BJS Bookshelf: Mastery
10 March 2023
31 October 2022
I trained at the Johns Hopkins School of Medicine (1972-1976) followed by a surgery residency at the Johns Hopkins Hospital (1976-78 and 1980-1984) including 2 years as a research fellow at the Mayo Clinic (1978-1980) under the direction of Dr Keith Kelly, a truly remarkable surgical scientist. I spent a year as a postdoctoral fellow at Johns Hopkins Hospital (1984-1985) under the tutelage of John Cameron and Gregory Bulkley; both formidable mentors. I was groomed to become the classic academic general surgeon of the times with a primary clinical and research interest in GI surgery and physiology and so I was appointed as an academic surgeon with an NIH-funded laboratory studying GI motility and absorption. My career then spanned the next 37 years at Mayo Clinic with extramural leadership positions in several national and international societies, a 5-year stint as a Director on the American Board of Surgery, Chair of the Department of Veteran’s Affairs Merit Review Committee (1995-1998), and editor of the journal SURGERY for 22 years (2000-2020). If I let my mentors down, it was that I never became Chair of a department of surgery, because I never wanted it. I would never have wanted the administrative responsibilities to interfere with my laboratory pursuits, hands on teaching and clinical interests. All of this is ancient history. What is more important is what follows and hopefully will help young surgeons find their way in our house of surgery.
What made you decide to become a surgeon?
My dad was a urologist, and as a kid looking at his medical books, I decided I could never be a urologist, but the father of one of my girlfriends was a paediatrician and I really admired him’, so I entered medical school thinking I was going to be a paediatrician ,that is, until I rotated through paediatrics. Two hour rounds 3 times a day and dealing with well-meaning but difficult parents and paediatric nurses who always thought we were barbarians out to hurt the kids (yes, it’s true) was enough to convince me that this was not my calling. I was a very serious student and at Hopkins was being groomed to be an academic physician, so I tried rotations in most specialties. I left the surgery rotation until last, because all I had heard from others was that surgeons were ‘jerks’, were not academic and not scientists. At the end of my third year, I had to do surgery and after 2 weeks, loved it. I enjoyed the work, the challenges, and the surgical personalities, but how could I be an academic as a surgeon? Then I met a several surgeon scientists (there were quite a few at Hopkins) who ran laboratories, were great teachers, and were exciting. From then on, I knew that surgery was my calling.
Who were your influences?
In medical school there were several. Dr Anthony Imbembo really turned me on to the vital role of teaching – dedication to hands on teaching and not just “passive” teaching by observation of having young surgeons on a clinical service. My second influencer and though younger than me, someone I still regard as a mentor, has been and still is Dr David Farley. He has taught me so much about how the younger generation thinks!
In terms of clinical surgery, Dr John Cameron was the go-to surgeon for the residents at that time; an excellent, uncompromising technical surgeon and also a hard-nosed teacher—-wouldn’t you want a hard-nosed, uncompromising (it had to be perfect, not just OK) surgeon to operate on you? In the field of research, Dr Robert Burdick a transplant surgical scientist and Dr Gregory Bulkley, a GI surgical scientist, were so impressive to a wide-eyed medical student.
What were your training highlights?
My training highlights continued until I retired. Training should never end; once you are totally set in your ways, it is time to retire.
As a 2nd year resident, I was looking for a research position for the next 2 years Our department chair Dr George Zuidema (who was the ultimate in giving erudite career advice) suggested that I speak with Dr William Silen, then a visiting professor. Dr Silen was a tall, slender, gruff looking but really insightful academic who listened to my plight and said ‘you want to work with a PhD who is the world’s expert on one focused topic like an enzyme so that you will then know more about that enzyme than anyone and can further scientific knowledge’’. Dr Thomas Gadatz who was a young surgeon at our Veterans Administration Hospital said ‘why not work with a surgical scientist who also operates’ and suggested that I look up Dr Keith Kelly at the GI Research Unit at Mayo Clinic. So I did and found the topics interesting. I returned to Dr Zuidema to ask about Dr Kelly and his response was, ‘great choice Mike, call him tomorrow’. I said I would call him today, but he said, ‘no call him tomorrow’. I didn’t understand the ‘wait until tomorrow’, but undoubtedly he called Dr Kelly and must have said something good about me, because I went off to Mayo Clinic later that year.
The clinical highlight in my training was during the 5th year of my residency. My chief resident Dr Larry Pennington, who I admired tremendously, and I had performed a modified Nissen fundoplication with fixation to the pre-aortic fascia. That night the patient developed severe hematemesis, so we rushed him to the OR. When Dr Pennington put his hand up at the gastro-oesophageal junction, he said with a look in his eyes I had never seen ‘Mike, do you know what it is like to feel desperate’? I said, ‘yes I think so’. He replied, ‘no you don’t; this man has an aorto-oesophageal fistula and I have never fixed one of these’. My response was, ‘you are right, I don’t know what it is like to feel desperate’. Larry used what he had been taught, got control of the aorta, and repaired the fistula. That lesson has been used by me many times.
Tell me about a surgical triumph
Many surgeons relate their triumphs with resection of large tumors or saving a patient’s life, but one of my triumphs was a middle-aged lady with severe morbid obesity (BMI of about 55) with a high-output enterocutaneous fistula present for 4 years, arising in the centre of a large skin graft in the middle of an incisional hernia. She had been on TPN for 4 years, had been seen in local and two major well-known medical centres and several big-name surgeons. The general opinion was that nothing more could be done for her. Her life was miserable, she was home-bound, had had several catheter infections, her stomal appliance feel off constantly, and she was understandably depressed. I took her to the operating room and under local anesthesia (remember a skin graft has no pain fibres nor does the bowel), incised the skin graft around the site of the fistula which was only about two cm in diameter, closed the bowel fistula site transversely, and then reapproximated the edges of the skin graft. She went home eating 4 days later. That was a triumph.
Tell me what you learned from a surgical disaster
Many years ago, I saw a lady with a hard axillary mass and no other findings. Suspecting an occult breast cancer, I did a needle aspiration biopsy, the pathologist reported “consistent with breast cancer”, so I performed a modified radical mastectomy, only to have the pathologist call me to say that the axillary mass was melanoma! A difficult but honest discussion with the patient included admission of an error on my part in basing an operation dependent on exact cell of origin on needle cytology. She listened, and though disappointed, understood.
What was your proudest achievement?
As an academic surgeon, I really need to address 3 categories-research, education, and clinical work.
In research, getting an National Institutes of Health (NIH) grant and then renewing it was always a source of great pride. I was successful 3 times and had an NIH-funded lab for 23 years.
Education is a vital part of being an academic surgeon. In my 30 years on the staff at Mayo Clinic, I received the Department of Surgery teacher of the year on a dozen occasions. It’s probably the award I am most proud of!
Regarding clinical work, I was a classically trained GI surgeon and used the lessons in physiology to create a practice of reoperative GI surgery, especially after bariatric surgical procedures that had gone wrong. At a meeting of the American Gastroenterology Association, I was the third speaker after two very distinguished physicians who had addressed the problem of obesity and nutritional problems that needed to be considered and managed postoperatively. The audience of about 2,000 directed virtually all of their subsequent questions to me – the surgeon!
What are your hobbies outside surgery?
I grew up in a small blue-collar town of 2,000 people in a rural setting. So, I do as I did as a
kid- I hunt, fish, and read non-medical books.
What advice would you give a young surgeon?
Follow your dream, work hard in medical school, and remain true to your oath as a doctor especially if you are a surgeon. Be a doctor as well as a surgeon- you are not just a surgical technician. Understand the difference between a great technical surgeon and a great surgeon (who is also a great doctor with all that implies).
Always admit your mistakes. Morbidity and mortality conferences are almost unique to surgeons. Discuss all of the patients (we did in my institution every week). These conferences should not be punitive, but educational, so that others learn. These conferences are some of the best opportunities for providing surgical education.
What would you be, if you had not been a surgeon?
Never thought of that!
Certainly; every mistake I made as a surgeon. They need to be remembered – both errors of omission and commission. Never forget them. I don’t and remain deeply sad for each one. Hopefully, those made me a better doctor! Always remember, the patient did not develop a complication postoperatively alone, the complication was always in part our fault, sometimes totally our fault. Patients do not develop complications, they suffer them!
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