A few words about this Blog

     This Blog was created to integrate the information on different aspects of Head and Neck Diseases. Its target audience includes medical students, residents, Otolaryngologists/Head and Neck Surgeons, Medical and Radiation Oncologists, Pathologists, Cancer researchers and all other specialists interested in head and neck. 

Two men and the Ocean, Ralph Steiner (1921)

       Τhe main topics of interest are clinical and translational head and neck cancer research, and academic surgery. Through interviews with leaders in the Head and Neck field, the blog aspires to increase awareness among medical students and help as a platform to inform, educate and inspire. This effort wouldn't materialize without the generous contribution of all participating faculty, sharing their expertise and knowledge. 

       Please keep in mind that the purpose of this Blog is informative and the Blog does NOT intend to replace your doctor. You should ALWAYS comply with your doctors' advice.

PS: The Blog's conception was inspired by a discussion with the unique in so many ways KD.

      Please do not forget to cite the Blog when you reproduce the material published here.

Dr Duvvuri - NYU Grossman School of Medicine

 

Umamaheswar Duvvuri, MD, PhD

Mendik Foundation Chair of the Department of Otolaryngology

NYU Grossman School of Medicine

 

Dr Duvvuri earned his MD and PhD at the University of Pennsylvania and completed a residency in Otolaryngology-Head and Neck Surgery at the University of Pittsburgh. He then trained in Head and Neck Surgical Oncology & Reconstruction at the MD Anderson Cancer Center. Currently he is the Chair of the Department of Otolaryngology at New York University. Dr. Duvvuri has over 190 published papers and more than 8,000 citations. He has taught in many countries around the world, trying to improve the quality of head and neck cancer care.

 

 

 

My first question is somewhat generic, and I intentionally include it in most of my interviews. This is because I believe it's valuable and helps me gain a good understanding of your background and perspective. So I wanted to know why you choose to subspecialize in head and neck surgery after after residency. What drew you to this field in particular?

So, in fact, I would say for me it was a little bit the opposite. I was drawn to the field because of head and neck surgery. You know, I have always had a very strong desire to help people. Clearly, that's why we're going to medicine. But specifically coming from India and having my background, - head and neck cancer is a very big problem in India- I thought that at some point, I would like to return and contribute by educating, training, developing, and establishing scientific enterprises there. And I thought the best way to do that would be for me to be trained in an area that was of particular relevance to India. And so, I was always drawn to head and neck cancer from that perspective. I was also drawn to cancer because my uncle unfortunately died from lung cancer when I was younger. So I was always sort of tuned to the cancer and the oncology world. And it was a confluence of events. I remember thinking about this. I could have pursued head and neck cancer as a general surgeon, plastic surgeon, oral and maxillofacial surgeon, etc. And I was talking to people about what the field of head and neck oncology looks like in this country. And they said that most of it is done by otolaryngologists, and so you should do otolaryngology first, and then you specialize in head and neck. So I realized that that's what I wanted to do and I applied to ENT.

 

That's very interesting! Is there something that you dislike about the subspecialty?

Well, to be honest with you, one of the things I think is hard to swallow is that it is one of the more underappreciated of cancers, in the sense that it's not consider such a big problem in the US, right? It doesn't get the same attention as other cancers. And I am not comparing it to lung or colon or breast cancers, which are very, very common. But if you think about it, pancreatic cancer has about the same incidence as head and neck. Right? Same for glioblastoma. But it feels that those diseases tend to get a little bit more press. I hope that answers your question.

 

You did! Like I said, these first two questions are somewhat generic and I constantly keep thinking about whether I should keep including them in my future interviews. But the kind of answers that I get, how different they are and how fascinating they are always convincing me to keep them in there. Moving on to the next question, you have a somewhat unique background. My understanding is and you were born in India, but you actually grew up in two different countries: India and Jamaica. And then you came to the US to pursue higher education. So I wonder how this diverse background shape you as a surgeon, as a leader and as a person, and what did you learn from it?

Oh, that's a very interesting question. I would say that I learned a couple of things from this. One is I learned that we often end up in very, very different scenarios than you think you might project yourself to be in. So, I started it in India. Then we moved as a family to Jamaica. And when I moved there, I realized that there's a whole different world, which is very different from what I knew. And yet people are still very much the same. So number one, it taught me the real value of diversity and harmony. The best way to put it, is the national motto of Jamaica “Out Of Many One People”. You know, in Jamaica you'll find people of Indian heritage, Asian, Chinese, East Asian, African heritage, Caucasians, Europeans, etc. And they are all melded into this this pot. So it really is a very, very interesting country from that perspective. And, you know, when you come from a very homogeneous country like India, where a lot of people look very similar, it's very different! So, it really taught me the value of diversity and respect for other cultures. And that I think this has carried over into my work and to my professional life.

The other thing that I've done a lot in my career is that I've traveled a lot and I've taught all over the world. I've operated in lots of countries. I've operated in Antwerp, Singapore, India, and Brazil. You're gonna learn from your patients- you can learn from everybody. And you have to be able to be a good doctor, and a good surgeon. You have to be able to relate to people on their level and make them feel trust and confidence in you because they're giving us an awesome privilege of literally cutting on their body. They’re putting their life in someone's hands. I just don't even have words to describe it. It's one of the most awesome and fantastic privileges to have. We shouldn't take that lightly. That's a very, very profound level of respect and trust that people place in us.

And so going back to your question, growing up in different parts of the world and operate in different parts of the world, I've been able to see how the different cultures interact and how we can take from each of those cultures. And learning to be worldly allows us to then meet people on their levels, so that you're not talking down to them and really develop a rapport and build some trust in us. I’m not sure if I answered your question, but I think that's probably the best one I have.

 

Thank you! Yes, you absolutely did! The uniqueness of your background is not necessarily limited to this aspect of your life. You have a PhD in biochemistry and molecular biophysics, and you also did your your fellowship training at MD Anderson. You are, by definition, a surgeon-scientist. You could have probably been very, very successful in one of these areas individually, but you chose to do both. Why is that? What drew you to try and combining them throughout your career?

This is an interesting, and colorful, and funny story. It really started when I was an undergraduate student at Penn. I studied engineering because I wanted to be a scientist. I wasn't really that keen on medicine. It wasn't my passion. But I liked the medical aspect of engineering and trying to have an application relevant to healt. So my interest was not just building bridges, but doing something that was relevant from a healthcare standpoint. So we had to do a senior design thesis as undergraduates. And I found a person in the medical school to work with.

His name was Jack Leigh. He was in biophysics and he was also in bioengineering. And Jack was an amazing guy. He was a complete iconoclast. I had worked with him as an undergraduate and I had written two papers with him. I was very proud of myself for that. And I asked him: “I want to go to graduate school. Would you write me a letter of recommendation?”. And I was fully expecting him to say yes. And he looked me straight in the eye and said no! And I said, “Why not? I've worked so hard. I wrote two papers- one as first author. I mean, most undergraduates don't do that!”. And he looked at me and he said: “listen, there are three kinds of people in this world. There are the ones that can build a hammer to solve a problem. These are the scientists and the engineers. The nails are the problems that need to be solved. There are the ones that use these tools to see the problems to be solved. The doctors, the dentists, the nurses, the people that actually take care of patients. And then finally, he said there's a third category, a very small group of people, that does both. He looked at me and said, “So if I gave you a choice right now, which one would you want to be?”. I looked at him and said, “Well, if you put it that way, then I want to be number three- the one who knows the problems and solves the problems”. And he looked at me and said, “Right, so I'm going to write you a letter of recommendation for an MD-PhD program. That's what you're going to do”. And that's why I did what I did.

But that story stuck with me my entire life because, you know, we do sit on that very cool interface between straight clinical, which is knowing the problems; and straight science, which is solving the problems that you think you know the answer to. But the hardest thing to do is to actually understand what the real problems are. You know, a lot of scientists stay in the lab, and they do great work. They write really, really impressive papers, but they don't necessarily truly understand what the problems are that the patients or the physicians are dealing with. I think we need to train even more people to do this. That's why I've always tried in my career to straddle that fence and be both clinically active and scientifically active. Yes, I could have maybe been a bigger scientist had I only done science, or maybe been a bigger surgeon had I only done surgery. But being on that on that interface, I think has given me the opportunity to see the best of both worlds.

 

This story is truly amazing. Wow! You said you could have been maybe a bigger scientist or a bigger surgeon. But in reality, you are producing a lot of very impactful papers every year, and I understand that you are also very clinically busy. So, what does it take? What does it actually take to stay on top in both of those two areas?

I’ll have to go back to my mentor, Jack Leigh, again, who as you can tell, had a profound impact on my life. You need mentors. That's really, really important. But Jack also gave me a very good piece of advice as I was a young trainee in his lab. He looked at me and he said, “you know, there are three kinds of people in this world, who are successful. There are those that work hard and they're successful. Then there are those that work very hard and they're even more successful. And finally, you have the top of the top, the best of the best, most successful people, and they display prodigious effort”. So the key here is, a) you have to be passionate, and b) you have to display prodigious effort. And that's the only way to be successful in this. There is no other secret sauce. There is no other magic. There's nothing else. The environment is of great importance. Because you cannot be prodigious and successful if you are in an environment that doesn't support that. You have to have mentors who recognize this. People who recognize the value of doing this. Because it's much easier to have a straight clinician on your faculty, for example. Now that I'm a chair, I see that. It's much harder to recruit physician-scientists. It's hard to give them that environment. It's hard to put them in that in that space. It's easier to have a scientist. Us physician-scientists, surgeon-scientists are in this weird amalgam. But we also have a lot to contribute. To be able to translate from the bench to the bedside and so on and so forth. I think is really, really important. As a young person, look for a place that has an environment to allow you to develop.

 

I've never thought about that in this in this particular way, but it makes makes a lot of sense. I can definitely see that. Now, you talked about you being Chair- you recently began your new appointment as the NYU Langone Chair. So, I wanted to know what is your vision for the Department.

The way that I feel about it now is that we've got a great clinical Department, with amazing people. They're doing great, great clinical work. There are also amazing people here doing tremendous scientific work. My vision is to try to leverage those strengths, build on those amazing, strengths and attributes to try to push us towards areas that we have not traditionally done here. Or to tackle problems with, with a slightly different light. As a physician scientist, I would be lying if I didn't say that I was committed and excited about developing the physician-scientists and developing abilities to treat people in that model. And I want to be clear: being a physician-scientist doesn't mean you have to be an MD-PhD. You can, but it doesn't even have to be that, you don’t have to be in the lab. You can be a physician-scientist in population health and clinical research and clinical trials. You can be a physician scientist in comprehensive general otolaryngology, or in a subspecialty. But, I don't want to present this as if physician-scientists are the pinnacle of greatness. No, that's not that's not the point. We just have a role to play like everybody else.  Like a football team. Everybody can't be a striker. Everybody can't be a goalkeeper. Everybody can't be a quarterback. Everybody has a role to play. This is just one of the roles. It's not better than anybody else. It's not worse than anybody else. It's just different. But you need some of those people to try to help develop the science aspect of things.

Most importantly the translational science aspect of things. I'd love to see NYU Otolaryngology under my tenure to grow in those areas. Surgical innovation, driving clinical growth and productivity as well, providing high value care. My slogan is: I want my Department to be patient centric, outcomes oriented, innovation driven.

1)    Patients first: Make it easy for patients to get their care.

2)    Excellent outcomes and high quality care.

3)    Innovate. Research innovation drives new technologies that will improve outcomes, push us to the higher levels while being patient-centric. So it's kind of like a triangle. All these three things should go together.

Another great mentor that I had was a surgeon scientist at Penn, Dr Doug Fraker, who did amazing amazingly high volume surgery and was a scientist. I asked him how he did that and he said “you need to make the operating room your laboratory. You need to find a way that your science comes from the OR. So your clinical practice gets folded into your science and into your investigation. That becomes how you do science, whether it's clinical trials or surgical innovation or taking the specimens from the OR to the bench to study it. These are the ways where your clinical work informs your science, and that's what I've tried to do.

Robotics has been my area. That's not all I do, but that's what I write about. Every patient that I operate on, I find a way to get their information, study that, write about new techniques, write papers on this stuff, and hopefully people will find it useful and it will help to be a force multiplier going forward by training other generations and other sets of people to push this forward.

 

And it probably allows you to create unique cohorts, unique samples, unique populations. Because you are actually seeing these patients. Like you said, you're seeing the problem that they're facing. Then you go back to the lab and try to create the right questions because you have the samples.

The biggest thing that that young people need to know is that they have to be able to say ”I'm not just going to keep doing something the way that I'm doing it, because my professor told me that's the way it should be done”. You need to ask the question, how could I do this better? Or is this the best way of doing it?. If we all thought the best way of treating cardiac disease was by giving everybody aspirin and just having them lie down with their feet off the bed, then we would still be having the same mortality that we did 50 years ago. It's because people said, well, is there some other way to do this? Is there some better way to do this going forward? That's why we invented stents, catheterizations, statins etc. That's why the survival for patients is so much better now.

We've moved because we've asked people to say, is there a better way of doing it? People have to ask that question. So that's what I think young surgeons need to know. And that's what, again, going back to your question about NYU, that's where I would like to go with my program for residency. I want to train the next generation of people who are not just great clinicians. They are going to be great clinicians performing standard of care as we have now. But at the same time be inquisitive enough to ask questions. I want to encourage them to think outside the box and to say, is there a better way of doing this? Because those are the people that are going to really change the field long after I'm gone.

 

Is it talent or is it character that makes a good surgeon, in your opinion? It's easy to say that it's both, but I know you're not keen on the on the easy choices.

I think here it is both, because both things play a role here. I think that it's hard to pick which one of those two very important things are there. I'll answer it this way. There's a famous quote that that I heard from Claudio Cernea, who was a maestro of head and neck surgery from Sao Paulo. And Claudio told me this when I was a young surgeon: one who works with his brain as a scientist, one who works with his hands is a craftsman, one who works with his heart is an artist but, the one who works with his heart, guiding his brain through his hands is a surgeon.

Compassion, intellect, character, and technical talent, are all really important aspects of being a surgeon. But what's what's more important in my mind is the thought behind that technical talent. There was a famous saying, I think it was by Halsted, that said, I cannot wait for the day when an academic institution will enroll in their faculty a surgeon without hands.

Because what we do with our hands is by far the least important of being a surgeon. It's all between the ears. It's all up here. This is where surgery happens. It's not the hands. So when you say talent, I think talent comes with character. I think it comes from people that display prodigious effort, which I think is character that asks the question why? Why aren't we doing it better? How can I do this differently? Or is this the best I can do? That's also a character, right? Caring for your patients is character. Wanting to do the right thing, even when it is easier to not. This is character. And this is right. This is why we see many, many talented surgeons do bad things and get into trouble. We see fraud of all kinds, not because these individuals are not talented, but because they lack character. And so I think that if you were to pin me down, I guess I would have to say both are important, but character is what defines surgical greats.

 

Thank you. What, in your opinion, is a predictor of success in residency? What are you looking for in an applicant, and what do you use to make an assumption about whether they're going to do good/ great/ poorly.

I think really what it comes down to is asking the question I mentioned earlier- somebody who is appropriately inquisitive and appropriately questioning will be successful. And so what I'm thinking on this, is how do we develop better versions of those in residency? The question we ask is, how do you know someone's going to be a good resident? Are they inquisitive? Are they thoughtful? Do they have character? Do they have the fortitude to actually do the right thing?. And are they willing to display prodigious effort to be great? Because you can coast through residency and be fine. Or you can work really hard and be great. And that is ultimately the measure. What residency is doing, in my opinion, is not just ending your training. You're just in the middle of your training, because you're going to continue to refine your art for your career. That's why it's called the practice of medicine. You're not done with residency. You're just learning how to think. That's my job- to teach you how to think. So if you can learn how to think, then you can continue to develop that.

At the end of the day, I'm looking for that. I'm also looking for people that actually want to drive some change in the field. That want to make an impact. And that impact doesn't have to necessarily be in the science or the bench. You can make an impact in your community by just being a great doctor that's practicing great cutting edge care in a rural community or in an urban center like New York.

 

So it sounds like you're looking for the foundation to build upon those qualities.

Yes. And I think some of these are qualities that people will develop over the course of their lives. I was lucky to have Jack as a mentor, who taught me and showed me that this is what I should be trying to aspire to. If I hadn't had that, I wouldn't be who I am now. I acknowledge that 100%. I owe much to him. And so, hopefully when I was applying to residencies, people saw that. And we're looking for that, but also acknowledging that not everybody is going to be like me and that's fine. Not everybody in residency has to do the same thing. We don't want everybody to do head and neck, or everybody to do general, or Peds. But some common themes in this are this desire to really be excellent.

 

What would you like to be remembered for as an academic surgeon? As a scientist? As a professional?

Wow, that's a great question. I don't know how to answer that one. I guess, there are a couple of ways. You know, people always talk about, what's my legacy going to be? People want to think of it from that perspective. I don't know that I necessarily think of it that way, but there are two things that come to mind. One is Satya Nadella, who is the CEO of Microsoft. He famously said once, “I didn't ask to be the CEO. That wasn't my next step. I just did the job in front of me as best as I could, at every point in time”. I think that's a great way of looking at it. I'm not looking at what my legacy is going to be. What I want, though, is to have the ability for people to say, you know, he did a great job at wherever he was at this point in time. Of course, I recognize that not everybody is going to like what I do. Not everybody like what anybody does. That's just life. But, I think there's opportunity for us to continue and push this forward.

So do the best job to be recognized as somebody that deeply cared about the people that that worked with me, my residents, my trainees, others. There's an old saying that the student of a master is a master and a half. I firmly believe that my goal is to train the next generation of surgeons, who are going to be even better than I am. Another great mentor of mine, who I'm very fond of, is Gene Myers, who was just amazing and gave me great mentorship. He was very proud of the fact that I became chair because he looked at me and said, “you know, you're the the last of the breed of the people that I trained”. And because I was that tail end of that career for him, he said, “you're the 28th chairman that I've trained”.

He was very proud of that. And why shouldn't he be incredibly proud of that? I would be, if I had that. He trained all of these chairs, and division chiefs and leaders. And so one should be proud of that. I think that there's great value in knowing that I contributed in some significant measure to that success for someone. And most importantly, going back to my slogan, patient centric. Feel that my patients benefited from my care for them as well. The most important reason we're here is to take care of the patients, to be patient centric, to do the right thing for the patients. And so if I innovate, if I develop, whatever I do, it should be with the idea that it's going to actually help people, not just write a paper for the sake of writing a paper.

 

I appreciate you sharing your thoughts.

Well, thank you for asking the questions. Good questions. Interesting. And I hope that it was useful to you and hopefully it'll be useful to other people.

Dr Michael Topf - Vanderbilt University

Michael Topf, MD

Assistant Professor of Otolaryngology-Head and Neck Surgery

Vanderbilt University Medical Center

 

Dr Topf earned his MD at the University of Rochester School of Medicine and Dentistry and completed a residency in Otolaryngology- Head and Neck Surgery at Thomas Jefferson University. He then trained in Head and Neck Oncologic Surgery at Stanford. Currently he is an Assistant Professor at the Department of Otolaryngology-Head and Neck Surgery at Vanderbilt University. Dr Topf is a pioneer in 3D surgical specimen mapping. He has over 60 published papers and more than 700 citations.

 

 

 

Why did you choose to subspecialize in head and neck cancer surgery after residency? What drew you to this field?

I have always been a bit of an oncology geek. I like clinical oncology, Kaplan-Meier curves and both non-surgical and surgical clinical trials. So, I think what, what drew me to head and surgical oncology fellowship was the care of cancer patients and the field of oncology as a whole.

 

Is there anything that you don't like about the subspecialty?

 I don't like that head and neck squamous cell carcinoma as a solid malignancy still has relatively poor outcomes, and that we have really not improved significantly in the last 2 to 3 decades. And with that comes patients that unfortunately don't do well from an oncologic standpoint. That's always challenging.

 

You're doing a lot of work with 3D specimen mapping. You've published a lot there. Honestly, I think it's quite amazing. I was hoping that you could share a few details about this, and also share how you see this technology involving evolving in the coming years.

Yeah, thanks for the question. It really started with a clinical unmet need. You know, as a fellow at Stanford, I saw difficulty in communication among members of the multidisciplinary cancer care team. This was seen in multiple phases of care. Intraoperatively, when we have anatomically complex resection specimens with multiple different types of tissue, that often require a face-to-face interaction between surgeon and pathologist. Particularly if the approach to margin analysis is a specimen driven approach. And this is time that the surgeon is not scrubbed in in the operating room advancing the case. So, I just wondered if we could do better with regards to intraoperative communication and delivery of frozen section results. If you think about it objectively, compared to other fields, why are we still delivering frozen section analysis results via telephone call without any visual aid in 2023?

You get a pathology report back a week or two after surgery for these complex cases, and inevitably there's some margin that may be close, hopefully not positive, but it happens- probably a fifth of the time for complex, locally advanced specimens. And we're again, left to written descriptions of the margin sectioning and the description of the specimen to try to reconcile those margins. The fact that there is a margin that is positive or close is concerning and potentially, an indication for adjuvant therapy. However, sometimes additional tissue has been resected that supersedes that area. And without a visual aid, those conversations between surgeon and pathologist are very challenging. These are also conversations that are had at multidisciplinary head and neck cancer tumor board, when we're dissecting through the pathology reports.

So, I thought there was a real clinical unmet need for creating 3D visual models of this specimen. I'd like to acknowledge a medical student who came to me with the background in 3D scanning: Kayvon Sharif, who really over a two-year period worked out a way to do this in real time with me and not interfere with normal surgical pathology workflow.

With regards to the second question, which is where I see it going, there are two barriers to widespread adoption. When I show people these scans and the protocol and the technology, I think everyone says “Wow, that's really cool. This is better”. But we still need to prove value, right? We need to prove the value of the technology because there are costs associated with it. So, we need to demonstrate value and that's going to be an academic and personal goal of mine over the next ten years. The other major hurdle is that the hardware and the software is not quite ready for the primetime yet. The vast majority of 3D scanners are not designed to 3D scan human tissue or resected specimens. And there are nuances that come with that. Similarly, the software that we use to annotate our 3D specimens to create these models and visual representations of the processed specimen is not designed for that use. So, we need to create software designed specifically to annotate virtual models of resected tissue. And when both the hardware software improves, I think that it's going to transform surgical oncology.

 

Having a background in Dentistry, when I hear you talking about this, there is one thing that comes to mind: dentists use these 3D scanners to do intraoral scans and they have multiple different software platforms for that. I wonder if you've had any experience with those or if there is any ideas from there that you could maybe apply to the 3D specimen mapping.

I think there's opportunity there. We have an active and ongoing study looking at an intraoral scanner that is used in the dental and oral surgery communities. The major issue is that the soft tissue resolution of a small handheld 3D scanner is not ready for intraoral 3D scanning. It’s really capable for scanning teeth, but when you start moving off of the teeth and start trying to scan the palate or the tongue, the resolution is poor. So in our hands the intraoral 3D scanners are not ready, but I'm sure that the hardware is going to improve in the next few years. In the future we could be using some sort of pencil 3D scanner in a patient's mouth to scan their tumor preoperatively!

 

Thank you. Now I want to transition to something different. Your department is consistently ranked as one of the top in the country. And my question for you is what did you and the rest of the team at Vanderbilt do to get there? And what do you do now to stay there? Because it's one thing to be ranked first, and it's another thing to consistently rank on top for so many years.

Yeah, I'd like to acknowledge that Vanderbilt's reputation and ranking is no thanks to me. I think you have to look at the people and individuals that built the Vanderbilt Department of Otolaryngology. It's a relatively young Department that started in the 1980s. But look at the previous Division Chiefs, Dr Ossoff, Dr Netterville, Dr Garrett, Dr Rees, Dr Haynes, and some of the early faculty members -some of them are still here- that built this Department and expanded it to what it is today. I think it starts with the Vanderbilt culture- we have a really good working environment. Everyone treats each other with respect. It sounds simple, but when you start with the working environment, you can create amazing things. I think that there's excellent support both for residents as well as fellows and faculty for research. There's a strong clinical research coordinator staff within the department that helps take clinician ideas and turn them into actual studies and produce meaningful prospective clinical trial results. Going back to our former chair Dr. Eavey, I think his vision for the Department and the residency training program, and his encouragement of faculty to pursue additional degrees, really had an impact in this place. I'm about to finish a masters of science in clinical investigation. When you look at the Department’s faculty, many of us have additional master's degrees. And I think that, that puts us outside our comfort zone and makes us better clinicians and academic researchers.

 

It is very, very interesting to hear about this approach. Now, I'll go to a different direction: is it talent or is it character that makes a good surgeon?

I would say it's both. But I would say character is probably more important than talent. Inevitably in surgery - particularly head and neck cancer surgery- you're going to have complications. How you handle those complications and the interactions with patients and their families is truly what makes you a good surgeon.

 

What, in your opinion, is a predictor of success during residency? What are you looking for in a resident?

Yeah, that's a good question. I don't know this literature as well as others, but there have been several studies that show that we can't necessarily predict who's going to be a good resident or a bad resident. And I think that the definitions of a good resident or a bad resident are something that is still a little unclear. But, you know, when I'm looking at residency applications, my favorite place to look at is the letters of recommendation. Perhaps I know the letter writer, but even if I don't, I think that you can learn a lot about an individual in a personalized letter of recommendation. And to me, that's where you get most excited to meet one of the applicants. I think the personal statement can also get me really excited to meet a prospective applicant!

 

What qualities are you looking for in a resident? What is important to you? I understand that the letters, based on what you said, are very important to distinguish and realize who's who. But what, what kind of qualities are you looking for in someone?

It might sound simple, but my answer is reliability and trustworthiness. I think you have to start there. My subspecialty is doing large cancer operations and reconstructions on patients. The perioperative care of those patients requires trust. Faculty aren't able to be in the hospital 24/7 but there is a resident in the hospital at all times. You need to trust that individual. So, for me, trustworthiness and reliability are the two most important qualities that a resident should have.

 

How important is research for you when you're evaluating someone. Does it play a role at all?

Yeah, it plays a role. For us at Vanderbilt, as a larger academic department of otolaryngology, it's great to see students that have participated in research. We now have a research track position, under the leadership of Justin Turner, one of our rhinologists. And that particular resident spot is really meant to train clinically and also academically a future surgeon-scientist that's going to have a career of discovery. And that could be in any aspect of research: clinical, translational or basic science. We just had our first match last year and look forward to future matches.

 

Are there any red flags for you in an application or during the interview? Things that are an immediate dealbreaker for you?

I don't know if there are any things that are a complete deal breaker for me on an application or an interview. Our approach to interviews and applications at Vanderbilt is very much a democratic process. We have several faculty reviewing applications, an entire committee, and the majority of the Department interviews candidates. So, I think it's more of a team approach. I trust my partners, and my residents who are also participating in this process. Certainly, if someone said something that I didn't like, that may be reflected in my perception of an applicant. But it's the whole body of the Department's review that I think is most important. Everyone's vote counts and is equal.

 

What are your goals for the next decade as an academic surgeon?

Clinically, I'm in my fourth year of practice now. I look back at how much I've grown as a surgeon, as an oncologist, and I look forward to future growth. Academically, I have aspirations to transform the way we approach surgical oncology, even beyond head and neck cancer. We're now using our protocol in breast oncology and musculoskeletal and bone and soft tissue sarcomas. I look forward to future collaborations in these areas. And personally, my daughter Madelyn just turned one this past week. So, I think further development of me as a father will be important over the next decade. That's what I'm most excited about in the next ten years. And I think I'm at a perfect place to do all three because I have wonderful senior partners: Eben Rosenthal, Sarah Rohde, Kyle Mannion, Robert Sinard, Alex Langerman, Jim Netterville, to develop me as a surgeon, as a clinician, as an oncologist, as a father and as a researcher. So, I'm, I'm very fortunate.

 

I know you have a strong presence on Twitter.  I'm just wondering how important having a presence there is and how influential it can be, in your opinion. I can tell you that from the perspective of a junior trainee it has been very helpful. But I just wanted to hear what you think about that.

Social media is very important for me. I look at social media as a way to learn. Gone are the days of receiving a in print journal as a way to stay up on the literature. I stay up on the literature by going to meetings, but also by social media. I follow JAMA Oncology, Lancet Oncology, Head and Neck, Laryngoscope, JAMA Otolaryngology etc. and that's how I learn my literature. I look at what they've recently published, I click, and I then I read the article. I am often told by or asked by trainees and colleagues, how do you stay up on the literature? And I say Twitter. It’s a powerful tool to learn. I also like to use it to disseminate our team's research. There is data to suggest that researchers that are more active on social media are going to have more reads of their paper. We do research to help our patients and also for people to learn about our research. So, if there's something that is going to apply to a broader audience, then I'm going to do it- particularly if it's if it doesn't take much time, which I don't think social media does. So, that's my approach to it. Also, you can learn from other people posting their experiences or their reviews of papers and trials. It's an awesome way to stay up to date.

 

Thank you so much Dr Topf!

Thank you. 

Dr Mark Edward P. Prince - University of Michigan

 

Mark Edward P. Prince, MD, FRCS(C), FACS

Charles J. Krause MD Collegiate Professor of Otolaryngology & Chair, Department of Otolaryngology-Head and Neck Surgery

University of Michigan

 

Dr Mark Prince earned his MD at Dalhousie University in Halifax and completed a residency in Otolaryngology-Head and Neck Surgery at the same Institution. He then trained in advanced head and neck oncology and microvascular reconstructive surgery at the University of Michigan. Currently he is the Chair of the Department of Otolaryngology-Head and Neck Surgery at the University of Michigan, and previously served as the Program Director at the same Department. Dr Prince has >200 published papers. He also co-leads a collaborative education initiative at Komfo Anokye Teaching Hospital in Kumasi, Ghana.

 

 

Dr Prince, you have a very unique career pathway with a background in the armed forces and also in engineering. So, my question for you is why did you end up choosing medicine and otolaryngology in particular?

On a superficial level, it's probably an easy question to answer but in reality, it's much more difficult! I think that both of those experiences, engineering and the Navy, taught me something pertinent to medicine. Engineering taught me a lot about how to think and gave me some ideas about how to approach solving a problem. That was an important set of skills I acquired and led me to a realization, that there was a lot that an individual could contribute through an intentional problem-solving approach. The armed forces experience came from a desire to serve my country, but also to make a difference in the world. The combination of my education as an engineer and my training in the navy gave me a great foundation to build on.

So how does that lead to medicine? Well, I don't think it naturally leads to medicine necessarily. It could lead almost anywhere. My story about how I got to medicine is not so unique. One factor was my older brother who entered into the field of medicine. I think hearing from him stories about what he was learning in medical school, combined with some of the stories my mother told me - she was a nurse at one point in her life - made me more interested in the human condition. Staying in Halifax in Medical School also kept me close to my girlfriend (now wife) and medicine seemed like a great place to make a difference and maybe to apply some of the skills that I was collecting along the way through these other things that I'd been doing. At this point in my life, it's really hard to know exactly what I was thinking back then. Sometimes I wonder if it just seemed like a pretty cool thing to be doing, medicine, with a lot of opportunity, and maybe that's not a bad reason to choose to get into something.

 

I see. That's a that's a really unique way to think about it, I think. Now, I wonder, is there something that you do not like about the specialty or the particular field of head and neck?

I didn't really answer the second part of your first question. I'm thinking now, why did I end up in otolaryngology? So, I'll just reflect on that a little bit because it's perhaps pertinent to the second question about what I don't like in otolaryngology. I was trained as a naval officer and as an engineer. Then I went to medical school, and I switched my career path in the Navy to a Medical Officer. I was what they call a General Duty Medical Officer, which is essentially a primary care physician. I also was lucky to be able to specialize in hyperbaric and diving medicine. When my time in the Navy started to come to an end, I was looking for other opportunities. Otolaryngology, which is something I had some exposure to in medical school, seemed like an interesting combination of clinical work, procedural work, and had the continuity of care, which was something I really loved about primary care.

 I think that's what drew me to Otolaryngology - It is a very unique combination medicine and surgery with continuity of care. There are others that are similar, but none that has the same degree of flexibility. You can be very clinical, you can be very procedural, you can be somewhere in between. You can look after people for years and years or you can see them for a short period of time. Otolaryngology has an amazing ability for you to design the practice that you want.

To answer your next question, whether there is anything that I would change. The obvious answer is that it'd be great if the world didn't need people like me, right? I mean, wouldn't it be wonderful if I could expend my energy, enthusiasm and my training doing something else? Not that I don't enjoy what I'm doing now. I love it because I do think I help people, but it would be an amazing world where nobody suffered from head and neck cancer.

It seems like a fanciful or superficial answer, but it's a truthful answer. If I were to give you something that's a little more immediate to my daily life and that of my patients, it would be to shorten our operating room turnover time.

 

Yeah, absolutely. And you said that it might sound superficial, but I have to tell you, it doesn't sound superficial at all to me. From an epidemiology or preventive medicine perspective, it's very deep, right? Someone getting in the OR to receive a procedure like that is a systemic failure on so many levels, prevention-wise. So, it's really deep.

There is a really neat book called “Upstream: The Quest to Solve Problems Before They Happen”, by Dan Heath. The book really reminds us about how we should be thinking about solving problems. In the United States, Canada and many other places in the world, we are very good at spending a huge amount of effort and energy to solve a problem when it becomes visible. Which is fabulous in one sense; if we spent the same amount of energy effort upstream from where the problem occurred, we might create even more remarkable results though.

I'll give you a non-head neck cancer example: type 2 diabetes. We're inventing wonderful drugs, which help people with their type 2 diabetes. I think that's incredibly valuable- it’s really amazing that we have developed these remarkable new treatments and we should keep doing that. At the same time, we should also think about providing better nutrition, opportunities for people to get exercise, education and eradicating inequities regarding nutrition and access to health care for less privileged groups. That approach would also have an incredible impact on type 2 diabetes. But it's a very different way of solving the problem than our typical approach. It’s an approach to preventing the problem from occurring. Much harder to do, I think, because sometimes the interventions required to solve the problem upstream seem abstract ideas whereas once you see Type 2 diabetes develop it is a concrete problem. How are you going to get fresh fruit and vegetables into an inner city? I mean, that seems a lot more difficult than treating somebody with type 2 diabetes with a new drug.

 

And it can probably have a greater impact, like you said, than fixing the problem at the point that it becomes really obvious. Now, I had the question actually here about how your previous experiences and background affected your career and your leadership style, but I think you have told me a lot about that already.

Let me tell you one more thing. I think a lot of people have misconceptions about how the armed forces and leadership work. I suspect that many people think that you get a rank and then you can just tell people what to do, and they run off and do it. That's really not how it works, though! I think the armed forces give really great leadership training. The training focuses on educating you about how to effectively work with teams, and how to give responsibility and authority at the right level so that people are ready and able to make decisions. In the Armed Forces, and in medicine, we need to train people to do their job at the highest level possible and then give them the authority and the responsibility to make decisions.

A leader in the Armed forces must be a great manager of people. They have to be able to identify strengths and weaknesses and work on those with the individuals they lead. In a very real way, the goal is to develop each individuals’ skills to the highest level possible. That's not hierarchical, that's no just telling somebody to do something. The team must trust and respect each other enough to do whatever they're asked to do. That trust is not easy to develop, right? That's not just wearing a rank on your shoulder that does that. To be a good leader you have constantly work to achieve the best for every member of your team.  I am not saying you have to join the armed forces to learn how to be a good leader. But people often ask me “How did being in the Navy made you a good leader? You just wear a rank, and you tell people what to do”. The answer is the Armed Forces has a focus on individual growth and teamwork that works very well in most circumstances. Importantly they do not think that excellent leadership skills come with a rank and the invest in developing those skills.

 

In my mind, at least, what you're describing is a very progressive leadership style. And it's really important that you explained how the Navy background led to that. I can definitely see that now. And it's good that we are having this in medicine as well today, at least in some places! Now, moving back to the Department, it is consistently ranked among the top in the country every year, maybe for decades. What did you do, personally and as a team in general, to first achieve, and then retain this distinction?

Well, the two questions are very much linked, because the first thing that comes to mind is the culture that is present, not just in my department, but at the University of Michigan, in general. That culture is a culture of great generosity and collaboration. I think that people here really are interested in success as it relates to the team and the members of the team, not solely individual success. The generosity piece refers to the fact that I've seen people here sharing all kinds of information, knowledge, new techniques, and even new thoughts that they have, about how to solve current problems or future problems. People here are willing to do that, because they recruit a lot of really good people, decent people who want to do the best, but also because the success of the team is seen as at least equal, if not more important than the success of any one individual.

I think our department reflects that culture, perhaps at a level that's even a little bit higher than the general level at Michigan. We don't measure value just on the amount of money somebody makes in their clinic or the number of R01s that somebody has in their lab, or the number of papers written. We believe that our people all bring value in many different ways to the department, and we believe that everybody comes here, with the intention of trying to do their best and to make things work.

Culture is really something that makes Michigan unique. I have benefited from that culture! If you look at my CV and the things that I've done, I've been fortunate to be in a place that's been so supportive and with people who've really helped me achieve the things that I have done with the members of my team.

Now as far as what have I done to retain this distinction for our department- what I have done really is what prior Chairs have done: tried to sustain and grow the best culture. We focus a lot on our culture here. We have a 360-degree evaluation around the values that our department has: civility, inclusion, engagement, accountability. We're asking people to evaluate each other and to judge their performance simply based on how they adhere to those values and demonstrate those values. It's part of our effort to have not only the most inclusive environment possible, but also one that's very supportive and behaves in the right way in every situation.

 

Thank you! My next question is somewhat related to this one. And it is about what makes a good surgeon. What makes a good surgeon? Is it talent or is it character that's most important in your opinion?

A lot of times students will ask me “what are you looking for in a in a resident” or, faculty members might ask me “what are you looking for in a faculty member?”. My answer is that what makes a good surgeon is the same things that make a good person. What makes a good surgeon is the same thing that makes a decent person, somebody that is always going to try to do their best and do the best for the people around them, whether that's for patients or other members of their team or whomever.

My dad used to like to use the word decent. I think what he meant by that, was just to treat people the very best way you can. One of the really important factors to being a decent person is not being afraid to say, “I don't know” or “somebody else does it better than me” or “I need help”. I believe that to be a really good surgeon, you need to have the humility to say those things. They're often true and if you can't ask for help or you can't send a patient to somebody else that, does it better than you or is more experienced, then you're probably not going to be the very best surgeon you can be.

Is it character or talent? I think, having trained a lot of residents and worked with a lot of medical students, most people can be trained to be technically good surgeons. It's a technical skill! There are some people that may have issues that make it difficult for them to acquire those skills, but even those individuals in the right environment can acquire them. So, to me, the technical aspects of being a surgeon, which is where talent can often make surgery look easier are not as important as the character. I really do think having the right approach to patient care and working with others is the really critical piece to being a great surgeon.

 

I see. Now, you obviously you have trained a lot of residents, and you said that you get asked a lot what are you looking for in a resident? My question will be slightly different. What is the difference between a good and a great resident?

I think, Jason, a lot of what makes a good resident is what I just reflected on. That, the resident who is really committed to always doing the right thing in every aspect of their training is going to be a great resident and doctor. When I say doing the right thing, I mean, for example that if you don't know something, you won’t be afraid to say so and you'll go and learn it. I believe that the drive to always do the very best, and do the right thing, that leads to a lot of wonderful things. Because you'll never take on something you shouldn't. You're never going to not keep up with your continuing education. You're never going to treat people poorly. We all make mistakes, and we do things that we regret, but if ultimately, your goal is to really try to do the right thing, you'll fix those things as well. And you will apologize and do whatever else needs to be done to fix things. We spend a lot of time trying to identify the students that have this quality in them.

 

Thank you! Now, I can't avoid asking you about research- you're doing cancer stem cell research, which is honestly amazing, and you have produced an incredible amount of work in this field. How and when did research become a part of your career? We talked about engineering, and we talked about your career in the Army before. But when did you start becoming interested in research as well?

Not until quite late, I’d say. In medical school we were asked to do some projects and not necessarily publish. I can't say that I was particularly interested in doing something very novel or very innovative and committing a lot of time to that. I was mostly focused on learning how to be a good doctor.

Interestingly, a couple of things happened once I started working as a General Duty Medical Officer and in hyperbaric medicine. I became aware that there was a lot of opportunity in diving medicine for advancement and new learning, and that got me interested in reading a little bit more of the literature and really trying to understand some of the science behind hyperbaric medicine.

I was fortunate I had a chance to go to the Defense and Civil Institute of Environmental Medicine, in Toronto where some really cool stuff is being done in aerospace and diving medicine. I didn't actually start doing anything then, but when I joined my Otolaryngology training program in Halifax, at Dalhousie University I was interested in trying to do learn something about research and doing something unique. I was very fortunate to run into one of my very first research mentors, Joseph Nasser. Dr Nasser, was interested in craniofacial growth and development. I won't go into the details of the project, but I spent a significant part of my time as a resident -all fitted in around clinical work because we didn't have a research block- doing some basic research.

When I finished my residency, I came to Michigan for my fellowship. And I was very lucky there to bump into Dr Tom Carey, who's quite well known in the field of head neck cancer. He had some really interesting perspectives on biology and how it might affect response to cancer treatment. So, I ended up dabbling in his lab. He was very generous, and I learned about basic science research from him. That experience in Michigan really made me very excited about biology, cancer, and basic science research. In retrospect it wasn't so purposeful- it was just an opportunity that came up that I took advantage of. Then there was some intentionality on my part about learning more about it and getting engaged. That led to an interest in cancer research. That's how it started: with me as a resident with a mentor who was very excited about science and then a fellowship, that gave me some opportunity to learn a lot more.

 

I know you have at least some ongoing research projects, if I'm not mistaken. How are you able to balance your clinical and admin duties today, along with your research projects?

Well, first of all, I don't balance them in the sense that they're not equal! The amount of effort that I have put into different things throughout my whole career has varied depending upon the needs of whatever was going on, the amount of time I had, and what was happening in my personal life. So, I manage them by working hard, and by being intentional about understanding how much effort I can apply to various things. Then the part that's great fun and makes it all possible is engaging with great colleagues, collaborators and teammates so you don't have to do it all yourself! I think that anybody that feels that they do it all themselves is probably misguided. For me, I've been very intentional through my life, to make sure that I that I'm a great team member and work hard as part of a team.

There are times when the rest of the team is focusing a lot more on the lab. Right now, a couple of my partners do all of that, while I'm spending a lot of time running the Department and trying to continue my clinical practice. It's really the team that will allow you to do a tremendous amount, much more than you could ever do on your own. Developing meaningful relationships, where you share the triumphs and sometimes the failures is what leads to success!

 

My final question is a more personal one. How would you -as an academic surgeon- would like to be remembered? What would you like to be remembered for?

For me, it's a very simple question to answer. If a few people thought that Mark Prince did his best to help others, and it made a difference to them then I would be very happy with that. If more than a few were able to say that, I'd be ecstatic!

 

Thank you for sharing these, Dr Prince!

Dr. David Cognetti, MD - Thomas Jefferson University

 

Dr. David Cognetti, MD

Professor & Chair, Department of Otolaryngology - Head and Neck Surgery,

Sidney Kimmel Medical College,

Thomas Jefferson University

Dr. Cognetti is an internationally recognized leader in head and neck cancer. He received  his medical degree from the University of Pittsburgh. He trained in Otolaryngology-Head and Neck Surgery at Thomas Jefferson University and did his fellowship in Advanced Head and Neck Oncologic Surgery  at the University of Pittsburgh Medical Center. Dr. Cognetti has numerous contributions in head and neck squamous cell carcinoma and salivary gland pathology. He has authored >120 publications and approximately 2,500 citations. He has served in multiple leadership positions within the American Head and Neck Society, and the American Academy of Otolaryngology-Head & Neck Surgery, among others.

 

Why did you choose to subspecialize in head and neck surgical oncology?

That's a great question. I just did a Head and Neck Cancer Awareness Week webinar yesterday with some patients with head and neck cancer. One of the questions that the moderator asked us - we had our multidisciplinary team present- was this exact question. So, it made me reflect on this. When I went into medical school, I didn't really know what I wanted to do, in terms of specialty. I was relatively naive. When I went through third year, I found myself liking much of everything. I liked variety, I liked new things, technology, etc. And I remember late in that year is when I was exposed to ENT/ Otolaryngology, and I thought it just had everything: exposure to young and old, men and women. But really what was great about it was the collaborative nature in addition to the innovation and everything that went into it. So that drew me to the field. But what really drew me to head neck oncologic surgery, if I had to be really honest, was watching Dr. Eugene Myers as a medical student, being exposed to him, doing clinic with him, and seeing his relationships with his patients. In the end, it was the head and neck cancer patients. Yes, of course, the surgery is fun, and the anatomy is amazing. We all know that. But at the end of the day, the enriching part of it is the relationships that we build with our patients, and the impact that we have on them, and quite frankly, the impact that they have on us.

 

That's a really, really interesting way to see it. Thank you for that. And is there anything that you don't like about the specialty in general or the sub-specialty?

Honestly, no, I don't have anything. Sure, it's difficult at times, both emotionally and physically. We see people through very difficult things. The complications can be hard on us, as surgeons and caregivers. But I wouldn't say there's anything I dislike. It's an incredibly rewarding field.

 

I'm glad to hear that. Now we want to move to some more clinical questions. Over the past 10-20 years. We've seen the studies on laryngeal preservation, the efficacy of chemo-radiation in HPV+ HNSCC and the more recent breakthroughs with targeted therapies, immune checkpoint inhibition etc. Where do you think this is going? Where do you see surgery in the in the future of cancer care? Will surgery retain its position, or are we transitioning to more debulking approaches followed by targeted therapies and systemic treatments? What is your take on that?

Oh, great question! And you're right. It's fun to look back at our history and see how much has changed in a short time. I consider myself a pretty young guy, but even in my relatively short career, there have been lots of new things introduced, like robotic surgery, immunotherapy, etc. All came after my training. There are now new things coming out yearly that are impacting how we approach things. And I think the speed at which the care of head and neck cancer evolves is only going to quicken. So that's exciting. That should excite people going into the field. Just before I joined the field, there was a lull in people going into head and neck surgery in part because of the VA trial that you referenced. Everybody was worried that surgery was going away. So why would you go into head neck surgery? And then there was a big rebound around my time and thereafter.

I would say I don't see surgery going away in my career, in your career, or in the career of current medical students. There will, however, be an evolution in the role of surgery, almost guaranteed! You could take the word surgery out and replace it with anything else radiation, chemotherapy, immunotherapy and whatever the next thing is. There will be an evolution in the role. I don't like the term “will surgery hold its position?”. I think we as a field, across disciplines, work together well and recognize that we all want the best outcome for the patient, both oncologically and functionally. If that's our goal and new advances mean we're doing less surgery, no problem! There will always be something for us to do.

 

I'll have to admit, it was a quite provocative question. I mentioned on purpose the first chemoradiotherapy studies in laryngeal cancer, because like you said, initially there was this enthusiasm about chemo-radiotherapy, and then the paradigm kind of changed again. The next question will also be somewhat provocative: You mentioned robotic surgery. And we saw the ORATOR-2 trial last year reporting surprisingly and probably unexpectedly more deaths than what we saw before in ECOG. What is your take there? What is the future of TORS?

In the ORATOR studies, I applaud the achievement of randomized data. Surgical RCTs are very difficult to do. I am grateful for the investigators, and grateful for the patients quite frankly. A challenge is it's a very small sample size, in terms of surgeon experience, adoption curve and other things that could impact outcomes. As a result, 1 or 2 deaths make a big difference there. The mortality data doesn't necessarily translate to the national and international experience. So, I don't think ORATOR-2 is going to end TORS. It hasn't. I do think there remains a role. In fact, as we look at some of the new treatments, TORS could play a role with neoadjuvant approaches where surgery is confirming pathologic responses that allow us to deescalate the adjuvant care or eliminate radiation therapy, which contributes most to long term toxicities. There is a balance here. There are currently patients who are getting surgery for oropharyngeal cancer that aren't benefiting. But I think, in general, TORS will still play a role for the foreseeable future.

 

It’s really great to hear this from you! Obviously, Jefferson is one of the few places with such a big volume of cases- it sounds like the department has a lot of experience with it. And in the past few years, or past few decades, Jefferson has trained some of the new generation leaders. So, I wanted to ask you about about that. What in your opinion makes Jefferson Oto unique? What are the main strengths today? And also, are there any areas that you feel that you can improve?

I appreciate your recognition/acknowledgement of the Department, and what we've done in the past decade to two. It's been tremendous for me to be here and participate in helping to drive that advancement. It's been with fantastic partners. So, I will just emphasize that you can name many people, but if you're looking Divisionally Joseph Curry -who I know you’ve previously interviewed -, Adam Luginbuhl and many others have been just outstanding partners for many years now! In terms of what are our strengths, I think there's a passion here amongst us, that's shared. We have a very strong collaborative spirit, in terms of pushing the field forward and offering the best care of our patients. We're committed to education. Starting our fellowship helped drive us forward because, as you said, working with the next generation of leaders and helping train them, helps us get better.

And finally, we have a passion for innovation. We're really excited about new things. When immunotherapy came on the scene, we started doing window of opportunity trials, and neoadjuvant trials because we want to learn. We want to help drive the evolution of the care that we talked about earlier. Maybe that's a point we can tag back to that previous question when you asked whether surgery will have a role in the future. It is better to ask whether surgeons will have a role in the future. I think surgeons will always have a role if we are participating in defining the future of the field, obviously with the patient's best interests in mind. That's what we try to do here.

 

I didn't mention that before, but it really made an impression on me that you noticed the wording, when I asked about surgery retaining its position, and you corrected me there. You were absolutely right. Surgery is one thing and surgeons are another. The fact that you actually rephrased that, I think it reflects on the collaborative spirit that you just described. Are there any areas that you feel that you're actively working on improving or that you envisioning improving in the next decade or so?

That's a broad question, I have to think about that. I mean, we're doing a lot of work here. As I mentioned, some of the clinical trials we've been working on are looking at the neoadjuvant setting. The other thing that we've been fortunate to participate heavily in is photo-immunotherapy, which I don't know if you're familiar with.  You are probably familiar with traditional photodynamic therapy. In that you infuse the patient with a light sensitizer. Then you target the tumor with light, and it's a nonspecific tumor kill. In photo-immunotherapy, the difference is that the light sensitizer is conjugated to a monoclonal antibody. It allows the light sensitizer to therefore attach directly to and concentrate at the tumor cells. This theoretically increases tumor kill and theoretically decreases systemic effects like light sensitivity, etc. We are really excited with what we've seen in some of these early clinical trials.

My point is that there are things coming down the pike that we haven't even thought of yet that potentially will be in the hands of surgeons, even if it's not traditional surgery. And going back to some of my message before that, we as surgeons and surgeon-scientists should be the ones to drive it.

 

I have to admit that I haven't even heard about photo-immunotherapy. It really sounds exciting and obviously very novel. And if you have a few more minutes, I wanted to ask you a couple of questions about residency as well. If you don't have the time, it's absolutely fine.

I have the time. This is this is some of the most important stuff we do. People did this for me, Jason, and I am happy to pay it forward to the next generation of applicants.

 

I really, really appreciate that. So what in your opinion, makes a competitive residency applicant? What are you looking for personally and what would make someone stand out in your eyes?

I might rephrase your question because as an applicant it's hard. We have a brief window with each applicant and it's a competitive specialty. So you do need good board scores and good grades. Strong letters of recommendation are very important. You want to show interest and engagement in the field. That's really where the research comes in: to show your interest, show your dedication to completing projects, etc. In terms of does that translate into a good resident or how do we pick them, that's a little bit more challenging. But I will tell you what I often say to the people who are interviewing with me who ask me what we are looking for in an applicant. I tell them we don't have a specific model that we're looking for. It's not a cookie cutter. We don't want them all to be the same. There is great benefit to having diversity of residents, and just diversity in general: different skills, different learning styles, different everything, that's good.  That strengthens our residency. The two things that I say are important for people to succeed in residency, and quite frankly, succeed in their careers and even succeed in life, are that you need to care and you need to be honest. You need to care about a job well done. You need to care about the patient. You need to care about your colleagues and partners. Support goes back to collaboration that we talked about before. And you need to be honest. And what I mean by that, especially as a resident, but even as far as you go in your career, you need to be able to admit when you don't know something, you need to be able to ask for help. You need to be able to admit when you're wrong. In your training it is important to build trust, but even in your careers, you need to build trust with your patients as well. So maybe humility is a better word.

 

I was about to ask if there are any red flags, but based on your response, I think one can infer the red flags from there. Probably dishonesty would be one of those I presume.

A huge red flag, yeah! You could be the most talented resident in the world, but if you're not trustworthy..

 

Absolutely. And I understand that you've had IMG colleagues before, but did you have any experience in the past with IMGs in residency? Would you consider one in your program?

We have had an IMG fellow. I don't think we've had an IMG resident in our program in the past. But I certainly would consider one, yes.

 

You have answered all my questions with some very, very interesting and inspirational answers. Thank you so much!

Thank you!