50. Technology companies see it as a real cash cow, and they want to get involved in even a small piece of the colonoscopy pie. The result is everything from a pillcam to virtual colonoscopy with computed tomography, but nothing so far has been able to replace colonoscopy. Furthermore, screening colonoscopy not only detects colon cancer but prevents it by removing polyps. Automated colonoscopy, where a physician is not needed, is on the drawing board. It is a self-propelled scope either by air pressure or by a membrane that would move and pull itself through the scope. A practitioner would place it in there and find the cecum. Gastroenterologists are not embracing that technology. I think screening colonoscopy will stick around. Its reimbursement, however, is going to go down, but most reimbursements are going down. Those are economic and political issues, not just medical.
Roberts: Is it true that people with the fastest transit time from mouth to anus have the least atherosclerosis?
DeMarco: That's a good question. I'm not sure. We don't typically measure mouth-to-anus time. There are ways to do that with the Smart Pill. We've measured mouth-to-cecum time, and that's easy to do with everything from breath test to the Smart Pill. The capsule routinely looks at the small bowel.
Roberts: Are you involved with hepatology anymore?
DeMarco: Minimally. That's a long story. I was a fellow when the first liver transplant was done at BUMC. Actually, my career took off when liver transplantation was started at BUMC. Initially, I did a tremendous amount of liver work. (I took care of Mickey Mantle when he got his transplant.) I still see a lot of postoperative liver transplant patients. I don't do pretransplant evaluations anymore and don't go to the committee meetings anymore. I was instrumental in bringing Gary Davis here and getting hepatology restarted after Jeff Crippin and Jeff Weinstein left. Crippin and Weinstein were partners.
Roberts: Are you happy about that?
DeMarco: I miss the liver work a little bit, but one can't do everything. I don't do endoscopic retrograde cholangiopancreatographies either. That is a specialized procedure. I only did 5 during my fellowship.
Roberts: What are your goals from here on?
DeMarco: To continue to build the endoscopy service at BUMC and to continue to train, improve, and support our gastroenterology fellowship. Also to stay with the CPT panel advisors to advance GI technology. I hope that I will not be working such long hours after age 65. Maybe I'll just fly.
Roberts: You really like flying?
DeMarco: Yes, it's great. I don't take risks. I like it because it gets me to where I want to go quicker and it's fun. Costwise, of course, it's a lot cheaper to drive.
Roberts: Do you and Cara attend church?
DeMarco: Yes. We were married in a Lutheran church in Dallas and go to church when I am in town. She has been more involved in the Unity Church the last couple of years. I take my mother to church when I do go. Our Lutheran church is near Valley View Shopping Center.
Roberts: Do you have alcohol in your home?
DeMarco: Yes. Mostly beer and wine.
Roberts: When you come home at night and you are not on call, do you have a drink?
DeMarco: Rarely. I'm usually working. I sleep well. When we go out, I'll have a glass of wine, but that's about it. We have a fair wine collection at home. Other than the GI lab Christmas party, we don't do much entertaining at home.
Roberts: You say you go out to eat a lot?
DeMarco: Yes. At least once or twice a week.
Roberts: Where do you go?
DeMarco: Our favorite restaurant is Adelmo's on Knox/Henderson. It's close. We try not to go more than twice a month. We live right next to Javier's and smell it every night and it's a good restaurant too. Other times we go somewhere that Michael likes.
Once when I was out at a football game, I was introduced to George Bush as the “Rear Admiral.” I have a patient who is good friends with President George W. Bush. At the 2009 Dallas-Philadelphia game, this patient invited Cara and me to sit with them in their box at the Cowboys Stadium. President Bush was next door in Jerry Jones' box. I had colonoscoped this patient on Friday and that's when he asked me if I wanted to go to the game. During the game the next day, President Bush came over to this guy's box with his entourage. My patient said that he wanted me to meet the president. Cara reminded me to call him “Mr. President.” The president came over and talked to the guy. The president knew that the guy had a colonoscopy the day before and asked, “How's the Rear Admiral?” The guy said, “He's right here.” I said, “Yeah, somebody has to do it” and then I shook the president's hand and said “Hi, George, how are you doing?” We talked a little bit but didn't have much to talk about, and he went back to his booth.
During my career at BUMC I have had the opportunity and privilege to take care of some very famous individuals, and, also due to BUMC's location, to take care also of many people who are prominent for other reasons.
Roberts: Those with no money and those with a lot of money.
DeMarco: BUMC sees a lot of indigent patients. I've always worked well with the emergency department and have been a big supporter of that department. One of my patients provided $1 million for the emergency department renovation.
Roberts: How challenging is taking care of famous individuals?
DeMarco: Very challenging. When Mickey Mantle was sick, the press called every night at 1:30 am because the newspapers went to press around 2:00 am. This was before the days of the Health Insurance Portability and Accountability Act privacy rules. Mickey did not want everybody to know how sick he was and that he was going to die. He and I got along very well. I told him right off the bat that I was going to treat him like a normal patient. I didn't believe in VIP medicine. I called him “Mr. Mantle” and he called me “Doc.” I think he appreciated that relationship. I ended up taking care of him until he died. I got to know his family very well. I was on the Today Show with Katie Couric and a couple of other TV spots. It was a little tough because Katie asked me, “How is he doing?” I knew that Mickey was watching. It was evident at that time that he had metastatic cancer and I said he would do okay for a while. We filmed the interview around 5:00 am at a studio in Dallas. Then, I was able to get to work and sit with Mickey while we watched the interview. He gave me the thumbs-up sign that I passed the interview. I didn't tell the press that he was going to die because I didn't want him to read it and he didn't want everyone to know.
When he died the press was mad at me and BUMC for not saying he was near death. An editorial entitled “Truth Telling” appeared in The Dallas Morning News. It came out on a Friday morning and before I knew it (it was one of the Friday mornings I played golf with my dad), I was off the golf course and in Boone Powell's office with John Fordtran and Marvin Stone, watching my whole career evaporate. Just 48 hours earlier, Boone Powell had congratulated me on how well I had done in taking care of Mickey. We discussed all kinds of damage-control scenarios. I finally talked them into doing nothing and letting it ride. I think everyone got over it, including The Dallas Morning News. The editorial basically accused me and BUMC of lying. My defense was that I did not care what they said. Mickey Mantle was my patient, and I did what I thought was right. Taking care of him was a real experience. Every day is a new experience with new endoscopic challenges for me. Dealing with the administration and political issues keeps life interesting.
Roberts: You've been very happy with the BUMC administration overall?
DeMarco: Yes. The relationship changes all the time. I have always pushed hard to advance GI. I worked for a good 5 years trying to convince the administration that we needed a new GI lab.
Roberts: Are there any other GI labs busier than BUMC's lab?
DeMarco: Not that I am aware of. The lab cannot get much bigger without losing efficiency.
Roberts: How long have you had a beard?
DeMarco: I grew a beard off and on in college. Whenever I went for a medical school interview, I shaved it. Then, when I got into medical school, I grew it for good. I had it all during medical school and when I first started practicing. When I turned 30, I shaved it. Then, I didn't have it for 10 years. When I turned 40, I grew it back and have had it ever since. When I grew it back at 40 it came back gray.
Roberts: Does Cara like you with or without a beard?
DeMarco: I think she likes it. I joked that I had thought about shaving it off the day we got married, and she sensed that and said not to.
Roberts: How do you see your professional life 10 years from now?
DeMarco: Not much different, a bit less travel. I do have a problem saying no to new opportunities, but hopefully by the age of 60 I'll learn. I see more free time. I see medicine being much more regulated, much more protocolized, and much less individualized. We are moving toward much less physician access, more physician extender access. Many patients tell me that when they go to see a new physician, they see instead the nurse or the nurse practitioner. I don't like that direction, especially for the physician-specialist. The patient deserves to see the specialist, not the specialist nurse practitioner. The specialist needs to do the full consultation type job that they are supposed to do.
Unfortunately, if you don't pay for something, it doesn't get done. Beginning in 2010, Medicare decided to stop paying for consultations. Now we have consultation codes for regular patients that are different than consultation codes on Medicare patients. Because Medicare decided to stop paying the consultation code, we have to code Medicare patients as new patient visit. The primary care physicians think that the consultation codes should be thrown out and that all physicians should get paid the regular new patient code. It's only maybe $10 to $40 difference depending on the level of service, but in principle I feel it's damaging to the specialties. One trains an extra 3 or 4 years to be a consultant and now Medicare is not paying for it. Eventually, I predict that all physicians' pay will fall under Medicare rules. That bothers me. I am concerned about the future of medical practice. The inability of physicians to work together is a challenge.
Roberts: What do you mean by that?
DeMarco: It's illegal for physicians to unionize or discuss fees with each other, but in other fields it's public knowledge. If it makes business sense, it's probably illegal in medicine. Physicians are a very bright group as a whole but don't have the ability to work together with each other for the benefit of their profession. Organizations like the American Medical Association haven't facilitated that either. Even within gastroenterology there are 3 organizations. I am a member of all 3, but I represent only one, namely the American College of Gastroenterology. The 3 organizations don't talk to each other and hence don't work well together. When it comes to issues, even like screening colonoscopy, each organization has its own agenda. If we could get the 3 societies to work together it would be beneficial to all gastroenterologists. If we could get all the specialties and all the physicians to work together we would all be better off. If doctors could work together, politicians would not be reforming health care. Physicians know more about taking care of patients and the delivery of health care than insurance companies or politicians. But who is doing the reforming?
Roberts: Do you think that most physicians will be on salary from a hospital or some institution in the near future?
DeMarco: Yes, a lot of it is being institutionalized. Just look at what is happening locally with the HealthTexas Provider Network and with the hospitalists. The regular doctor can no longer afford to have an office practice and take care of sick inpatients. Everything is being delegated to a hospitalist who doesn't know the patient outside the hospital. I think that all of these movements are leading to the idea of physicians being salaried. I still think, however, that it's going to be less than half the physicians. When it comes down to it, it's just the doctor seeing the patient and the patient wanting to get better and the doctor wanting to make the patient better. The beauty of medicine will still be there. No matter how the physician is paid, there will still be good doctor-patient relationships. I'm still going to be proud to be a doctor, but things are going to change.
Roberts: How much time do you spend teaching the housestaff, not the gastroenterology fellows?
DeMarco: I spend a considerable amount of time with the GI fellows; I tend to work with the first-year fellows before they move on to the specialized procedures, so I call my year the “left-right-up-down” fellowship because I am teaching them left, right, up, and down turns with the scope. I teach the medicine housestaff 1 month a year as a ward attending, and about 6 or 8 months a year I have housestaff rotating on my service. I usually have a fellow, a resident, sometimes an intern or two, and, of course, a fourth-year medical student who wants to come to BUMC for housestaff training. (The medical students apparently think that if they rotate on my service that helps them get a residency position later.) I actively work with Mike Emmett in the intern-selection process. Late in the year I am often without a fellow, or resident, or student.
Roberts: How many patients as a rule do you have in the hospital at any one time?
DeMarco: Usually 5 to 15. It's variable because on weekends when on call I can pick up 10.
Roberts: When you are on call on the weekend, starting Friday night through Monday morning, how much of those 60 hours would you be home?
DeMarco: Usually, I would work 10 hours on Saturday and 6 on Sunday. Additionally, we do a lot of elective procedures on Saturdays. I will do 4 to 6 procedures and make rounds and take care of new inpatients and any transfers. Often for transfers into BUMC, it's very difficult to get a bed, get it cleaned, and get the transportation arranged. As a result, transfers usually come in at odd hours like 10:00 pm.
Roberts: You have a lot of calls at home?
DeMarco: The only thing that keeps the calls away is the Cowboys games.
Roberts: Daniel, is there anything else you would like to bring up?
DeMarco: One of my other jobs is chairman of animal research at BUMC. We have monthly meetings where we approve animal protocols. It's like the institutional review board for animals. A lot of things are done to humans because you can get their consent, but there are only limited things you can do to animals. It's been a challenge. I have some animal protocols on advanced endoscopy. We like to do those procedures on animals before trying them on humans. I used to complain about the functioning of the committee and how hard it was to work with them. Before I knew it I was on the committee. A couple of years later I was chairman of the committee. The same thing happened in the GI lab. I complained about how things were going there, and before I knew it, I was director of endoscopy.
Roberts: On behalf of BUMC Proceedings, I appreciate your openness and am sure the readers will too!
DeMarco: Thank you.