A surgical life by Donald E. Low

Although I have spent nearly all of my career in the US, I am Canadian by birth. My General Surgical training was split between the University of Toronto and Queen’s University following which I brought my family to Seattle, Washington to do a Thoracoesophageal Fellowship with Dr. Lucius Hill. I also spent time in the UK NHS with Dr. Michael Pagliero and Dr. Hugo Matthews in Exeter and Birmingham, and with Dr. Joel Cooper  at Washington University in St. Louis, Missouri helping set up the first Lung Transplant programme in the US and the second in the World. I then took up a post at Virginia Mason Medical Center in Seattle as the first full-time General Thoracic Surgeon in Washington State.

My clinical interests encompass all aspects of General Thoracic Surgery although the largest component of my practice and major academic interest has been in the management of esophago-gastric disorders. I was Chief of Thoracic Surgery and Thoracic Oncology at Virginia Mason Medical Center for 30 years. I have been President of the Ryan Hill Research Foundation which supports Thoracoesophageal research and has funded a research fellow at Virginia Mason for over 50 years. I have received honorary fellowships from the Royal College of Surgeons in Ireland, England and Edinburgh. I am currently the President of the International Esophageal Study Group which oversees the administration of the International Esodata Esophagectomy database.

What made you decide to become a surgeon?

It became clear to me early on that I needed to find a profession that facilitated being innovative and productive while working in a team environment but also providing the opportunity to work with my hands. My role models were my grandfather and father who were both academic surgeons practicing obstetrics and gynecology. They both became Heads of their respective academic departments and provided a template of how a busy surgical practice could be effectively combined with an active role in medical research and education.

Who were your influences?

The greatest influence regarding achieving personal goals was made by a project manager over four summers working for the Department of Lands and Resources for the Province of Ontario. This gentleman was a recent immigrant from Italy and  I have never met an individual with a greater capacity for work. He could fix anything and there did not seem to be a technical issue he could not resolve. In my teenage years, he impressed upon me that with hard work, focus and a degree of ingenuity, people are able to achieve virtually any realistic life goal.

What were your training highlights?

This is difficult to answer because I was very fortunate in the diversity of my surgical training and mentors. My fellowship with the famous American surgeon Lucius Hill was an eye-opening experience. Dr. Hill was a master of surgical exposure and one of the fastest and most efficient surgeons I have ever witnessed. Even in his senior years, he was continually looking for avenues to better understand clinical problems and improve surgical technique. My training period in the NHS was also profoundly beneficial. I was involved in over 1200 Thoracic, Esophageal and Cardiac operations and came to understand that there are multiple appropriate methodologies for the surgical management of esophago-gastric issues. Many of the technical approaches that I applied during my surgical career were amalgamations of techniques learned in Canada, the US and England.

My involvement in the first 30 lung transplants done in the US in St. Louis represented a unique training highlight. This was in part related to the fact that every organ retrieval that I participated in was the first occasion that other transplant teams had to accommodate the harvesting of lungs in addition to the heart, liver kidneys etc. The degree of excitement associated with being involved with the introduction of this new transplant programme was a very special experience.

My surgical training also highlighted that this journey is both a personal and a family affair. My wife, Diana, and our three young children moved seven times over five years involving three countries and two continents. Looking back, we all agree that it was a challenging but profoundly satisfying experience for us all.

Tell me about a surgical triumph?

I could provide multiple examples of operative outcomes that were personally satisfying, however, I will use this opportunity to highlight a series of collective outcomes rather than a single surgical procedure. In the 1990s, multiple publications highlighted that the outcomes of esophageal resection, even in high volume centers, was associated with unacceptable levels of mortality (5-15%) and anastomotic leaks (10-20%). In conjunction with multidisciplinary colleagues at Virginia Mason, we established a protocol for standardized clinical pathways (the precursor of ERAS) that we utilized to manage a series of over 300 consecutive esophageal resections between 1991 and 2006. This was the first publication to demonstrate that under the right circumstances, mortality rates could be brought to very low levels, in this case 0.3%, and the incidence of anastomotic leak could also be improved; in this series 3.8%. These results remain a source of significant professional satisfaction.

Tell me what you learned from a surgical disaster?

Surgeons who routinely perform high risk surgery know that even with the most meticulous training, personal preparation and attention to detail that unexpected complications with negative outcomes are components of surgical life. Early in my career a patient in his 40’s presented with a central lung cancer that we removed with a carinal resection. He sustained a partial tracheal anastomotic dehiscence four days postoperatively. In the process of preparing to surgically stabilize the situation, the patient had a ventricular dysrhythmia and died. While the family was completely understanding and forgiving, this unexpected outcome was a reminder throughout the rest of my career to never take good outcomes or uncomplicated recoveries for granted.

What was your proudest achievement?

With the support of all major Thoracic and Upper Gastrointestinal societies, we proceeded to put together a group called the Esophageal Complications Consensus Group which met initially in Newcastle, England in 2011. This group, through a series of Delphi surveys and face-to-face meetings produced and published a standardized platform for complications and quality measures as well as definitions for complications that has become a standard for reporting international esophagectomy outcomes. This project subsequently led to the establishment of the International Esodata Dataset – the first secure online dataset recording global esophagectomy outcomes. Esodata is now collecting data from 75 centres from 21 different countries. This process not only accomplished the critical goal of standardizing the reporting of post-esophagectomy outcomes, but also demonstrated the significant opportunities inherent with collaborative international research projects.

What are your hobbies outside of surgery?

Outside of time with family and friends, I enjoy spending time in my woodworking shop on Mercer Island, Washington. I have been involved in construction and woodworking since my teenage years and, as expressed previously, find great satisfaction associated with working with my hands. I spend as much time as I can on the golf course which is a constant reminder that expectations should always be tempered by personal realities.

What advice would you give a young surgeon?

This opens up so many opportunities to provide meaningful commentary but I will concentrate on one personal impression which I have consistently shared with trainees. Simply put, “have the right partner at home and have the right partners at work.” If you have these two components, you will be able to weather any unsettled period in your career. I know this advice to be true in that I have been profoundly fortunate to be married to the best person I have ever met and have benefited from the fact that my interaction with my surgical partners has always been based on mutual respect, professional support and friendship.

What would you be if you had not been a surgeon?

I would probably have ended up teaching history, maybe with a secondary job as a construction contractor or building custom furniture.

Any regrets?

In truth, very few. However, for the first 15 years at Virginia Mason I was the only thoracic surgeon practicing in my medical system. Building a practice and being on call all the time resulted in less family time than I would have hoped, and my family deserved. No one wants the epitaph of “Dr. X was a great surgeon but should have spent more time with family and friends.”